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Maintained plasma
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information, refer to the professional information approved by SAHPRA, May 2021. 1) Bui, K., et al (2013).
Pharmacokinetic profile of the extended-release formulation of quetiapine fumarate (quetiapine XR): clinical implications.
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ZNODTA606/09/2020.
ISSN 2409-5699
AABBOOUUTT ththeeddiscisicpliipnelineFOFROtRhethdeiscdipislinceiplinisesue 30 • FEBRUARY 2022
POST COVID-19:
AN ASSESSMENT
APPROACH
LIFE ESIDIMENI -
LESSONS FROM
A TRAGEDY
THE HPCSA AND ITS
DISCIPLINARY
PROCEDURE
MB EADY NOENSDS
- THE PODCAST
2ND SOUTHERN AFRICA
MULTIDISCIPLINARY
VIRTUAL ADHD CONGRESS
PUBLISHED IN ASSOCIATION WITH THE www.southafricanpsychiatry.co.za
SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS
TURN
THEIR
WORLD
RIGHT
SIDE UP
“Adult ADHD should not be a barrier to realising my potential.”
Unlocking potential
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contains 27 mg methylphenidate hydrochloride. Contains sugar (sucrose). S6 CONTRAMYL XR 36 mg (Extended Release Tablets). Reg. No. 49/1.2/1139.
Each extended release tablet contains 36 mg methylphenidate hydrochloride. Contains sugar (sucrose). S6 CONTRAMYL XR 54 mg (Extended Release
Tablets). Reg. No. 49/1.2/1140. Each extended release tablet contains 54 mg methylphenidate hydrochloride. Contains sugar (sucrose). For full prescribing
information, refer to the Professional Information approved by the Regulatory Authority.
Mylan (Pty) Ltd. Reg. No.: 1949/035112/07. 4 Brewery Street, Isando, Kempton Park, 1600. Tel: (011) 451 1300. Fax: (011) 451 1400. www.mylansa.co.za
M3667f Exp: 03/2023
Features POST
BEYOND 25COVID-19:
19MADNESS AN ASSESSMENT
APPROACH
THE PODCAST
51LIFE ESIDIMENI -
LESSONS FROM A
TRAGEDY
THE HPCSA AND 2ND SOUTHERN
ITS DISCIPLINARY AFRICA
PROCEDURE MULTIDISCIPLINARY
VIRTUAL ADHD
59
65CONGRESS
NOTE: “instructions to authors” are available at www.southafricanpsychiatry.co.za
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 5
CONTENTS
CONTENTS FEBRUARY 2022
8 FROM THE EDITOR
9 NEW PODCAST SERIES MAPS THE JOURNEY AND PURPOSE
OF MODERN PSYCHIATRY AND MENTAL WELLNESS
12 POST COVID-19: AN ASSESSMENT APPROACH TO ENHANCE
CLINICAL UNDERSTANDING AND FURTHER RESEARCH
24 THE GAUTENG DOH DISASTER, WHAT CAN PSYCHIATRY LEARN
FROM THE DEATH OF THE 144 LIFE ESIDIMENI PATIENTS?
28 THE HPCSA AND ITS DISCIPLINARY PROCEDURE
31 2ND SOUTHERN AFRICA MULTIDISCIPLINARY VIRTUAL ADHD
CONGRESS 1- 4 SEPTEMBER 2021
32 THERAPY AND ADHD
40 NON-MEDICAL USE OF STIMULANTS
43 ADHD AND EDUCATION
51 A REPORT OF SELECTED SESSIONS
60 CMSA: PRESIDENTIAL PONDERINGS ON THE PANDEMIC…
65 THE MAMA CONFERENCE 2021
71 OF TOOLBOXES AND TALKING
73 KETAMINE CLINICS OF SA - LATEST NEWS AND VIEWS
75 DEPARTMENTS OF PSYCHIATRY
79 BOOK REVIEW: THE WAY OF INTEGRITY FINDING THE PATH TO
YOUR TRUE SELF
81 POEM: ON THERAPY...
82 WINE FORUM: THE EVOLUTION OF KLEIN CONSTANTIA
SAUVIGNON BLANC
84 SASOP
* PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online.
Disclaimer: No responsibility will be accepted for any statement made or opinion expressed in the publication.
Consequently, nobody connected with the publication including directors, employees or editorial team will be held liable for any opinion, loss or
damage sustained by a reader as a result of an action or reliance upon any statement or opinion expressed.
© South African Psychiatry This magazine is copyright under the Berne Convention. In terms of the South African Copyright Act No. 98 of 1978, no part
of this magazine may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by
any information storage and retrieval system, without the permission of the publisher and, if applicable, the author.
COVER IMAGE: 'Cempasuchitl flower' by ray on AdobeStock
Design and layout: The Source * Printers: Raptor Print
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FROM THE EDITOR
Dear Reader,
Welcome to the 1st issue of 2022 – a belated happy new year and here’s
hoping you are all in good health. As we commence this new year one
cannot help but question what it portends based on our collective
experiences of 2020 and 2021. I allude of course to the pandemic.
These past two years have been momentous. Personally I cannot
recall a time, certainly in my living memory, where a preoccupation
with death was so pronounced. Fear of the unknown. The numbers,
the images – relentlessly conveyed by the media. Narratives, counter
narratives - divisiveness. Politicians guided by experts – pronouncing,
issuing decrees. “Follow the science” – probably the phrase most
likely to be instantly associated with these times in the years ahead.
For an interesting perspective on the pandemic I would recommend
an article from the BMJ http://dx.doi.org/10.1136/bmj-2021-068094
The issue has a range of topical content from Leigh Janet’s Feature on a proposed post COVID
assessment scale to Lennart Eriksson’s Perspective on the Life Esidimeni tragedy, as well as a
plethora of reporting from the 2nd Southern African Multidisciplinary ADHD Congress – kindly
curated by our Associate Editor, Renata Schoeman.
On a personal note, and since the last Dear Reader, in August 2021, I was privileged to be
involved in hosting a podcast series “Beyond Madness”. The series featured many of South
Africa’s leading psychiatrists in conversation with myself related to a range of issues in Psychiatry
and of relevance to society. Essentially we took the written word of South African Psychiatry and
converted it into the spoken word, for a larger audience that extended beyond the discipline.
It was a challenging experience, but rewarding. When I set out on this journey I was told it was
“season 1”and now it appears there will indeed be a “season 2”- watch this space.
I hope, as always, you will enjoy the issue and until the next one – take care.
Editor-in-Chief: Christopher P. Szabo - Department of Psychiatry, University of the Witwatersrand
Associate Editor: Renata Schoeman - University of Stellenbosch Business School
Advisory Board: Ugash Subramaney - Head, Department of Psychiatry, University of the Witwatersrand
Soraya Seedat - Head, Department of Psychiatry, Uiversity of Stellenbosch
Dan Stein - Head, Deprtment of Psychiatry and Mental Health, University of Cape Town
Taiwo Akindipe - Head, Department of Psychiatry, Sefako Makgatho Health Sciences University
Funeka Sokudela - Head, Department of Psychiatry, University of Pretoria
Janus Pretorius - Head, Department of Psychiatry, University of The Free State
Zuki Zingela - Head, Department of Psychiatry, Walter Sisulu University
Bonga Chiliza - Head, Department of Psychiatry UKZN; President South African Society of Psychiatrists
Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading
Design and Layout: Rigel Andreoli
"The views expressed in individual articles are the personal views of the authors and are not necessarily shard by the editor, associate editor, advisory board,
advertisers or the publisher."
8 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
PODCAST
NEW PODCAST SERIES
MAPS THE JOURNEY
AND PURPOSE OF MODERN
PSYCHIATRY AND MENTAL WELLNESS
Anew podcast series that maps not only the “If patient care is at the centre of our efforts, then
practical aspects of psychiatry, but also its information impacting on such care should be
purpose and shares a broader view on the accessible. Patients have families, friends, colleagues
service and outcomes that the discipline – all of whom are impacted by patient well-being. In
provides to society. The podcast series Beyond this sense, patients impact communities and society
Madness, hosted by founder and editor in chief of at large,” Professor Szabo adds. And October is
South African Psychiatry Professor Christopher Paul Mental Health awareness month.
Szabo, intends to share the narrative of the discipline
and in the process demystify both psychiatry and PROFESSOR SZABO SELECTED THE TITLE
the plight of those afflicted with mental illness. OF THE PODCAST SERIES CAREFULLY. IT IS
“The idea of a podcast came as a natural extension INTENTIONALLY SLIGHTLY PROVOCATIVE
of the work related to South African Psychiatry, BUT AT THE SAME TIME INTENDED TO
which provides a platform for content that is not HIGHLIGHT THAT THERE IS A NARRATIVE
only for the discipline of psychiatry but importantly TO MENTAL ILLNESS, AND IT IS A LAYERED
about the discipline,” says Professor Szabo. “The STORY.
written word is one thing, the spoken word another.
Moreover, the interactive nature of the podcast “This is a serious podcast, one that takes you
medium allows for the emergence of thoughts and “beyond madness” and delves into issues that are
ideas beyond a published piece.” He hopes that beyond the immediate clinical reality of psychiatry
the podcasts will reach clinical professionals as well but integral to its practice,” he says. “In a sense it
as resonate with the general public. will take you behind the scenes through the voices
of selected individuals, and whilst their work may
appear to have specific relevance to psychiatry,
each issue raised will ultimately share broader
societal implications.”
“Psychiatry is a fascinating discipline and sharing
insights will not only enhance the field amongst
professionals, but it is intended to bring to the
fore and demystify as well as destigmatise many
preconceptions. It’s also about providing insight
to third parties like friends and family who are
impacted in some way or another by psychiatric
challenges faced by a loved one,” notes Professor
Szabo.
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 9
PODCAST
Adcock Ingram OTC Sponsors of Brave spokesperson 4. Is the use of stimulant medication for
Nicole Capper says the reason the pharmaceutical performance enhancement ethical? With Dr
company has sponsored a podcast like this is Renata Schoeman and Dr Chris Verster
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challenges of the mental well - being of themselves 5. Genetics and Psychiatric illness with Dr Kobus
and their families. Roux and Dr Leigh Janet
"WE ALSO HOPE TO SPREAD MORE 6. COVID and mental health with Prof Soraya
ENLIGHTENMENT ON MENTAL HEALTH Seedat and Dr Sandra Fernandes
ISSUES LAUNCHING IN OCTOBER WITH
THE SERIES AS IT’S MENTAL HEALTH 7. The role of spirituality in the healing process
MONTH” . with Prof. Suvira Ramlall
The Psychiatry Podcast Series: “Beyond 8. Madness – an interview with the author of the
Madness” with Prof Christopher Paul Szabo book Madness, stories of uncertainty and hope,
Episodes: Dr Sean Baumann
All episodes available at CliffCentral.com / Spotify/
Apple & Google podcasts 9. Eating disorders – when food is the enemy,
1. The practise of Psychiatry in a cross- cultural with Dori Weill (“Dr D”)
South Africa with Prof Solly Rataemane 10. Problems of living – an interview with
2. Sexual offending and personality with Prof the author of the book Problems of living,
perspectives from philosophy, psychiatry
Sean Kaliski and cognitive-affective science, Prof. Dan
3. Mental illness, human rights and dignity with Stein
Dr John Parker 11. Ketamine and Psychiatry with Dr Alan Howard
12. Pain and mental illness, with Dr Eugene Allers &
Dr Anersha Pillay
13. Substance abuse with Dr Shaqir Salduker
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ZA-BRIN-0143 July 2021
FEATURE
POST COVID-19:
AN ASSESSMENT APPROACH
TO E N H A N C E CLINICAL
UNDERSTANDING AND
FURTHER RESEARCH
Leigh Janet
B y November 2021, there had been In the first week of October 2021, the Leigh Janet
247 968 227 confirmed cases of Severe Acute World Health Organization (WHO)
Respiratory Syndrome-Coronavirus-2 (SARS- released a paper defining Post
CoV-2 or COVID-19) worldwide with 5 020 204 COVID-196 as follows: Post COVID-19
confirmed deaths.1 condition occurs in individuals with
Many sources agree these numbers are a history of probable or confirmed
underestimates because of restrictions on testing SARS-CoV-2 infection, usually 3
early in the pandemic, limited capacity for testing months from the onset of COVID-19
in many resource-poor settings, and ongoing non- with symptoms that last for at least
testing of mild and asymptomatic cases. 2 months and cannot be explained
COVID-19 is a new disease and knowledge of its by an alternative diagnosis.
multiple pathomechanisms, clinical presentations,
course, and long-term outcomes is evolving. Common symptoms include fatigue, shortness of
In common with other known viral infections, breath, cognitive dysfunction but also others which
the possibility of long-term clinical syndromes generally have an impact on everyday functioning.
associated with COVID-19 exists.
Symptoms may be new onset, following initial
FOLLOWING ACUTE COVID-19 INFECTIONS, recovery from an acute COVID-19 episode, or persist
SIGNIFICANT NUMBERS OF PATIENTS DO from the initial illness. Symptoms may also fluctuate
NOT RETURN TO THEIR PRE-COVID STATE or relapse over time. A separate definition may be
OF HEALTH, EVEN WHERE THE INITIAL applicable for children.
COVID-19 INFECTION WAS MILD OR
ASYMPTOMATIC.2,3 This definition will result in a more cohesive body of
research in future.7,8,9,10,11,12 An emergency use ICD-10
The first case of Long COVID was self-described by code has been allocated to Post COVID-19—U09 +
Amy Watson on 11th April 2020 on social media.4 The specific condition. For ICD-11 the emergency use
term ‘Long COVID’ was coined on Twitter by Elisa code is RA02 + specific condition.13
Perego.5 Following many similar reports, patients
organized on social media to drive a research From a clinical and research perspective, it would
program into their condition, culminating in the be useful to delineate various aspects of Post COVID
World Health Organization formally recognizing syndromes more fully. The only scale thus far is based
Long COVID in August 2020.4 on the lived experience of patients with Long COVID.
The author of this paper proposes a pragmatic,
stratified clinical approach to Post COVID-19 called
The Post-COVID-19 Assessment Schema (PCAS),
which is aligned with the WHO definition.
12 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
FEATURE
PROPOSED POST COVID-19 ASSESSMENT 1. Presentation-1: Tier-1: (P1T1)
SCHEMA (PCAS):
The Post COVID-19 Assessment Schema (PCAS) These conditions follow delayed recovery from
divides all Post COVID-19 patients into four symptom
clusters called presentations: Presentation 1 to 4 the acute COVID-19 infection. Because COVID-19
The first two Presentations are broad medical is a new illness, the roles of the multiple possible
groups. pathomechanisms of COVID-19 in each of these
Presentation 1 is called Prolonged COVID-19 presentations are yet to be established.20
Presentation (PCP). This group refers to patients
who experience a prolonged acute COVID-19 P1T1 presentation examples include:
illness. These presentations arise during the acute
COVID-19 infection and relate to the acute infection. a. Specific multi-system and multi-organ medical
The second cluster, Presentation 2, is called illness (e.g. pulmonary fibrosis, acute cardiac
Long COVID Presentation (LCP). This group refers events, acute renal failure, cerebrovascular
to patients whose symptoms arise, or become events). 21
prominent, as the acute COVID-19 episode
declines, or within 60 days thereafter. These are b. Specific single system or organ medical illness
typically post-viral syndromes or presentations. (e.g. pulmonary fibrosis or myocardial infarction.)
Presentation 3 includes all Mental Health Related Many organ systems are known to be affected
Presentations (MHP) in the context of COVID-19 by SARS-CoV-2.22
infections. These presentations may arise at any
stage but are common in Post COVID-19. c. Disordered immune responses to acute COVID–19
Presentation 4 comprises patients with a infection, whether hyperimmune, hypo-immune
combination of symptoms from any of the first or autoimmune, or other disordered immune
three Presentations and is referred to as having a response to the acute infection.23,24,25
Combined Post COVID-19 Presentation (CPCP).
Most Post COVID-19 presentations are of the d. Coagulopathies such as persistent protein
combined type. Patients with CPCP may exhibit clotting pathology with anomalous microclot
complex admixtures of conventional medical formations resistant to fibrinolysis.26
symptoms, novel post-viral presentations, and
mental health related symptoms. e. Systemic medical illness e.g., Fatigue, pain
PRESENTATION 1: PROLONGED COVID-19 syndromes, insomnia, anorexia.2
PRESENTATIONS (PCP)
PCP involves all medically related presentations f. Delayed recovery of symptoms (e.g., shortness
of the acute COVID-19 infection that do not remit of breath).2,27
when the infection resolves. This includes prolonged
infection and secondary infections as well as g. Other medical illnesses (e.g., septicaemia,
complications arising from these infections. secondary infections, autoimmune thyroiditis,
other autoimmune disorders).
A DELAY IN RECOVERY USUALLY FOLLOWS
THE EFFECTS OR COMPLICATIONS 2. Presentation 1: Tier-2
OF SEVERE OR CRITICAL COVID-19
INFECTION, ADVERSE EFFECTS OF Tier 2 reflects symptoms due to delayed recovery
TREATMENTS, OTHER DELAYED RETURN from treatments or Interventions applied during
TO BASELINE, OR NEW MEDICAL the acute COVID-19 illness.
CONDITIONS ARISING IN THE ACUTE
AND POST-ACUTE INFECTIVE PHASE. P1T2 examples include:
The pathomechanisms of COVID-19 presentations a. Post Intensive Care Syndrome (PICS),28 prolonged
are incompletely understood. Post-discharge immobilization, social isolation.
follow-up studies showed elevated risk of mortality,
readmission, and organ dysfunction in C0VID-19 b. Post ventilation pulmonary complications such
patients compared with matched controls.17,18,19 as pneumothorax, pulmonary fibrosis.
In the proposed Post COVID-19 Assessment Schema,
Presentation 1: Prolonged COVID-19 Presentations c. Adverse effects of medication or other
are stratified into 5 Tiers. intervention such as steroids, antibiotics,
immunotherapies, anticoagulation therapy,
dialysis, etc.
d. Dysbiosis.20
e. Complications of other therapy or intervention.
3. Presentation 1: Tier-3: (P1T3)
P1T3 comprises any delirium occurring during an
acute COVID-19 infection.
The occurrence of delirium during an acute
infection confers worse outcomes compared
with patients who do not experience delirium.29
Delirium is so common in hospitalized patients
with COVID-19 that some researchers have
proposed making the condition one of the
disease’s diagnostic criteria.17 Delirium suggests
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 13
FEATURE
the patient will have difficulty alerting medical Tier 3, etc. However, some presentations are best
staff to alterations in symptoms and, post- allocated to more than one Tier, that is, Tier 1
discharge, will have poor recall for details of and Tier 2, for example. If the PCAS is deployed in
their hospitalization. Where possible, factors the clinic, higher levels of precision in allocation
contributing to the delirium should be recorded. of tiers will occur as knowledge of mechanisms
Delirium may presage other neuropsychiatric advances.
presentations and has implications for late-stage PRESENTATION 2: LONG COVID PRESENTATIONS
neurodegenerative brain diseases.30 (LCP)
4. Presentation 1: Tier-4: (P1T4) LCP refers to post-viral presentations that are
Tier 4 records new onset medical illnesses arising not better allocated to Presentation 1: PCP. As
during the acute COVID-19 episode or after more is learned about the mechanisms of these
discharge from hospital, but where the acute presentations, some presentations will be more
COVID-19 is believed to be causally related to the accurately allocated to Presentation 1.
new illness. LCP refers to presentations that usually arise, or are
detected, or become prominent, when the acute
THE NEW ONSET ILLNESSES ARE DEEMED COVID-19 is resolving or has resolved, or in the 60
NOT TO BE POST-VIRAL SYNDROMES days thereafter.
AND THEY NOT BETTER ACCOUNTED Because COVID-19 is a new illness mechanisms
FOR BY TIERS 1-3 ABOVE. and variations specific to COVID-19 may be found
in these presentations.
According to one study, discharged COVID-19 Symptoms that come and go, and fluctuate
patients had six times the risk of new onset in intensity, are widely reported with these
respiratory disease; three times the risk of major presentations.
cardiovascular disease; 2.8 times the risk of Because LCP may arise following asymptomatic
chronic liver disease; almost twice the risk of and even undocumented infections, the PCAS
chronic kidney disease and one and a half times includes specific affordances to deal with such
the risk of new onset diabetes as compared to presentations.
discharged non-COVID matched controls from In the PCAS Presentation 2: Long COVID
the general population. These risks were higher Presentations are stratified into 3 Tiers.
in those younger than 70 and in non-white 1. Presentation 2: Tier-1 (P2T1) (High probability of
individuals.18 Similar findings were reported in
another study.19 Post COVID-19- > 0.66).
These are recognized post-viral syndromes that
In the 12 months post severe COVID-19,
unexplained increased mortality of 233% in can be linked to a COVID-19 infection.
patients under 65 years, has been reported.31 These presentations mimic post-viral presentations
5. Presentation 1: Tier-5: (P1T5) that have occurred following other viral infections.
Where the patient experiences a relapse, Some presentations such as POTS and MCAS are
well described and there exist known treatments.
progression, or a modified presentation of The caveat of COVID-19 being a new illness
illnesses that were present premorbidly — applies.
before the onset of the COVID-19 infection—these Examples of presentations allocated to this Tier are:
changes are allocated here. a. Post Viral fatigue syndromes—These are
A distinction should be made between situations
where the relapses or progression occurred amongst the commonest long term sequelae
because of failure to maintain symptom control of COVID-19 and include Chronic Fatigue
due to pandemic-related interference with Syndrome-like presentations, such as Systemic
ongoing chronic disease management and Exertional Intolerance and post-exertional
changes due to direct influence of COVID-19. malaise.32 In general, these conditions follow
the known patterns of fatigue and exertional
P1T5 INCLUDES CIRCUMSTANCES malaise emerging as the acute infection remits.
WHERE THE TREATMENT FOR THE There are multiple ways COVID-19 infections
PREMORBID ILLNESS REQUIRED could generate fatigue and a single mechanism
ADJUSTMENT BECAUSE OF COVID-19. for all presentations is unlikely.
b. Postural Orthostatic Tachycardia syndrome
Many patients will have presentations matching (POTS). Autonomic dysfunction during the
more than one Tier. Where there is difficulty acute COVID-19 infection might propose
deciding upon the most appropriate Tier, the
default suggestion is to use the lowest Tier number
possible; that is Tier 1 ahead of Tier 2, ahead of
14 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
FEATURE
this Post COVID-19 presentation. POTS has a 2. Presentation 2: Tier-2 (P2T2) (Medium probability
complex presentation which may underpin of Post COVID-19 i.e., 0.33-0.66).
some presentations of LCP.
c. Mast Cell Activation Syndrome (MCAS). Many This Tier is reserved for patients who present with
LCP presentations have features of MCAS, which what may be a post-viral syndrome relating to
is a chronic, multisystem, relapsing-remitting COVID-19, but where attribution is not clear.
disease. However, there remains some doubt as
to the efficacy of the usual treatment measures As many patients present with post-viral
with respect to LCP. syndromes but do not have evidence of prior
d. There are multiple potential presentations of post- COVID-19 infection, this category allows such
viral autoimmune disorders. Where these arise patients to be assessed without confounding
in the post-viral phase of the disease they are the data where the diagnosis of COVID-19
best allocated to LCP. Examples include elevated was confirmed—as in P2T1 above. When
autoimmune antithyroglobulin antibodies, more information accumulates regarding
anti-phospholipid antibodies, and antibodies pathomechanisms of the Tier-2 LCP, the patients
against multiple other epitopes.33,34,35,36,37 may be better assigned to P2T1.
Clinicians and patients may not recognise these
as Post COVID-19 presentations. PRESENTATIONS THAT QUALIFY FOR
e. Inflammatory, neuropathic, and musculoskeletal THIS TIER ARE SITUATIONS WHERE THE
pain and fatiguability syndromes. PATIENT HAS SYMPTOMS COMPATIBLE
f. Insomnia. WITH A POST VIRAL SYNDROME OR A
g. Brain Fog38 where the cause appears related to POSSIBLE POST-VIRAL SYNDROME AND
the acute COVID-19 infection. Brain fog is defined ONE OR MORE OF THE FOLLOWING
in Human Phenotype Ontology as follows: ‘Brain APPLY:
fog is a type of transient cognitive dysfunction
that comprises a constellation of symptoms a. There is no clearly documented COVID-19
that impair intellectual functioning to a level infection. However, as per the WHO definition, the
that interferes with daily activities, commonly symptoms result from a probable Post-COVID-19
including forgetfulness, mental slowness, Syndrome and cannot be better accounted for
difficulty thinking or focusing, a perceived by an alternative cause.
slowing of mental processing speed, inability to
find the right words, a sensation that the mind b. The acute infection might have been mild and
went blank or is "cloudy". Brain fog tends to recur asymptomatic.
and may be triggered by factors such as physical
fatigue, lack of sleep, and prolonged standing c. The LCP symptoms are not typical of any known
or may appear to occur spontaneously.’ post viral syndrome.
There are studies documenting brain d. The symptoms commenced more than 60
architectural changes40, and hypometabolic days after an acute COVID-19 infection with a
regions of the brain on imaging during acute sustained symptom-free period intervening.
COVID-19 infections.41 These findings were
reported in patients who experienced only mild e. The timing of the onset of the COVID-19 infection
COVID-19 infections as well as patients who and /or the onset of the post-viral syndrome are
experienced severe infections. unknown.
A RECENT STUDY OF 14 PATIENTS Clearly patients allocated to P2T2 should be
COULD NOT CONFIRM SIGNIFICANT carefully evaluated for other causes for their
CHANGES ON PET SCANNING OF presentations and COVID-19 should not be
INDIVIDUALS PRESENTING WITH BRAIN assumed to be the cause without thorough
FOG.42 evaluation.
h. Anosmia and related symptoms are common in Examples of P2T2 presentations include:
acute COVID-19 infections and going on to LCP,
especially with the alpha and beta variants. a. Brain Fog. Where the brain fog is not accompanied
by altered smell or taste and there are no other
i. Dysgeusia is well described as an acute features that confirm COVID-19 as the likely
COVID-19 and LCP symptom. cause of the LCP, the patient is allocated to P2T2.
j. Many other presentations of LCP are described. b. Pain syndromes—many forms, e.g. muscle
Many studies attest to the variety of symptoms pains, joint pains, headaches, Gastro-intestinal
and presentations that can occur as part of the pain syndromes, etc.
post-viral COVID-19 syndrome.2,11,43 Further study
is required for the optimal classification of these c. Fevers, especially intermittent fevers as well as
symptoms. flushing and sweating, anorexia, insomnia etc.
d. There are many other presentations from
multiple organ systems compatible with this
presentation.2
e. Functional neurological disorder (FND)
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 15
FEATURE
presentations. These diagnoses should only on function and require concerted rehabilitation
be made using positive diagnostic criteria for efforts by multidisciplinary teams.
FND, and not merely as a diagnosis of exclusion.
Given the sensitivity of this diagnosis specialized CAREFUL ASSESSMENT FOR SOFT
FND units should be used wherever possible for NEUROLOGICAL SIGNS AND OTHER
the diagnosis and management of functional NEUROLOGICAL PRESENTATIONS IS
conditions ESSENTIAL IN ALL POST COVID-19
PRESENTATIONS.
3. Presentation 2: Tier-3 (P2T3) (Low probability of
Post COVID-19 i.e. < 0.33). 2. Presentation 3 Tier-2 (P3T2)
Patients are allocated to P2T3 if they manifest a Post These presentations are of new onset psychiatric
COVID-19 syndrome but did not have COVID-19 diagnoses (according to DSM 5 and/ or ICD-10/11
infection. This requires an absence of serological criteria) or sub-threshold conditions occurring
evidence of infection (but see discussion “How the
diagnosis was confirmed” below).44 The patient a. During the acute COVID-19 infection, or
may present with symptoms compatible with LCP b. During the Post COVID-19 course.
P2T1 or P2T2, but in P2T3 these symptoms are judged
more likely to be non-COVID-19-related causes and These presentations require detailed workup for
mechanisms.45 their association with COVID-19 and there should
a. There is overlap between many symptoms of be a high index of suspicion for an organic
mechanism.48
LCP and non-specific symptoms a person might
experience because of pandemic-related stress Typically, the conditions are mood49 or psychotic
or other causes. disorders50,51 but anxiety disorders and others may
b. Common symptoms such as fatigue, burnout, occur.52
insomnia, pain syndromes and gastrointestinal
stress related conditions may result from many THE IMPACT OF PANDEMIC-RELATED
causes. Full evaluation is required and a non- STRESS ON THE ORIGIN OF THESE
COVID-19 related cause should be found.46 PRESENTATIONS SHOULD BE ESTIMATED.53
c. Patients may self-identify their symptoms as
being due to ‘Long Covid’. Given there is much 3. Presentation 3 Tier 3 (P3T3)
to learn about this new illness, unresolved cases
should be assessed and managed with this in Psychological and Trauma related presentations
mind. may occur as part of PCP and LCP and are
PRESENTATION 3: MENTAL HEALTH RELATED assessed as follows:
PRESENTATIONS OF POST COVID-19 (MHCP)
Mental Health Related Presentations (MHCP) a. Psychological trauma presentations related to
occur across all the Presentations and Tiers.2,23 severe illness and / or hospitalization
In the PCAS Mental Health Related Presentations
are stratified into 4 Tiers. i. Severe COVID-19 disease
1. Presentation 3 Tier-1 (P3T1) ii. Hospital-related and ICU related traumatic
P3T1 consists of a broad range of neuro-
cognitive symptoms with a wider symptom array experiences
and greater symptom severity than the limited b. Psychological and trauma-related presentations
cognitive deficits of Brain Fog.
related to
POST-COVID-19 INFECTION RESULTS i. the consequences of the prior COVID-19
IN A HIGHER-THAN-EXPECTED
OCCURRENCE OF DEMENTIA, infection and treatments, as well as due to
ES PECIALLY IN THE OVER - 6 0 ii. the prolonged dysfunction, distress, or
AGE GROUP,47 BUT A FEW CASES IN
YOUNGER ADULTS HAVE ALSO BEEN burden of the post COVID-19 syndrome.
FOUND. THE OUTCOME OF THESE c. These presentations may be exacerbated by
DEMENTIAS IS UNKNOWN AT PRESENT.
prior pandemic related trauma (which will be
Not all the presentations are this severe. dealt with in a companion paper relating to
However, cognitive deficits have a major impact Pandemic-related events).
d. Onset of, or further aggravation of these
presentations may occur because of prolonged
dysfunction and impairment.
4. Presentation 3 Tier 4 (P3T4)
These presentations reflect relapse, exacerbation,
progression, or modification of pre-existing
psychiatric disorders because of COVID-19.
16 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
FEATURE
ONE NEEDS TO DISTINGUISH DESCRIPTORS FOR POST COVID -19
SITUATIONS WHERE THE RELAPSES OR PRESENTATIONS
PROGRESSION OCCURRED BECAUSE
OF FAILURE TO MAINTAIN SYMPTOM Descriptors capture additional information about
CONTROL OF PSYCHIATRIC DISORDERS the patient’s illness that is not reflected in the
DUE TO PANDEMIC-RELATED OR OTHER presentations assessment thus far. These descriptors
‘INTERFERENCE’ WITH ONGOING are necessary to capture the full scope of the Post
CHRONIC DISEASE MANAGEMENT, COVID-19.
INCLUDING FAILURE OF THE MENTAL
HEALTH SERVICES BECAUSE OF THE There are two clusters of descriptors.
PANDEMIC.54
a. Descriptors of the Acute COVID-19 Episode
a. This Tier includes changes in the prior psychiatric b. Descriptors of the Post COVID-19
disorder (presentation, symptom control, new
symptoms) due to influence of COVID-19. 1. THE ACUTE COVID-19 EPISODE DESCRIPTOR
b. It also includes cases where the treatment The acute COVID-19 Episode Descriptor is assessed
for the premorbid psychiatric illness needed according to 7 items
to change because of COVID-19-related
events. 1. How the diagnosis of COVID-19 was confirmed
PRESENTATION 4: COMBINED PRESENTATIONS a. This descriptor informs the certainty of the
OF POST COVID-19 (CPP) COVID-19 diagnosis. The result may be via PCR
Presentation 4 (CPP) is applied when there are test, or Rapid antigen test or another validated
symptoms from more than one presentation (1-3) test.
and more than 1 Tier and all are the focus of clinical
attention. B. IF THE TESTING WAS NEGATIVE OR
Where Presentation 4 is used, the relevant NOT PERFORMED, THE DIAGNOSIS
presentations and Tiers are all listed. OF COVID-19 MAY BE SUPPORTED BY
Presentation 4 is the commonest presentation of STRONG CLINICAL EVIDENCE FOR
Post COVID-19. EXAMPLE CHARACTERISTIC CHANGES
IN SUMMARY ON CHEST X-RAY.
THUS FAR WE HAVE DELINEATED VARIOUS c. Possibly anti-COVID-19 antibodies or other
SYMPTOM CLUSTERS WHICH SHARE biomarkers will be useful for backwards
THE CHARACTERISTIC OF SUSTAINED diagnostic and / or pathognomonic confirmation
CLINICAL ILLNESS AFTER THE ACUTE at some time. However, there is a reported false
COVID-19 INFECTION HAS RESOLVED. IN negative antibody test rate, more common in
THIS PAPER WE TERMED THESE SUSTAINED females, and possible seroreversion, usually
CLINICAL STATES PRESENTATIONS. following milder infections, complicating this
assessment.
There are 4 Presentation clusters:
Presentation 1 includes medical complications that d. As there remains doubt as to how to proceed
sustain COVID-19 illness. This is divided into 5 Tiers. with seronegative patients with Post COVID-19,
Presentation 2 includes post viral presentations and the PCAS accommodates these occurrences
is divided into 3 Tiers. via the hierarchical system described above.
Presentation 3 includes the mental health related
presentations which are divided into 4 Tiers 2. Type of Infection:
Presentation 4 is used when more than one
presentation is present. All Presentations and all i. First infection
the Tiers that present in one person are listed ii. Recurrent infection
here. iii. Breakthrough infection
The final clinical stratification that we apply is the 1. Vaccination type received
Descriptor Cluster. 2. Adequate initial vaccination level and
duration
3. Special case infection: Pregnancy,
neonate, child, adolescent.
3. The Clinical Presentation of the acute
COVID-19 infection: Supportive investigations
and imaging, significant negative findings,
and results
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 17
FEATURE
a. This description will be highly individualized but vii. THE OCCURRENCE OF POST COVID-19
there will also be common findings representative FOLLOWING VACCINATION IN THE
of the patient with an acute COVID-19 illness ABSENCE OF COVID-19 INFECTION
OR OTHER PC-19 PRESENTATION
b. The details of this descriptor are beyond the REMAINS UNDECIDED.
scope of this paper.
5. Treatments administered
c. Relevant findings from the acute episode
influence the post COVID-19 course and should i. Setting: Home, Isolation centre or hospital.
be included in the post COVID-19 assessment. ii. Early antiviral treatments, Monoclonal
4 . T h e S eve r i t y o f th e Acu te COVI D -19 antibodies, and or convalescent plasma.
episode58,59,60,61 iii. Oxygen home or in hospital
iv. ICU, Ventilation (type) or HFO
A. THERE ARE FORMAL SYSTEMS FOR v. List of all treatments, including novel
RATING EPISODE SEVERITY. HOWEVER,
WITH RESPECT TO POST COVID-19 treatments within a trial or not in a registered
THERE ARE PATIENTS PRESENTING trial. Include all self-medication.
WITH CLINICAL STATES MIMICKING
LCP BUT WHO HAD NO EVIDENCE 6. Course of the acute COVID-19 infection
OF AN ACUTE COVID-19 EPISODE.
THIS SEVERITY DESCRIPTOR PROVES a. For tracking PC-19, recording of dates is
A MEANS FOR DEALING WITH SUCH necessary
CIRCUMSTANCES. i. Document the onset of the incubation
period as best as possible. Where the date
b. The severity of Acute COVID-19 Episode of exposure to the virus is known with high
Descriptor is as follows: degree of certainty, that date of exposure is
i. PC-19 follows an episode of Critical COVID-19 recorded as Day Zero (DZ_). DZ_ is used for all
illness. This may occur in about 5% of patients. subsequent calculations.
ii. PC-19 follows an episode of Severe COVID-19 ii. Where the date of exposure to the virus and
illness. Most of these patients are treated hence the incubation period cannot be
in hospital, except where there were bed determined with any certainty, use a default
shortages. About 14% of patients with acute date of seven days prior to the onset of the
COVID-19 experienced this level of severity. first clinical symptoms of COVID-19. This date
iii. PC-19 may occur after moderate severity of onset-of-symptoms-minus-7 is Day Zero,
acute COVID-19 illness. These patients were e.g., DZ_14th May 2020.
mostly managed at home. iii. Where there is uncertainty, Day Zero is
iv. PC-19 may occur after a mild episode of recorded as DZ_?7, where the '?' indicates
COVID-19. Mild and moderately severe cases uncertainty. This is recorded as DZ_14th May
comprised about 81% of patients who tested 2020_?7. (The symptoms of acute COVID-19
positive for COVID-19. started on 21st May 2020).
v. PC-19 may follow asymptomatic COVID-19 iv. For COVID-19 the incubation period is from
illness. These patients were seldom tested 1-14 days, with 5-12 days being typical.
for COVID-19. In some studies, asymptomatic Day Zero is the best guesstimate of day of
patients are the most common group of exposure.
all62,63 especially amongst the younger age v. Document the time from onset of symptoms
groups. But asymptomatic cases may not to the resolution of the acute phase. The
be common.64 There may be geographical acute illness has usually resolved by 30 days,
prevalence differences. but delayed resolution of 20-40 days is more
vi. PC-19 or PC-19-like syndrome may occur in typical in severe and critical cases.
patients with no history of COVID-19 illness. vi. Critical and severe illness periods may take
1. With high probability that the acute illness up to 3 months or more to resolve.
was COVID-19. vii. Document prolonged illnesses in days.
2. With uncertain or low probability, the Prolonged illness and severe illness are more
illness was COVID-19. likely to result in P1 presentations.
3. This group of patients had symptoms of
possible COVID-19 illness but were not b. The acute episode resolved fully or did not
assessed or tested at the time of this resolve.
illness. It remains unclear whether this is
part of the PC-19 group at all but use this 7. The SARS-CoV2 Variant
descriptor should such patients present to
PC-19 clinics. a. Currently variants are not documented. This
option is added if there is a need to document
a specific variant, or where this information is
available.
18 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
FEATURE
2. DESCRIPTORS OF THE POST COVID-19 3. PC-19 Symptom Stability over time
Post COVID-19 Descriptor consists of 4 items. i. The symptoms worsen over time or new
symptoms develop.
1. The Onset of the Post COVID-19 with respect to
the acute COVID-19 infection Delayed, new onset symptoms commonly
include mental health related symptoms,
a. Early onset of the PC-19—the Post COVID-19 especially depression and anxiety.
symptoms or syndrome started within 30 days of
onset of the COVID-19 infection ii. The symptoms persist unchanging over time.
iii. The symptoms persist but improve over time.
b. Intermediate onset PC-19—symptoms started iv. The symptoms resolve over time.
within 30-60 days of the COVID-19 infection. The
onset of the Post COVID-19 is recorded as (LC30- PC-19 symptoms frequently fluctuate over time,
60) mimicking remissions and exacerbations.
c. Late onset PC-19—symptoms started between WITH FLUCTUATING PRESENTATIONS,
60-180 days after the COVID-19 infection. (LC61- SYMPTOMS COMMONLY FLARE WHEN
180) THERE IS STRESS, INSOMNIA AND
DISRUPTED DAILY SCHEDULING, OVER-
d. Delayed onset PC-19—symptoms started more EXERTION—BOTH PHYSICAL AND
than 180 days after the COVID-19 infection MENTAL, AND WHICH MAY BE VERY
(LC180+) MILD EXERTION IN SOME CASES—
INTERCURRENT INFECTIONS OR
2. The Duration of the PC-19 since DZ_ ILLNESSES, POOR DIET, SUBSTANCE USE
OR ABUSE, PREMENSTRUAL, AND SO ON.
a. The duration of the Post COVID-19 Syndrome is
measured as the time since the exposure to the Different symptoms may have different temporal
virus, defined as DZ_ above. trajectories. If necessary, each symptom trajectory
is recorded individually.
b. Where there was asymptomatic infection or
even no obvious infection date anchor dates 4. Distress, Functional impairment, and Burden
may be used as follows: resulting from the Post COVID-19
i. The date the patient took OTC pain or
headache medication or medication to One can use available rating scales such as the
manage a fever can be used to estimate Subjective Units of Distress Scale (SUDS), Quality
DZ_. Subtract 7 days from the onset of such of Life, or the Global Assessment of Function
use. (GAF) score, but a simple rating of each of these
ii. Where there are no other suitable dates to parameters can be performed, for example rate
anchor PC-19 onset the convention is that each of distress, dysfunction and disease burden
DZ_ is assumed to be 45 days before the resulting from PC-19 on a six level rating:
onset of the first symptoms of PC-19.
iii. Day Zero post undefined COVID-19 infection i. None
is recorded as DZ_20th May 2021_?45. Here ii. Mild
20th May is 45 days before the onset of POST iii. Moderate
COVID-19 symptoms. iv. Severe
iv. An unofficial convention has emerged, v. Extreme
expressing the duration of the Post COVID-19 vi. ? Uncertain
as follows: (LC240) means the PC-19 has
persisted for 240 days since DZ_. Given the many unusual features and impacts of
v. In the example above, (LC240?) will be 15 COVID-19 there may be scope for a rating scale
Jan 2022, for DZ_20th May 2021_?45. adapted to this disorder.
vi. The '?' indicates the uncertainty and is omitted
where there is no uncertainty about dates. CONCLUSION
c. We express periods for duration of PC-19: Post COVID-19 presents complex clinical challenges,
i. PC-19 symptoms lasting 12 weeks (3 months). not least of which is a vast array of presentations and
This is up to 3 months from Day Zero as symptoms. The above paper proposes a pragmatic
calculated above. This is the shortest period clinical approach to Post COVID-19. The approach
possible for PC-19 because per the WHO divides the lingering presentations of COVID-19
definition, the PC-19 must last at least 2 into medically based presentations, post-viral
months (and the incubation and the infection presentations, mental health related presentations
take up the first 30 days). and combined presentations.
ii. PC-19 Symptoms lasting 24 weeks (6 months)
iii. PC-19 Symptoms lasting 52 weeks (up to 1
year)
iv. PC-19 Symptoms lasting > 1 year
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 19
FEATURE
The presentations are further refined by two levels 7. Taquet M, et al., Incidence, co-occurrence, and
of descriptors. evolution of long-COVID features: A 6-month
The first descriptor defines the acute COVID-19 retrospective cohort study of 273,618 survivors of
infection according to seven parameters, which COVID-19. PLOS Medicine September 28, 2021
include the verification method used to confirm
the diagnosis of COVID-19, the relevant clinical https://doi.org/10.1371/journal.pmed.1003773
and supportive findings, the severity of the acute 8. Jiang DH, et al. Postacute Sequelae of Severe
episode, the type and course of the infection, the
SARS-CoV-2 variant, and the treatments that were Acute Respiratory Syndrome Coronavirus 2
used in the management of the acute infection. Infection: A State-of-the-Art Review. J Am Coll
The second descriptor defines the Post COVID-19 Cardiol Basic Trans Science. 2021 Oct, 6 (9-10)
syndrome with respect to four parameters. These 796–811
are the time of onset of the Post COVID-19 syndrome 9. Huang L, et al. 1-year outcomes in hospital
relative to the acute episode, the duration of the Post survivors with COVID-19: a longitudinal cohort
COVID-19 syndrome, the stability or otherwise of the study The Lancet Vol 398, Issue 10302, P 747-758,
symptoms, and the levels of distress, dysfunction, August 28, 2021 https://doi.org/10.1016/S0140-
and burden that the patient experiences. 6736(21)01755-4
10. Lopez-Leon, S., Wegman-Ostrosky, T., Perelman,
MANAGEMENT DECISIONS ARE C. et al. More than 50 long-term effects of
MORE READILY FORMULATED BASED COVID-19: a systematic review and meta-
UPON A SYSTEMATIC AND STRATIFIED analysis. Sci Rep 11, 16144 (2021). https://doi.
APPROACH. HOWEVER, THERE IS STILL org/10.1038/s41598-021-95565-8
MUCH TO LEARN ABOUT COVID-19 AND 11. BMJ 2020;370:m3489
PARTICULARLY POST COVID-19. 12. https://www.cdc.gov/coronavirus/2019-ncov/
long-term-effects/
In a companion paper, the author describes 13. https://www.who.int/standards/classifications/
a pragmatic approach to documenting and classification-of-diseases/emergency-use-icd-
evaluating the pre-COVID-19 status and the impact codes-for-covid-19-disease-outbreak
of the pandemic on the patient. Hopefully, the two 14. Tran V, Development and Validation of the
papers form a comprehensive approach to the Long Coronavirus Disease (COVID) Symptom
description of Post COVID-19. and Impact Tools: A Set of Patient-Reported
REFERENCES: Instruments Constructed From Patients’ Lived
1. https://www.who.int/diseases accessed November Experience, Clinical Infectious Diseases, 2021;
ciab352, https://doi.org/10.1093/cid/ciab352
21 15. Harrison AG, Mechanisms of SARS-CoV-2
2. Editorial: Understanding long COVID: a modern Transmission and Pathogenesis, Trends in
Immunology, Volume 41, Issue 12, 2020, 1100-
medical challenge. The Lancet Volume 398, 1115,
Issue 10302, P 725 August 28, 2021 https://doi. 16. Salimi-Jeda Ali, SARS-CoV-2: Current trends
org/10.1016/S0140-6736(21)01900-0 in emerging variants, pathogenesis, immune
3. Davis, H. E., Assaf, G. S., McCorkell, L., Wei, H., responses, potential therapeutic, and
Low, R. J., Re'em, Y., Redfield, S., Austin, J. P., & vaccine development strategies, International
Akrami, A. (2021). Characterizing long COVID in Immunopharmacology, Volume 101, Part
an international cohort: 7 months of symptoms A, 2021, 108232, ISSN 1567-5769, https://doi.
and their impact. EClinicalMedicine, 38, 101019. org/10.1016/j.intimp.2021.108232.
https://doi.org/10.1016/j.eclinm.2021.101019 17. Parasher A, COVID-19: Current understanding
4. Zimmer B. ‘Long-Hauler’: When Covid-19’s of its Pathophysiology, Clinical presentation
Symptoms Last and Last. Wall Street Journal. and Treatment Postgraduate Medical Journal
ht tps://w w w.wsj.com/ar ticles/long - hauler- 2021;97:312-320.
when - covid -19s - symptoms - last- and - last- 18. Ayoubkhani D, et al., BMJ (Clinical Research
11609524809. Published January 1, 2021. Ed.) Vol. 372 n693. 31 March, 2021.
Accessed February 5, 2021. 19. Al-Aly Z, et al. High-dimensional characterization
5. Perego, Elisa & Callard, Felicity. (2021). Patient- of post-acute sequelae of COVID-19. Nature
made Long Covid changed COVID-19 (and the 594, 259–264 (2021). https://doi.org/10.1038/
production of science, too). 10.31235/osf.io/ s41586-021-03553-9
n8yp6.
6. WHO/2019-nCoV/Post_COVID -19_condition/
Clinical_case_definition/2021.1
20 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
FEATURE
20. Osuchowski MF, et al., The COVID-19 puzzle: 2351 2021 https://www.frontiersin.org/
deciphering pathophysiology and phenotypes article/10.3389/fmed.2021.778434 DOI=10.3389/
of a new disease entity. The Lancet Respiratory fmed.2021.778434
Medicine: Vol. 9 Issues 6 P 622-642 June 01, 2021
ht t p s://w w w.t h e l a n c et.c o m/j o u r n a l s/l a n re s/ 32. Jason LA, et al. Chronic Fatigue Syndrome
issue/vol9no6/PIIS2213-2600(21)X0006-9. versus Systemic Exertion Intolerance
Disease. Fatigue. 2015 Jul;3(3):127-141. Doi:
21. Roberts, CM, et al. COVID-19: a complex 10.1080/21641846.2015.1051291. PMID: 26345409;
multisystem disorder. British journal of PMCID: PMC4556426.
anaesthesia, 125(3), 2020; 238–242. https://doi.
org/10.1016/j.bja.2020.06.013 33. Macela A, et al. Why Does SARS-CoV-2 Infection
Induce Autoantibody Production? Pathogens.
22. Marik PE, et al, A scoping review of the 2021; 10(3):380. https://doi.org/10.3390/
pathophysiology of COVID-19. International pathogens10030380
Journal of Immunopathology and
Pharmacology Volume 35: 2021; 1–16. 34. Arthur JM, et al. Development of ACE2
autoantibodies after SARS-CoV-2 infection.
23. Ramos-Casals M, et al. Systemic and organ- PLoS ONE 16(9): 2021; e0257016. https://doi.
specific immune-related manifestations of org/10.1371/journal.pone.0257016
COVID-19. Nat Rev Rheumatol 17, 2021; 315–332.
https://doi.org/10.1038/s41584-021-00608-z 35. “Autoantibodies stabilize neutrophil extracellular
traps in COVID-19,” JCI Insight. DOI: 10.1172/jci.
24. Woodruff MC, et al. Extrafollicular B cell insight.150111
responses correlate with neutralizing antibodies
and morbidity in COVID-19. Nat Immunol 36. Khamsi R, Nature 590, 29-31 (2021) doi: https://
21, 2020; 1506–1516. https://doi.org/10.1038/ doi.org/10.1038/d41586-021-00149-1
s41590-020-00814-z
37. Chang SE, et al. New-onset IgG autoantibodies
25. Macela A, et al. Why Does SARS-CoV-2 Infection in hospitalized patients with COVID-19. Nat
Induce Autoantibody Production? Pathogens. Commun. 2021 Sep 14;12(1):5417. doi: 10.1038/
2021; 10(3):380. https://doi.org/10.3390/ s41467-021-25509-3. PMID: 34521836; PMCID:
pathogens10030380 PMC8440763.
26. Pretorius E, et al. Persistent clotting protein 38. Brennan Sabina, Beating Brain Fog. Orion
pathology in Long COVID/Post-Acute Sequelae Spring, 2021
of COVID-19 (PASC) is accompanied by
increased levels of antiplasmin. Cardiovasc 39. Hpo.jax.org Accessed 7th November 2021
Diabetol 20, 2021; 172. https://doi.org/10.1186/
s12933-021-01359-7 40. Douaud G, Brain imaging before and
after COVID-19 in UK Biobank. medRxiv:
27. ht t p s://w w w.w h o.i nt/e m e rg e n c i e s/d i s e a s e s/ the preprint server for health sciences.
novel - coronavirus -2019/media - resources/ 10.1101/2021.06.11.21258690. (2021)
science - in - 5/episode - 47- - - post- covid -19- conditi
on?gclid=CjwKCAiAp8iMBhAqEiwAJb94z9sZoEZ 41. Guedj E, et al. 18F-FDG brain PET hypometabolism
mwDOI75FVxB-9Y3EYLg44dNoPMvahjPmEld3WB in patients with long COVID. Eur J Nucl Med
txPtLVc6hoCyfAQAvD_BwE Mol Imaging. 2021 Aug;48(9):2823-2833. Doi:
10.1007/s00259-021-05215-4. Epub 2021 Jan 26.
28. Jaffri, A, et al. Post-Intensive care syndrome and PMID: 33501506; PMCID: PMC7837643.
COVID-19: crisis after a crisis?. Heart & Lung: the
journal of critical care, 49(6), 2020; 883–884. 42. Dressing A, et al. Neuropsychological profiles and
https://doi.org/10.1016/j.hrtlng.2020.06.006 cerebral glucose metabolism in neurocognitive
Long COVID-syndrome Journal of Nuclear
29. Marengoni A, et al. The impact of delirium on Medicine Oct 2021, jnumed.121.262677; DOI:
outcomes for older adults hospitalised with 0.2967/jnumed.121.262677
COVID-19. Age Ageing. 2020 Oct 23;49(6):923-
926. Doi: 10.1093/ageing/afaa189. PMID: 43. Nalbandian A, et al. Post-acute COVID-19
32821901; PMCID: PMC7499475. syndrome. Nat Med 27, 2021; 601–615. https://
doi.org/10.1038/s41591-021-01283-z
30. Arnold C. Could COVID delirium bring on
dementia? Nature 588, 22-24 02 December, 44. Matta J, et al. Association of Self-reported
2020 doi: https://doi.org/10.1038/d41586-020- COVID-19 Infection and SARS-CoV-2 Serology
03360-8 Test Results With Persistent Physical Symptoms
Among French Adults During the COVID-19
31. Mainous III AG, et al.COVID-19 Post- Pandemic. JAMA Intern Med. Published
acute Sequelae Among Adults: 12 Month online November 08, 2021. doi:10.1001/
Mortality Risk, Frontiers in Medicine, 8, jamainternmed.2021.6454
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 21
FEATURE
45. Amin-Chowdhury Z., et al. Causation or Psychotropic Prescribing, Fatigue, and Sleep
confounding: why controls are critical for Problems Among UK Primary Care Patients.
characterizing long COVID. Nat Med 27, 2021; JAMA Netw Open. 2021;4(11):e2134803.
1129–1130. https://doi.org/10.1038/s41591-021- doi:10.1001/jamanetworkopen.2021.34803.
01402-w 54. https://www.who.int/news/item/05 -10 -2020 -
covid -19 - disrupting - mental - health - ser vices - in -
46. Onuora, S. Antibodies induce fibromyalgia most-countries-who-survey.
symptoms. Nat Rev Rheumatol 17, 507 (2021). 55. Eyre, DW, et al. Stringent thresholds in SARS-
https://doi.org/10.1038/s41584-021-00679-y CoV-2 IgG assays lead to under-detection of
mild infections. BMC Infect Dis 21, 187 (2021).
47. De Erausquin GA (Presenter) Olfactory https://doi.org/10.1186/s12879-021-05878-2
dysfunction and chronic cognitive impairment 56. Vashisht R, et al. Age- and Sex-Associated
following SARS-CoV-2 infection in a sample Variations in the Sensitivity of Serological
of older adults from the Andes mountains Tests Among Individuals Infected With SARS-
of Argentina. 2021 Alzheimer’s Association CoV-2. JAMA Netw Open. 2021;4(2):e210337.
International Conference 29 July 2021 https:// doi:10.1001/jamanetworkopen.2021.0337
a l z .c o n f e x .c o m/a l z /2 0 21/m e e t i n g a p p .c g i/ 57. Poland GA, Antibody Dynamics, Seroreversion,
Person/48302 and Persistence After Severe Acute Respiratory
Syndrome Coronavirus 2: Another Answer,
48. Taquet M, et al. Bidirectional associations Clinical Infectious Diseases, 2021; ciab243,
between COVID-19 and psychiatric disorder: https://doi.org/10.1093/cid/ciab243
retrospective cohort studies of 62 354 COVID-19 58. ht t p s://w w w.c ov i d19 t re a t m e ntg u i d e l i n e s.n i h.
cases in the USA, The Lancet Psychiatry, Volume gov/overview/clinical-spectrum/
8, Issue 2, 2021, Pages 30-40, ISSN 2215-0366,
https://doi.org/10.1016/S2215-0366(20)30462-4. 59. Son, Kyung-Bok, et al. Disease severity
classification and COVID-19 outcomes,
49. Iqbal Y, etal. Psychiatric presentation of Republic of Korea. Bulletin of the World Health
patients with acute SARS-CoV-2 infection: a Organization, 99 (1), 2021; 62 - 66. World
retrospective review of 50 consecutive patients Health Organization. http://dx.doi.org/10.2471/
seen by a consultation-liaison psychiatry team. BLT.20.257758
BJPsych Open. 2020 Sep 10;6(5):e109. doi: 60. Salbach C, et al., Validation of two severity
10.1192/bjo.2020.85. PMID: 32907692; PMCID: scores as predictors for outcome in Coronavirus
PMC7484218. Disease 2019 (COVID-19). PLOS ONE https://doi.
org/10.1371/journal.pone.0247488
50. Ferrando SJ, et al., COVID-19 Psychosis: A 61. Marcos M, et al., PLOS ONE Development of
Potential New Neuropsychiatric Condition a severity of disease score and classification
Triggered by Novel Coronavirus Infection and model by machine learning for hospitalized
the Inflammatory Response? Psychosomatics. COVID-19 patients. https://doi.org/10.1371/
2020 September-October; 61(5): 551–555. journal.pone.0240200
Published online 2020 May 19. doi: 10.1016/j. 62. https://www.uptodate.com/contents/covid-19-
psym.2020.05.012 PMCID: PMC7236749 clinical-features
63. Asymptomatic SARS-CoV-2 infection: A
51. Smith CM, et al., COVID-19-associated systematic review and meta-analysis | PNAS.
psychosis: A systematic review of case reports. Accessed November 22, 2021. https://www.
Gen Hosp Psychiatry. 2021 Nov; 73: 84–100. pnas.org/content/118/34/e2109229118
Published online 2021 Oct 25. doi: 10.1016/j. 64. Boon SS, et al. Seroprevalence of Unidentified
genhosppsych.2021.10.003 PMCID: PMC8546431 SARS-CoV-2 Infection in Hong Kong
During 3 Pandemic Waves. JAMA Netw
52. Rogers JP, et al. Psychiatric and neuropsychiatric Open. 2021;4(11):e2132923. doi:10.1001/
presentations associated with severe jamanetworkopen.2021.32923
coronavirus infections: a systematic review and
meta-analysis with comparison to the COVID-19
pandemic. Lancet Psychiatry. 2020 Jul;7(7):611-
627. doi: 10.1016/S2215-0366(20)30203-0.
Epub 2020 May 18. PMID: 32437679; PMCID:
PMC7234781.
53. Abel KM, et al. Association of SARS-CoV-2
Infection With Psychological Distress,
Leigh Janet undertook his undergraduate medical degree at The University of the Witwatersrand (Wits). He qualified in 1987 as a
psychiatrist, also at Wits and he has spent the past 30 years in private practice. He has a specific interest in bipolar mood disorder
and treatment non-responsive depression. His Interests include all aspects of the scientific basis of mental illness. Correspondence:
[email protected]
22 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
RESET EXPECTATIONS WITH NEW ®
NEW ®
REXULTI® is indicated in adult patients for treatment of schizophrenia
South Africa: S5 REXULTI® film coated tablets. Each tablet contains brexpiprazole. Reg No. 0,5 mg: 51/2.6.5/0501;1 mg: 51/2.6.5/0502; 2 mg: 51/2.6.5/0503; 3 mg: 51/2.6.5/0504; 4 mg: 51/2.6.5/0505.
Lundbeck SA (Pty) Ltd. Unit 9, Blueberry Office Park, Apple Street, Randpark Ridge Extension 114 Tel: +27 11 699 1600. For full prescribing information refer to the professional information approved by
the medicines regulatory authority. ZA-REXU-0093 July 2021
PERSPECTIVE
THE GAUTENG
DOH DISASTER
WHAT CAN PSYCHIATRY LEARN FROM THE
DEATH OF THE 144 LIFE ESIDIMENI PATIENTS?
Lennart Eriksson
A s clinical specialists who take on the Life Esidimeni has a long history. Lennart Eriksson
responsibility for patients entrusted to our A psychiatric facility able to
care we cannot avoid addressing the care for SPMI patients requires,
issue of the Life Esidimeni Disaster. Our firstly, a suitable infrastructure.
responsibility includes both the protection as well The buildings, care facilities,
as the care of persons with serious and persistent equipment and staffing demand
mental illness (SPMI). The SPMI category of patients a motivated and functional
– who most often have significant neuropsychiatric infrastructure. And nothing in this
pathology – remain central to our professional world is free. Thus, a private public
interest and expertise. partnership based on a joint
Important areas need to be retrospectively commitment – both financial and
reviewed in the wake of the Esidimeni Disaster. This administrative – must be in place.
is necessary to ensure that we as mental health
professionals remain active participants. Our role LESSON: As clinicians our role, as leader of the
in the care of the institutionalised or community clinical team, is to ensure that ethical clinical
based SPMI patients is explored in this Perspective standards are maintained. The buildings,
– representing a personal opinion. The Esidimeni maintenance, administration, financing are all
Disaster – which in effect was an event caused by operational responsibilities.
irresponsible behaviour by the Gauteng Department
of Health - cannot be allowed to happen again on As clinicians, however, we will demand an input
our watch. where and when operational issues impact on the
clinical care of our patients. Dr Kiran Sukeri and the
THIS INHUMANE EFFORT BY THE GAUTENG Tower Hospital matter is a case in point.
DOH WAS ALSO A TRAVESTY OF JUSTICE.
THE ROLE OF THE PSYCHIATRIST IN THE WORK
I will now explore the complexity of what is needed OF THE DECISION TEAM
to be in place to care for SPMI patients in any Life
Esidimeni facility. The Decision Team has as a primary responsibility
THE PHYSICAL ENVIRONMENT AND THE ROLE to create an environment that is conducive to and
OF THE PSYCHIATRIST supportive of the humane and sustained care of all
SPMI patients
The care and rehabilitation of persons admitted
to a Life Esidimeni facility is not the work of single
entity. The owners of the institution – in this case Life
Esidimeni – and Department of Health share a joint
responsibility. The contract specifications give the
DOH an oversight responsibility. This will take place
at regular intervals. The report of such inspections
is not shared with the inspected facility. The legal
framework for the care of institutionalised SPMI
patients is detailed in the Mental Health Care act
of 2002. Amongst other provisions detailed in the
24 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
PERSPECTIVE
Act empowers the Mental Health Review Board to LESSON: Psychiatry – under the leadership of SASOP
ensure that each and every person admitted to a – made brave attempts to influence and reverse
Life Esidimeni facility remains protected. the Gauteng DOH policy decision. The disastrous
result of the implementation of this policy remains –
nationally and internationally – for all to see.
THE YEARLY PERIODICAL REPORT:
LESSON: The voice of practicing psychiatrists, The Mental Health Care Act (MHCA 2002) details the
SASOP and facility based mental health support responsibilities and functions of the Mental Health
staff (Professional Nurses, Occupational Therapists, Review Board (MHRB). The duties of the Psychiatrist
Social workers) must demand that the DOH remain and management of the health establishment are
accountable for policy changes made without also detailed in the Act.
due consultation. This has not been the case to The MHCA of 2002 required that a yearly periodical
date with the resulting death of 144 SPMI patients. report be completed and forwarded to the Mental
It is imperative that the DOH remain in consultation Health Review Board (MHRB). A member of the board
with relevant medical specialists - psychiatrists and will then read the report and make a decision on
medical officers. Administrators may not always be the need for each and every Involuntary Admission
fully aware of the realities facing persons who have to remain in a Life Esidimeni facility.
neuropsychiatric disability.
PSYCHIATRY’S ROLE IN THE POLICY DECISION WITHIN A PERIOD OF 30 DAYS THE MHRB
MAKING PROCESS MUST SEND A WRITTEN NOTICE OF
THE MHRB DECISION TO THE HEALTH
The Gauteng DOH took policy decisions with ESTABLISHMENT.
respect to the Care and Rehabilitation of SPMI
patients. The SPMI patients in Esidimeni facilities A copy of the final decision will also be made
are Involuntary Admissions under the provisions of available to the DOH stating the reasons for the
the MHCA. The issue of individual responsibility for decision.
the implementation of the disastrous DOH policy LESSON: The attending psychiatrist, who also has a
remains a matter for the Life Esidimeni inquiry. This legal custodial role to protect the rights of the SPMI,
inquiry resumed on the 18th January 2022. It is must demand a written notice of the decision of the
unlikely that any criminal charges will be successful. board. I have, to date, never had sight of a single
Shared blame may be the “order of the day”. The MHRB decision report. To illustrate this concern a
lack of consultation with all relevant stakeholders – 2002 SASOP Congress presentation titled “Who
see diagram – was conveniently ignored. remains in institutional care for 40 years” concluded
that no correspondence was ever received from
the MHRB to confirm legal authority to continue the
“detention” of an institutionalized SPMI.
THE DEBATE AROUND THE DEINSTITUTIONALISATION
Deinstitutionalisation of SPMI patients in Gauteng
health facilities was discussed in a paper by Ray
Lazarus titled “Managing de-institutionalisation in
the context of change: The case of Gauteng, South
Africa”.
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 25
PERSPECTIVE
THIS PAPER OPENED THE DEBATE AROUND • Inclusion in the pre-graduate and post-graduate
INSTITUTIONALISATION WITH REFERENCE curricula of a course on the holistic understanding
TO GAUTENG. NATIONALLY THE DEBATE and care required for persons disabled by a
ON DEINSTUTIONALISATION HAS ALSO serious and persistent mental illness
RECEIVED ATTENTION.
• Improved awareness by clinicians, financial
Crick Lund wrote – “Effective community planners, politicians and - most importantly -
services should be in place before a fashion administrators within the Department of Health - for
of deinstitutionalisation is followed blindly in the need to make adequate provision for the care
South Africa”. Leff wrote “A desire to implement of this group of mentally ill members of our society
deinstitutionalisation by the Department of Health
has a long history. • The MHRB responsibilities be reviewed to ensure
The implementation of “hasty” deinstitutionalisation that the patients admitted to any psychiatric
– not even adhering to the prescriptions contained facility remains protected under the law. This
in the MHCA which was written to protect involuntary legal protection will demand that the financing
admissions to a Psychiatric health facility – should of such care be adequately provided.
never have been allowed to happen" - SASOP
congress August 2021. Lennart Eriksson is a retired psychiatrist who remains
The above summary around deinstutionalisation involved with matters Spiritual and, of particular
gives the debate some perspective. concern, the care of patients with Severe and Persistent
LESSON: The African solution to deinstitutionalisation Mental Illness. This concern is supported by many
is yet to be discovered. It remains an insoluble issue years’ experience with Life Esidimeni. References
until the funds and system for a humane alternative can be obtained from the author. Correspondence:
is in place. We need to be reminded by the words [email protected]
of Bantu Stephen Biko – “Great Powers of the world
have done wonders in giving the world an industrial Face of African Scops Owl - Photographer: Lennart Eriksson
look but the great gift still has to come from Africa –
giving the world a more human face”.
CONCLUDING REMARKS
The attention given to the care and rehabilitation
of persons disabled by Serious and Persistent
Mental Illness (SPMI) is a much-neglected area. The
attention given to this area of our clinical practice
may benefit from the following suggestions: -
26 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
TpalRipeEridoVneIpCalmTitaAte®
prolonged release suspension for injection
THE
TREVICTA® PLAN*
What’s your plan for your patients
living with schizophrenia?
Help your patients to 4 PER YEAR
take ownership of their TREVICTA®
schizophrenia with the
enduring efficacy and Paliperidone
convenience of the unique Palmitate. 7
four-per-year (4PY)
TREVICTA®. 1,2,3,4,5,6
MONTHLY
XEPLION®
Paliperidone
Palmitate. 8
DAILY
ORALS
Risperidone/
Paliperidone. 8,9
* The TREVICTA® Plan is the initiation of XEPLION® then moving to TREVICTA® when stabilised - in line with the approved indications for both treatments.7 XEPLION® is indicated for maintenance treatment of schizophrenia and
for the prevention of recurrence of symptoms of schizophrenia. 8 TREVICTA®, a 3-monthly injection is indicated for the maintenance treatment of schizophrenia in adult patients who are clinically stable on 1-monthly paliperidone
palmitate injectable product. 7
References: 1. Schreiner A, Bergmans P, Cherubin P, et al. A Prospective Flexible-Dose Study of Paliperidone Palmitate In Nonacute But Symptomatic Patients With Schizophrenia Previously Unsuccessfully Treated With Oral
Antipsychotic Agents. Clinical Therapeutics 2014;36(10):1372-1388e1. 2. Berwaerts J, Liu Y, Gopal S, et al. Efficacy and Safety of the 3-Month Formulation of Paliperidone Palmitate vs Placebo for Relapse Prevention of Schizophrenia.
A Randomized Clinical Trial. JAMA Psychiatry 2015;72(8):830-839. 3. Savitz A, Xu H, Gopal S, et al. Efficacy and Safety of Paliperidone Palmitate 3-Monthly Formulation for Patients with Schizophrenia: A Randomized, Multicenter,
Double-Blind, Noninferiority Study. International Journal of Neuropharmacology 2016;19(7):1-14. 4. Hargarter L, Bergmans P, Cherubin P, et al. Once-monthly paliperidone palmitate in recently diagnosed and chronic non-acute
patients with schizophrenia. Expert Opinion on Pharmacology 2016;17(8):1043-1053. 5. Caroli F, Raymondet P, Izard I, et al. Opinions of French patients with schizophrenia regarding injectable medication. Patient Preference and
Adherence 2011;5:165-171. 6. Gopal S, Vermeulen A, Nandy P, et al. Practical Guidance for Dosing and Switching from Paliperidone Palmitate 1-Monthly to 3-Monthly Formulation in Schizophrenia. Current Medical Research and
Opinion 2015;31(1):2043-2054. 7. TREVICTA® Professional Information Leaflet. December 2020. 8. Xeplion Professional Information Leaflet. May 2019. 9. INVEGA® Professional Information Leaflet. January 2010.
S5 TREVICTA® 175 mg, 263 mg, 350 mg, 525 mg prolonged release suspension for injection. 175 mg prolonged release suspension for injection: Each pre-filled syringe contains 273 mg paliperidone palmitate equivalent to 175 mg
paliperidone. 263 mg prolonged suspension for injection: Each pre-filled syringe contains 410 mg paliperidone palmitate equivalent to 263 mg paliperidone. 350 mg prolonged release suspension for injection: Each pre-filled syringe
contains 546 mg paliperidone palmitate equivalent to 350 mg paliperidone. 525 mg prolonged release suspension for injection: Each pre-filled syringe contains 819 mg paliperidone palmitate equivalent to 525 mg paliperidone.
Marketing Authorisation Number/s: EU/1/14/971/007; EU/1/14/971/008; EU/1/14/971/009; EU/1/14/971/010. For full prescribing information, refer to the latest professional information leaflet. December 2020.
S5 XEPLION® 50, 75, 100 or 150mg Prolonged release suspension for intramuscular injection. Each pre-filled syringe contains sterile paliperidone palmitate equivalent to 50, 75, 100 or 150mg of paliperidone respectively. Reg.
Nos.:44/2.6.5/0866; 44/2.6.5/0867; 44/2.6.5/0868;44/2.6.5/0870. For full prescribing information, refer to the latest professional information insert. May 2019.
JANSSEN PHARMACEUTICA (PTY) LTD, (Reg. No. 1980/011122/07), No 2, Medical Street, Halfway House, Midrand, 1685. www.janssen.com. Medical Info Line: 0860 11 11 17.
CP-243117
MEDICO LEGAL
THE HPCSA AND ITS
DISCIPLINARY PROCEDURE
Volker Hitzeroth
In this article, the third of a medicolegal series of articles, Dr Volker Hitzeroth will
explain the role of the HPCSA and specifically clarify its function with regards to
the disciplinary process that South African Health Care Practitioners are subjected
to when a complaint of alleged unprofessional conduct is lodged before it.
T he Health Professions Act 56 of 1974 is one OMBUDSMAN / MEDIATION
of numerous statutory provisions regulating
the healthcare sector and the conduct of If the HPCSA Registrar believes
Health Care Practitioners (HCPs) in South that the complaint relates to a
Africa. It specifically provides for the establishment minor transgression they may refer
and management of the HPCSA by outlining it to the HPCSA Ombudsman for
the HPCSA’s various objectives, functions, and mediation. If the complaint falls
powers. The Health Professions Act also addresses outside the HPCSA’s jurisdiction
the education, training, and registration of HCPs. the complaint is forwarded to the
Furthermore, in conjunction with Regulations R102 relevant authority. Examples of
and R632 it provides the framework and guidance minor transgressions could include Volker Hitzeroth
regarding the HPCSA’s disciplinary powers.
Most members of the public are unaware of the billing queries, miscommunication, unauthorized
broader role that the HPCSA plays within the larger advertising, delays in report writing or a failure to
health care arena. They tend to view it more as a complete administrative forms.
vehicle to express their dissatisfaction, distress or upset
in the hope that the implicated HCP will be taken The Regulations stipulate that the Ombudsman
to task by a higher authority. While the majority of should call for more information, if this is required,
complaints are lodged by patients and their relatives within 7 days. The Ombudsman may also seek
it is not unheard of that a complaint is lodged by a further external information to confirm the factual
fellow practitioner or departmental colleague. basis of the complaint. The practitioner is informed
Complaints to the HPCSA are common and varied of the complaint and should receive a copy.
in nature. They range from minor billing queries and The Ombudsman will usually attempt to find a
allegations of poor manner and attitude to serious mediated settlement to resolve the issues. Once
adverse outcomes including side effects, injuries, the Ombudsman has made a final determination
and deaths. They may even relate to non-clinical and both parties agree thereto the matter is
conduct arising from outside the health care arena. finalized and concluded. Alternatively, if one or
THE INITIAL COMPLAINT both parties decline to abide by the determination
A complaint may be lodged by any individual (or the unresolved complaint is referred back to the
juristic person like a Medical Aid), any group, or any Registrar who is obliged to escalate the complaint
professional society or training institution. to the Preliminary Committee of Inquiry (PCI). As
The complaint must be in writing and addressed to all the information received by the Ombudsman
the Registrar, the Council or the relevant Professional is legally privileged, they may not pass any further
Board. The Council and Professional Board are information to the Registrar.
obliged to pass the complaint to the Registrar who
must acknowledge the complaint within seven THE HPCSA OMBUDSMAN HAS NO
days. Upon receipt of any complaint, the Registrar DISCIPLINARY POWERS AND HENCE
must peruse and analyze the complaint, categorize MAY NOT IMPOSE ANY FINES OR OTHER
the complaint according to its significance and PENALTIES.
seriousness, record the complaint against the
name of the practitioner concerned and refer any PRELIMINARY COMMITTEE OF INQUIRY
complaint relating to a minor transgression and
matters falling outside the HPCSA’s jurisdiction to If a complaint is deemed not to be a minor
the Ombudsman. transgression, or if the Ombudsman’s mediation
attempts have failed, the Registrar has to refer the
complaint to the PCI. The purpose of the PCI is to
investigate and determine whether a prima facie
case of unprofessional conduct exists. It is therefore
an inquisitorial process in order to investigate the
28 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
MEDICO LEGAL
matter rather than an adversarial process in order If the PCC finds that there was no evidence of
to penalize a practitioner. unprofessional conduct, and both parties accept
this outcome, the matter is concluded. Alternatively,
Upon receipt of the complaint the Registrar may if the PCC determines that there was unprofessional
seek further information from the complainant and conduct the practitioner may be subject to a
seek to confirm the factual basis of the complaint. number of penalties:
A Letter of Notice should be sent to the practitioner
within 7 days. The practitioner in turn has 40 days 1. A caution or a reprimand
to provide the PCI with a written response to the 2. A fine
complaint. Any such response is not privileged 3. Suspension from practice for a specific period
and may be used against the practitioner in
later proceedings. It is therefore imperative that a of time
practitioner, upon receipt of a complaint, does not 4. Erasure from the professional register
respond in haste or in anger. As any complaint may 5. A period of compulsory professional service
impact on a practitioner’s practice and career it 6. A cost order to pay for the proceedings
would be prudent to seek immediate legal advice. A
practitioner may choose not to respond but should Either party may appeal the PCC’s outcome and
only do so after seeking appropriate legal advice has 21 days to lodge an appeal with the Registrar.
and would still have to inform the PCI that they have An appeals committee is formed by a legal officer
chosen not to answer to the complaint. Merely (chair) and has four members.
ignoring the HPCSA correspondence and hence not
responding at all will usually attract a complaint of AN APPEAL MAY NOT BRING NEW
contempt of Council with a resultant fine. INFORMATION BUT ONLY CHALLENGE
THE PROCESS FOLLOWED.
Upon receipt of the practitioner’s written response
the PCI may: SECTION 41 AND AN HPCSA RAID ON THE
1. Accept the submission and conclude that there PRACTICE
was no unprofessional conduct. This would The HPCSA Registrar may direct that an
usually lead to a dismissal of the complaint and investigation under S41A of the Health Professions
conclusion of the matter. Act be launched. They would usually appoint
2. Invite the practitioner to appear before it in an investigating officer who would also receive a
person. This would usually involve an informal certificate of appointment. A practitioner is entitled
meeting in order to investigate the matter and to request sight of this certificate which should set
to clarify issues. Legal representatives may not out the specific investigation and appointment.
participate in the meeting but may attend as
observer. The investigator must have a search warrant
3. Find there was unprofessional conduct, albeit authorized by a judge or magistrate in order to
minor in nature. The PCI may then issue a caution, search the practice and / or to seize relevant
reprimand or a fine. If a practitioner rejects the material, unless:
fine the matter is automatically escalated to the 1. the person concerned consents to such a search
Professional Conduct Committee (PCC).
4. Find that there was serious unprofessional for and the seizure of the article in question;
conduct and escalate the complaint to the PCC 2. the person who may consent to the search of
for further action. A practitioner may be given
the option to pay an admission of guilt fine as the premises consents to such search for and
an alternative to escalating the complaint to the seizure of the article in question; or
the PCC and hence avoiding the associated 3. the investigating officer on reasonable grounds
stress, ongoing delays, publicity, absence from believes that a search warrant will be issued
the practice and the uncertainty of the ultimate to him or her under paragraph (c) if he or she
outcome. applies for such warrant and that the delay in
obtaining such warrant would defeat the object
PROFESSIONAL CONDUCT COMMITTEE of the search.
Unlike the PCI which is inquisitorial a PCC hearing Upon conclusion of the investigation the
is adversarial and very legalistic. It is also open to investigating officer is obliged to compile a report
the public. Formal charges against the practitioner which may form the basis of a formal complaint
are formulated and a pro-forma complainant before the PCI.
is appointed who is tasked with prosecuting
the practitioner. Legal representation for the As above, a Health Care Practitioner should contact
practitioner is critical. The enquiry follows general their Medical Defence Organisation for advice
court processes including oral evidence, cross immediately if they are the subject of a HPCSA
examination and the use of independent expert complaint, or if they are in any doubt about any
witnesses. It is a lengthy process requiring the correspondence received from the HPCSA.
attendance of the practitioner and their legal
representatives throughout the enquiry. Volker Hitzeroth is Medicolegal Consultant at Medical
Protection Society in London, United Kingdom.
Correspondence: [email protected]
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 29
DISRUPTS THEIR LIVES
AND FUNCTIONING
BUILD THEM
UP AGAIN WITH
Restoring order to their lives1,2,3
References: 1. De Bruyckere K, Bushe C, Bartel C, Berggren L, Kan C, Dittmann R. Relationships Between Functional Outcomes and Symptomatic Improvement in Atomoxetine-Treated Adult Patients with Attention-Deficit/
Hyperactivity Disorder: Post Hoc Analysis of an Integrated Database. CNS Drugs 2016; 30:541–558. 2. Young JL, Sarkis E, Qiao M, Wietecha L. Once-Daily Treatment With Atomoxetine in Adults With Attention-Deficit/Hyperactivity
Disorder: A 24-Week, Randomized, Double-Blind, Placebo-Controlled Trial. Clin Neuropharm 2011; 34:51–60. 3. Lenzi F, Cortese S, Harris J, Masi G. Pharmacotherapy of emotional dysregulation in adults with ADHD: A systematic
review and meta-analysis. Neurosci Biobehav Rev 2018; 84:359–367.
For full prescribing info please refer to package insert approved by the South African Health Products Regulatory Authority (SAHPRA.) S5 INIR 10. Reg. No.: 43/1.2/0809. Each capsule contains atomoxetine hydrochloride equivalent
to atomoxetine 10 mg. S5 INIR 18. Reg. No.: 43/1.2/0810. Each capsule contains atomoxetine hydrochloride equivalent to atomoxetine 18 mg. S5 INIR 25. Reg. No.: 43/1.2/0811. Each capsule contains atomoxetine hydrochloride
equivalent to atomoxetine 25 mg. S5 INIR 40. Reg. No.: 43/1.2/0812. Each capsule contains atomoxetine hydrochloride equivalent to atomoxetine 40 mg. S5 INIR 60. Reg. No.: 43/1.2/0813. Each capsule contains atomoxetine
hydrochloride equivalent to atomoxetine 60 mg. Dr. Reddy’s Laboratories (Pty) Ltd. Reg. No. 2002/014163/07. Tel: +27 11 324 2100 www.drreddys.co.za ZA/08/2020-22/INIR/072
ADHD CONGRESS
2ND SOUTHERN AFRICA
MULTIDISCIPLINARY
VIRTUAL ADHD
CONGRESS
1-4 SEPTEMBER 2021
Renata Schoeman
I t is estimated that ten to twenty percent of Netherlands, New Zealand, UK and
children and adolescents experience mental Taiwan), from across 19 disciplines
health problems worldwide, while in Sub- (psychiatrists (107), general
Saharan Africa, epidemiological studies practitioners (18), neurologists (4),
indicated that 40.8% of adolescents struggle with paediatricians (11), psychologists
emotional and behavioural problems. International and counsellors (40), occupational
studies estimate the prevalence of ADHD as therapists (21), social workers (2),
five percent of school-aged children, with 65% speech therapists, researchers and
of patients having symptoms that persist into scientists, physiotherapists, and
adulthood. more, participated in the congress.
The congress was hosted by the Renata Schoeman
HOWEVER, IT IS POSSIBLE THAT THE University of Stellenbosch Business School, in
PREVALENCE RATES IN SOUTHERN AFRICA partnership with the Goldilocks and the Bear
MAY BE HIGHER. FURTHERMORE, ACCESS Foundation. A wide variety of topics (see www.
TO CARE REMAINS A CHALLENGE, AND adhdcongress.co.za) were covered and truly
CARE DELIVERY – IN BOTH THE PUBLIC enhanced all healthcare providers’ knowledge of
AND PRIVATE SECTOR – REMAINS ADHD.
FRAGMENTED. A big word of appreciation to our title sponsor
(Dr Reddy’s), our platinum sponsors (Pharma
The 2nd Southern African Multidisciplinary ADHD Dynamics, Life Path Health, and Sandoz), our gold
Congress, held as a virtual event from 1st to 4th sponsors (Acino, Cipla, Sanofi, and Viatris), our
September 2021 succeeded in its aim to bring silver sponsors (Adcock Ingram and Novartis) and
together psychiatrists, paediatricians, general our bronze sponsor, DNALYSIS, and to Londocor for
practitioners, psychologists, and occupational all their logistical assistance.
therapists – the whole team involved with the optimal We are looking forward to welcoming you to the 3rd
management of ADHD across the lifespan. Two- Southern Africa Multidisciplinary ADHD Congress,
hundred-and-seventy participants from 9 countries 31 August to 3 September 2022!
(South Africa, USA, Australia, Canada, Namibia, the
Renata Schoeman is a psychiatrist in private practice; Associate Professor, Leadership, University of Stellenbosch Business
School. Correspondence: [email protected]
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 31
REPORT
THERAPY
AND ADHD
Claire Tobin
T he therapeutic session of the 2nd Southern difference is that women are less
African Multidisciplinary ADHD Congress likely to be diagnosed because
covered various topics such as ADHD, their symptoms are less overt.
marriage and interpersonal violence (by Additionally, she made mention
Dr Lerato Dikobe-Kalane), ADHD and parenting that there are also many adults
(by Angela Vorster and Jessica Cheesman) and that may not be aware that they
workplace interventions for ADHD (discussed by have ADHD and have become
Linda Hiemstra). The presenters in this session were accustomed to finding daily tasks
extremely knowledgeable and provided useful challenging. Dr Dikobe-Kalane
and practical information to use when working specified that when ascertaining
with clients. They often provided insight drawing outcomes and treatment of ADHD Claire Tobin
from their personal experience working with clients.
These sessions are summarised below. in an individual, it is also important to consider that
ADHD, MARRIAGE, AND INTERPERSONAL ADHD is commonly associated with mood, anxiety,
VIOLENCE learning disorders, as well as other psychiatric
The first speaker for the session was Dr Dikobe- disorders (such as personality disorders and
Kalane, who is a psychiatrist in private practice. substance use disorders).
Dr Dikobe-Kalane’s presentation focused on
how ADHD presents in adulthood, how it affects WITH REGARDS TO THE INCIDENCE OF
romantic relationships, and the incidence of ADHD AND VIOLENCE, DR DIKOBE-
interpersonal violence in conjunction with ADHD. KALANE PROVIDED A REVIEW OF THE
She summarised the theory of ADHD and presented LITERATURE. SHE REPORTED THAT MALES
three case studies which highlighted how ADHD WITH BOTH ADHD AND CONDUCT
can present itself differently in different people. She PROBLEMS IN ADULTHOOD ARE MORE
emphasised that each individual requires unique LIKELY TO BE VERBALLY AGGRESSIVE AND
and tailored treatment plans. VIOLENT THAN THOSE WITHOUT ADHD
Dr Dikobe-Kalane provided a brief overview of adult AND CONDUCT PROBLEMS.
ADHD and highlighted the differences in symptom
presentation between men and women. She Additionally, there has been some evidence of an
advised that men are more likely to show symptoms association between adult ADHD and interpersonal
related to hyperactivity and impulsivity, whereas violence (IPV) and domestic violence (DV). She
women are more likely to show symptoms related mentioned that the theory behind these findings
to inattentiveness. Dr Dikobe-Kalane noted that may be the deficient emotional regulation that often
the National Institute of Mental Health estimates accompanies ADHD, which can result in aggression
that approximately 5.4% of men are diagnosed and violence. It was also noted that alcohol and
with adult ADHD, compared to 3.2% of women. illicit drug use (which is common in young adults
She indicated that the possible explanation for this with ADHD) may also play a role in IPV. Furthermore,
it was noted in the literature that adult males with
32 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
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ADHD who were exposed to domestic violence as difficulties (money mismanagement), frequent car
children, are more likely to perpetuate IPV. These accidents, low self-image, poor mental health, and
types of behaviours are usually accompanied by a suicide attempts. Dr Dikobe-Kalane emphasised
co-morbid disorder, such as antisocial personality that the correct treatment of ADHD can assist
disorder. in preventing these negative outcomes. She
ADHD may impact an individual’s life in a variety advised that treatments should include thorough
of spheres, these include work/career, family medical investigations (to determine any organic
dynamics and interpersonal relationships. Dr causes) and holistic management of ADHD. This
Dikobe-Kalane focused on the ways in which typically should include conservative and medical
symptoms of ADHD can impact romantic management.
relationships. She went on to describe how
complications may arise when an individual MEDICATION MAY INCLUDE STIMULANTS
struggles to follow conversations and mindlessly (SUCH AS METHYLPHENIDATE), NON-
agrees to issues that are later forgotten or forget STIMULANTS (SUCH AS ATOMOXETINE),
what was discussed (inattention). This can lead AND MEDICATION TARGETING POSSIBLE
to partners feeling devalued and may cause CO-MORBID DISORDERS, SUCH AS
resentment. The partner with ADHD may also be MOOD STABILISERS, ANXIOLYTICS AND
viewed as unreliable, incapable, or untrustworthy. ANTIDEPRESSANTS.
AT TIMES, INDIVIDUALS WITH ADHD On a therapeutic level, Dr Dikobe-Kalane indicated
MAY INTERRUPT CONVERSATIONS AND that there are various treatment modalities that an
BLURT OUT INAPPROPRIATE THOUGHTS individual can access depending on their needs.
(IMPULSIVITY), WHICH CAN ALSO LEAD These include Cognitive Behavioural Therapy
TO A PARTNER FEELING HURT AND THE (CBT), Dialectical Behaviour Therapy (DBT), family
PARTNER WITH ADHD BEING VIEWED AS therapy, couples therapy, ADHD coaching, and
INCONSIDERATE. occupational therapy.
Dr Dikobe-Kalane outlined three case studies and
Disorganisation around the home and difficulties emphasised that, while it is important to understand
holding down jobs resulting in financial difficulties the ADHD theory, in practice we often need to
for the family may also result in resentment. adapt our treatment according to the needs of
Further challenges can arise when the individual the patient, she described this as the “reality talk
with ADHD struggles with emotional regulation show state”. She humorously called her case study
and has difficulties coping with stress and presentations “Married to ADHD Mzansi”.
frustration, which can trigger anger outbursts and In her case studies, she discussed the various
aggression, leaving the partner feeling abused challenges of the “cast members” and noted
and fearful. how each cast member presented with unique
Dr Dikobe-Kalane went on to describe how ADHD challenges with undiagnosed ADHD. Examples
can impact various dynamics in relationships. included forgetting important anniversaries and
Conflict may arise when one partner feels like they engagements, forgetting to pay bills, emotional
have another child, rather than a partner in the regulation difficulties (such as having a short
household (parent/child dynamic). The partner temper and being aggressive), severe anxiety
with ADHD may require more attention, avoids (panic attacks), excessive alcohol consumption,
taking responsibility, and constantly needs to be and impulsive and reckless behaviour. All cast
reminded when and how to do things. In turn, the members presented with difficulties in several areas
person with ADHD may feel continuously scrutinised of their lives, including interpersonal relationships,
(constant critique dynamic). work, and spirituality. Dr Dikobe-Kalane outlined
how she treated all three patients in a unique and
IN ADDITION, ONCE THE HYPER-FOCUS holistic manner. Each cast member received their
STAGE OF THE RELATIONSHIP COURTSHIP own tailored treatment plan and their symptoms
WEARS OFF, THE PARTNER MAY BE LEFT and lives showed marked improvement.
FEELING ALONE BECAUSE THE PARTNER Through her case study discussion, she
WITH ADHD BECOMES DISTRACTED BY demonstrated how each patient presented with
OTHER INTERESTS AND THE NEW PARTNER different symptoms and experienced their own
IS NO LONGER THEIR HYPER-FOCUS unique challenges. Dr Dikobe-Kalane emphasised
(HYPER-FOCUS COURTSHIP DYNAMIC). throughout her presentation that it is important to
find “the right medication and the right dose for the
It was also mentioned how untreated ADHD can right patient”.
lead to additional difficulties, like poor educational PARENTING AND ADHD
attainment, unstable relationships (higher divorce This topic was thoroughly covered by Angela Vorster,
rates), job instability, legal problems, financial a clinical psychologist in private practice and
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 33
REPORT
Jessica Cheesman, an educational psychologist important to keep in mind that parents with ADHD
in private practice. They both included useful do not necessarily have lower levels of warmth and
information about how parents can cope while attachment than parents without ADHD, however,
managing their own ADHD symptoms and how they they tend to struggle more with the expected
can manage their children with ADHD. behaviours required for parenting. They may
Angela Vorster provided an overview of how ADHD seem less responsive (distracted), find multitasking
symptoms can affect parenting practices and stressful, and have difficulty anticipating outcomes.
how this can impact the success of parenting Angela emphasised that the “goodness of fit”
programmes for parents of children with ADHD. She (between parent and child) plays an important role
explained the impact of executive functioning, in the parent-child dynamic.
and difficulties with problem solving and planning,
which can hugely affect parenting practices. Angela recommends that one takes three specific
executive functioning elements into consideration
AT TIMES, PARENTING MAY SEEM QUITE when examining challenges and how these
BORING (BUT ESSENTIAL), AND IF A challenges influence their parenting ability, namely:
PARENT STRUGGLES WITH ADHD, IT CAN
GET FRUSTRATING DOING THE SAME • cognitive or executive dysfunction;
ACTIVITY REPEATEDLY. • deficits in self-regulation; and
• deficits in motivation and incentive-based
At the same time, Angela emphasises that it is
important to note that ADHD presents very differently reporting.
in everyone, and every parent will have own unique For example, she explained how a parent with
experience. She advised that more than a half of difficulties with executive dysfunction may have
adults with a diagnosis of ADHD, have at least one challenges with working memory, verbal memory,
child with ADHD, which can lead to intertwined planning and effortful control. This may in turn
challenges for both parents and children. influence parental discipline (which may be
Angela described various challenges associated inconsistent or overreactive), the parent’s ability
with parenting including working memory deficits to plan, prioritise and organise and exhibit
(in particular, verbal memory), difficulties with challenges keeping with time limits, as well as task
communication, and the ability to shift attention shifting.
from something that is very interesting to listening
to their child telling the same story over and over. When working with parenting programmes, Angela
Furthermore, Angela mentioned that there can recommends that these programmes should focus
also be elements of the parent’s own projections specifically on cognitive skills such as:
onto their children, especially if the parent really
struggled as a child. Often, parents battle with • Focusing on the benefit of long-term goals
prioritising and planning, as well as self-monitoring (not immediate goals)
(losing track of time). They may struggle to be
consistent with their discipline and require constant • Focusing attention on the child
reminders. • Focus on higher-order planning and problem-
The core dysfunctions of parenting with ADHD
were explained by Angela. She emphasised the solving skills
importance of being mindful of the many factors
that can influence how these dysfunctions present Other considerations in parenting programmes
themselves, including a parent’s background, should be a parent’s own experience of ADHD
personality, temperament, and possible psychiatric during childhood, parent training, and treatment.
co-morbidities.
CHALLENGES IN PARENTING ARE
THE CORE DYSFUNCTIONS INCLUDE NOT RELATED TO AFFECTIVE STATES
INSUFFICIENT LEVELS OF CONTROL, OR DISPLAYS OF WARMTH AND
OVERREACTING, HARSH PARENTING, AFFECTION, BUT MORE ASSOCIATED
REDUCED FAMILY COHESION AND WITH ORGANISATION, ATTENTION AND
INCREASED FAMILY CONFLICT (HIGHER CONSISTENCY.
DIVORCE RATE).
Angela also mentions that there are distinct
Parents with ADHD also appear to be less consistent differences between mothers and fathers with
in monitoring or managing family routines. As a ADHD. Mothers tend to be more inconsistent with
result of the inconsistent discipline, the child is often discipline and have challenges supporting their
exposed to inappropriate repetition of commands, children. Additionally, mothers tend to be more
criticism, and possible physical punishment. It is neurotic (more likely to present with co-morbid
anxiety) and are less conscientious. They do
however have equally positive and empathetic
abilities compared to mothers without ADHD.
Fathers tend to also be inconsistent with discipline,
appear to have less involvement and are harsher in
their parenting styles.
34 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
REPORT
ANGELA REFERRED TO STUDIES WHICH • Ask your partner to get involved when you feel
INDICATE THERE ARE HIGHER SEPARATION overwhelmed
RATES, INTERPERSONAL CONFLICT AND
DIVORCE RATES WHEN ONE PARTNER • Self-compassion (often parents feel incompetent
HAS ADHD. SHE ALSO MENTIONED THAT and feel guilty)
THERE IS OFTEN MORE NOTABLE ‘HOME
CHAOS’. Angela Vorster mentioned that her underlying
message is not to pathologize ADHD but to focus
Home chaos describes an environment with high on goodness of fit and encourage lots of self-
background noise and is low in structure and compassion. She concluded her presentation with
routine. The lack of structure, routine, and planning the quote:
impacts the child’s overall functioning, as well as
parenting in general. “Chaos in the world brings uneasiness, but it also
allows the opportunity for creativity and growth”
Listed below are some of the practical tips provided Tom Barrett
by Angela of how parents can manage their home The second presentation on ADHD and
and family environment. parenting was centred around the challenges
of parenting a child with ADHD when a parent
• Explain ADHD to your family (de-pathologize has ADHD themselves. This presentation was
ADHD) comprehensively covered by Jessica Cheesman
and she provided useful tips on how to guide
• Solve problems together (no finger pointing) professionals in assisting parents with ADHD from
• Learn to communicate effectively (child needs a therapeutic approach.
to be heard, create an atmosphere where the JESSICA EMPHASISED THAT PARENTING
child feels safe to express themselves). IS NOT A WALK IN A PARK, AND THAT
• Keep a calendar and use different colours to AT TIMES, THAT PARK CAN FEEL LIKE A
keep track of schedules (e.g., phone apps) “JURASSIC PARK” AND CAN BECOME
• Keep a solid exercise routine (including yoga, EXTREMELY CHALLENGING.
meditation, relaxing activities to do as a family)
• Take time to cool down before engaging in Jessica introduced her presentation reviewing
arguments relevant research with regards to parents and
• Organise someone to look after your children children with ADHD. She highlighted important
if you are working from home findings that indicate that parents of children with
• Get professional help on how to manage ADHD are significantly more stressed than those
children with ADHD with neurotypical children. Additionally, mothers
• Work as a team with your family tended to present with significantly higher scores
• Get outside help for chores which create of maternal depression, and more mental health
tension in relationships concerns overall. This was further increased
• Do not fight with picky eaters (supplement with when the mother had more than one child with
vitamins and healthy snacks) ADHD. In Jessica’s master’s degree research
• Use humour (Cheesman, 2019), she found that the main
• Establish quiet time/zones (e.g., no TV while percieved challenges of single mothers with ADHD
eating) were managing work responsibilities, personal
• Pick your battles well-being, financial constraints, reactivity
• Enlist the “no interruptions rule” at the dinner within parent-child interactions, managing
table or use “passing-the-talking-stick” method household responsibilities, and maintaining new
• Establish routines (write them down) but relationships.
maintain flexibility When working with parents in therapy, Jessica
• Be consistent mentioned that it is important to be aware that
• Keep explanations short parents often feel that they are expected to appear
• Problem-solve ahead of time to be in control. However, in reality, what parents
• Prepare the night before to avoid possible usually feel is vastly different from the way they
morning chaos (pack lunches, backpacks, portray themselves to others. It is therefore crucial
lay clothes out and so on) to provide a safe space for parents to express how
• Take time away with your spouse they genuinely feel, and to acknowledge and
attempt to understand their unique experience.
PARENTS OFTEN ANTICIPATE RECEIVING
NEGATIVE FEEDBACK AND MAY APPEAR
DEFENSIVE IN A DISCUSSION AROUND
PARENTING.
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 35
REPORT
Therefore, the role of a therapist is often emotional • “Is ADHD even real?”
containment and providing support to parents. • “Why does my child have ADHD?”
Jessica highlighted that the goals in therapy • “But he can focus on Lego/Minecraft etc”
are commonly to reflect and build on the skills • “Why is she well behaved at school but has
that the parent inherently possesses in order to
manage themselves and their children more meltdowns at home?”
effectively. It is also important to emphasise that • “The YOU magazine says he will turn into a
every parent’s journey is different and unique and
that each parent knows their child/children better zombie”
than anyone else. Jessica suggested explaining
to parents that having ADHD as an adult enables In terms of guiding parents, Jessica emphasised
them, as a parent, to better understand and the importance of focusing on practical strategies
empathise with their children with ADHD. This can and strategies that can easily be implemented,
be a useful tool when encouraging and developing particularly with regards to morning and night-time
parental empowerment. routines, homework and social skills. The therapist
should also discuss the importance of boundaries,
ONE OF THE BENEFITS OF BEING A communication and consistency in parenting.
PARENT WITH ADHD, IS THE ABILITY TO BE It is also vital to discuss and manage parental
MORE OPEN WHEN COMMUNICATING expectations and remind them that there is no
WITH THEIR CHILDREN AND BEING MORE manual to parenting in general, and especially
EMPATHETIC TOWARDS THEIR CHILD’S parenting a child with ADHD. As a therapist, it is
EXPERIENCE. crucial to emphasise that the parent knows their
family system best, and that they know which
Jessica provided important strategies that therapists practical strategies they can apply in their homes
can utilise when guiding parents with ADHD. She or experiment with.
highlighted three strategies, namely: structured
parenting; preparing for the future; and self-care. IN GENERAL, JESSICA ADVISES THERAPISTS
She emphasised the importance of having a routine, TO BREAK DOWN DISCUSSIONS INTO
nourishing independence, and using creativity to SPECIFIC FOCUS AREAS, BECAUSE IT
prepare for the future (e.g., visual charts). MAY BE OVERWHELMING FOR PARENTS
TO DISCUSS PARENTING IN GENERAL.
IT IS ALSO ESSENTIAL FOR PARENTS TO
ALLOW TIME FOR SELF-CARE, WHICH These specific areas might include night-time
T YPICALLY INCLUDES ENSURING routine, morning routine, homework, and social
MEDICAL MANAGEMENT OF THEIR OWN skills. However, regardless of these areas, Jessica
ADHD, ATTENDING THERAPY, LEADING emphasises that the “golden thread” should be
AN ACTIVE LIFESTYLE AND SIMPLY TAKING woven throughout all discussions about parenting,
SOME TIME OUT FOR THEMSELVES. is that of boundaries, communication, and
consistency. She also recommended that it may
Similar to what Angela Vorster mentioned above, be useful to email brief summaries of discussions to
Jessica also highlighted the importance of parents parents, or to provide them with something tangible
understanding ADHD. The role of psychoeducation to take home, such as like a resource list.
is important and creates a space to develop a
parent’s insight and it also provides the therapist To conclude her presentation, Jessica provided
an opportunity to answer questions and eliminate some useful parenting tips. A few of these tips are
misperceptions which parents may have. listed below:
Furthermore, it is important to determine the parent’s
level of flexibility and openness to diagnosis. Jessica • Commit time and be involved
also mentioned that that the power of language • Find positive behaviour and praise it
is important when framing the discussion around • Use simple, clear, one-part instructions
ADHD and it can be useful to consider if the parent • Use specific instructions (instead of “clean
responds better to a more tentative language or
more directive language. your room”, try “put away your toys”)
Jessica provided some useful examples of questions • Be aware of your own feelings: children feel
commonly posed by parents about ADHD. She
mentioned that is important to be prepared for the what parents feel
questions that parents may ask. When answering • Provide choices
these types of questions, Jessica explained that • Avoid judgements
it is often helpful to try use visual imagery and
explain how ADHD symptoms differ in children and In summary, both presentations by Angela and
adults. Some of the questions she has frequently Jessica highlight that parenting is multifaceted and
encountered are: there is no perfect formula for parenting or for how
to guide parents on their parenting journey. It is
important to always keep in mind that parents and
36 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
REPORT
children are unique individuals and an approach (like meetings), difficulties with task completion,
that might work for one parent, might not work for arriving late to work and to meetings, being
another parent. Furthermore, parenting becomes overtalkative, over-promising, impatient, acting
more complex when both the parent and child have impulsively and seeking sensory stimulation. They
ADHD. The key is to find a formula of intervention also appear distractible, have difficulties making
that works for both parent and child. It is important decisions, get bored easily, seem to be sensitive to
that ADHD should not be pathologized, but rather work stress and may be insensitive towards others.
understood. It is imperative to focus on the strengths However, Linda mentioned that although ADHD
of the individual, and not solely on the challenges. can impair an individual’s ability to function at
It was concluded that parenting in general is work, there are often positive qualities that should
complex and presents with many dynamics. There not be overlooked. These include openness to
is a wealth of knowledge that can explored with new ideas, creativity, divergent thinking, passion,
assisting parents and children with ADHD. insightfulness, spontaneity, and having a good
Cheesman, J. E. (2019). Parenting a child with sense of humour.
ADHD: Exploring the experiences of single mothers
with ADHD (Masters dissertation, Stellenbosch: INDIVIDUALS WITH ADHD APPEAR TO HAVE
Stellenbosch University). AN UNUSUAL ABILITY TO SEE PATTERNS
WORKPLACE INTERVENTIONS FOR ADHD AND INDIRECT CONNECTIONS AND CAN
The complex topic of ADHD in the workplace FIND SOLUTIONS TO PROBLEMS THAT ARE
was presented by Linda Hiemstra, who is an NOT OBVIOUS TO OTHER PEOPLE WITH
occupational therapist in private practice. Linda RELATIVE EASE. ADDITIONALLY, LINDA
indicated that the topic is considered complex ADVISED THAT INDIVIDUALS WITH ADHD
because everyone has their own preconceived ALSO HAVE THE ABILITY TO SUSTAIN RARE
ideas about ADHD and individuals can be biased LEVELS OF INTENSITY AND FOCUS ON
in the workplace towards individuals with ADHD. ACTIVITIES AND PROJECTS THAT CATCH
Linda mentioned that when an individual with ADHD THEIR INTEREST.
reaches adulthood, there is a shift in symptom
presentation, and symptoms tend to become more As mentioned in previous articles, Linda emphasised
subtle. This shift may be from hyperactivity and that is very important not to pathologize ADHD and
impulsivity to inner restlessness, disorganisation, to also focus on the goodness and creativity that
and inattention. individuals can bring to teams and to the workplace in
general. Individuals with ADHD are capable of highly
SHE WENT ON TO EXPLAIN THAT OFTEN original thoughts, often have a wide range of interests
CHILDHOOD PREDICTORS OF ADULT and bring a great breadth of general knowledge.
ADHD INCLUDE SYMPTOM SEVERITY, CO- The ADHD brain works differently, and Linda
MORBID MENTAL HEALTH CONDITIONS, indicated that it needs to be considered whether
SOCIAL ADVERSITY AND PARENTAL ADHD is a disability, because this may impact
PSYCHOPATHOLOGY. their ability to function in the workplace. This is
because most jobs and workplaces are designed
Interestingly, Linda pointed out that research with the neurotypical brain in mind. In defining
indicates that the prevalence rates of ADHD tend what a disability is, Linda came to the conclusion
to equalise in men and women in adulthood. She that most definitions are extremely negative
explained that a possible explanation for this is (seen as “not able”, “no ability”) and somewhat
that male children tend to display more behaviour disrespectful and negative when describing an
related difficulties and are therefore more likely to individual with a disability. She mentioned that
be provided with early intervention by their parents. often people with ADHD do not see their ADHD as
In female children, symptoms of ADHD tend to a disability but acknowledge at times they can
be less obvious (more inattentive), and parents find certain environments challenging.
may not seek assistance for their child. However, Linda highlighted that in South Africa we do not
in adulthood, an individual can pursue their own have disability legislation and only have legislation
treatment when they find that their well-being is regarding equity, namely the Employment Equity
being affected and they are struggling with their Act (EEA). In the EEA, a person with a disability
relationships and productivity at work. Linda points is defined as “someone that has a long-term or
out that when an individual is not functioning well recurring physical or mental impairment which
in workplace, it can often affect other areas of their substantially limits their entry into or advancement
life. in their employment”. Linda mentions that this
In the workplace, Linda indicated that people with definition suggests that an individual is less capable.
ADHD are often described as not being able to relax, However, the benefits of recognising ADHD as a
constantly on the go, fidgety, unable to sit still for disability can be a means to accessing workplace
extended periods in situations where this is required accommodations for an individual. Therefore, if an
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 37
REPORT
individual with ADHD finds that their physical space for a comprehensive assessment to determine any
is disabling, then the EEA may assist in motivating mismatch of domains (person occupation, and
for workplace accommodations. environment).
What are workplace accommodations? Linda
described these as adjustments made in a system to IT IS CRITICAL TO IDENTIFY IF ANY
accommodate or create fairness (equity) within the IMPAIRMENT IS A RESULT OF AN
same system, for an individual, based on a proven EMPLOYMENT MISMATCH, AND IF SO,
need. These needs can be religious, physical, TO FACILITATE INVESTIGATION OF MORE
mental/emotional, academic, or employment SUITABLE EMPLOYMENT OR JOB ROLE.
related, and these are often mandated by law.
As stated in the EEA, these accommodations may Linda recommended that skills also be taught in the
be put into place if it does not impose hardship workplace including coping skills, emotional and
to the company. Unfortunately, companies may sensory regulation techniques, use of movement,
often use this requirement to deny an individual building in routines, communication skills,
accommodations in the workplace. Linda noted identifying strengths and weaknesses and helping
that providing accommodations in the workplace the individual to find their “diamond time” (the time
place is specifically about treating someone with a when the person is at their best) and to schedule
disability in a different way so that they can work on challenging tasks during this time.
the same level as others. THE OCCUPATION DOMAIN
As mentioned above, ADHD can impact an When looking at a suitable job, it is important to note
individual’s ability to function in the workplace that although there is no particular occupation
because workplaces and jobs are usually designed that suits a person with ADHD, there are various
with neurotypical employees in mind. Therefore, elements that need to be considered. Some
individuals with ADHD often struggle with their job occupations require more neurotypical function
performance, tend to have lower occupational and entail routine, minimal initiative, low deadline
status and less job stability. pressure and fixed rules. Linda advises that a person
with ADHD would perform better in an environment
JOB SEEKING CAN BE SPORADIC AND that allows for flexibility, creatively, variation and
DISORGANISED AND THEY OFTEN EITHER passion. She mentioned that often flexitime is useful
DO NOT KNOW WHAT TYPE OF JOB THEY and alternating between working from home and
SHOULD BE LOOKING FOR AND WHERE working from the office can be beneficial.
THEIR STRENGTHS AND WEAKNESS LIE. THE ENVIRONMENTAL DOMAIN
In terms of the environment, Linda mentioned that
Moreover, they may over-represent themselves in the physical space can be adjusted to include
interviews and come across as scattered or overly room dividers, physical placement in an office
friendly. Therefore, Linda advised that it is also good (in a quiet corner where there is less movement),
to take into the account the occupational fit of the providing individuals with the opportunity to use all
individual with ADHD. senses, allowing fidget toys and movement breaks,
Linda explained that the occupational fit is the adapting information dissemination practices
goodness of fit between the person, the occupation, (e.g., using verbal instructions in conjunction with
and the environment. If all three domains are checklists, colour coding for importance), regular
successfully achieved, the individual will be able feedback and support. Additionally, it is equally
to attain maximum job performance. Important to imperative that these accommodations should not
note is that this should be seen as universal for all be disabling for anyone else in the workplace.
employees and not just for those with ADHD. Linda concluded that when you achieve the
THE PERSONAL DOMAIN right fit with the person, the occupational and
In terms of the person domain, it is important the environment domains, the outcomes will be
to ensure that individuals receive an accurate improved performance, job satisfaction, happiness
diagnosis and identify where their challenges are. and overall wellness. She emphasised that ADHD in
The aim of the accommodations is to empower and the workplace does not have to be a disability and
facilitate self-management. A person with ADHD that employers should also be aware of the ways
may need to have their routines and environments in which the person can be a valuable asset to a
modified to match their unique characteristics. workplace and a team. When considering whether
Linda advises that employers monitor functioning ADHD should be considered a disability in the
in workplace and ask the individual regularly workplace, Linda advised that it should ultimately
about their performance in workplace. However, if be the employees’ decision to disclose if they feel
difficulties persist, then the person should be referred they require the accommodations.
Claire Tobin is a Psychometrist in Independent Practice (Oude Westhof Medical Suites, Oude Westhof, Cape Town).
Correspondence: [email protected]
38 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
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References: 1. Sandoz SA (Pty) Ltd. Data on file. Pricing data. September 2021. 2. About us. Sandoz. Accessed September 7, 2021. https://www.sandoz.com/about-us/who-we-are/innovation-quality-and-supply. 3. Sandoz SA (Pty) Ltd. MEFEDINEL™. Professional
information. February 22, 2021. 4. Sandoz SA (Pty) Ltd. ATASTRAT®. Professional information. April 28, 2021. 5. About us. Sandoz. Accessed September 7, 2021. https://www.sandoz.com/about-us/who-we-are. 6. Sandoz SA (Pty) Ltd. Data on file. TPMIMS data. January
2021. 7. Schapperer E, Daumann H, Lamouche S, et al. Bioequivalence of Sandoz methylphenidate osmotic-controlled release tablet with Concerta® (Janssen-Cilag). Pharma Res Per. 2015;3(1), e00072:1-8. 8. Guideline to the scheduling of medicines. South African Health
Products Regulatory Authority. November 6, 2019.
MEFEDINEL™ 18 (prolonged release tablets). Reg. No.: 48/1.2/0092. Composition: Each MEFEDINEL™ 18 (prolonged release tablet) contains 18 mg methylphenidate hydrochloride. MEFEDINEL™ 27 (prolonged release tablets). Reg. No.: 48/1.2/0093. Composition:
Each MEFEDINEL™ 27 (prolonged release tablet) contains 27 mg methylphenidate hydrochloride. MEFEDINEL™ 36 (prolonged release tablets). Reg. No.: 48/1.2/0094. Composition: Each MEFEDINEL™ 36 (prolonged release tablet) contains 36 mg methylphenidate
hydrochloride. MEFEDINEL™ 54 (prolonged release tablets). Reg. No.: 48/1.2/0095. Composition: Each MEFEDINEL™ 54 (prolonged release tablet) contains 54 mg methylphenidate hydrochloride. Pharmacotherapeutic group: centrally acting sympathomimetics. ATC Code:
N06BA04.
For full prescribing information refer to the Sandoz Professional Information approved by the South African Health Products Regulatory Authority.
ATASTRAT® 10 mg (hard capsules). Reg. No.: 52/1.2/0976. Composition: Each 10 mg hard capsule contains 11,428 mg atomoxetine hydrochloride equivalent to 10 mg atomoxetine. ATASTRAT® 18 mg (hard capsules). Reg. No.: 52/1.2/0977. Composition: Each 18 mg
hard capsule contains 20,570 mg atomoxetine hydrochloride equivalent to 18 mg atomoxetine. ATASTRAT® 25 mg (hard capsules). Reg. No.: 52/1.2/0978. Composition: Each 25 mg hard capsule contains 28,570 mg atomoxetine hydrochloride equivalent to 25 mg atomoxetine.
ATASTRAT® 40 mg (hard capsules). Reg. No.: 52/1.2/0979. Composition: Each 40 mg hard capsule contains 45,711 mg atomoxetine hydrochloride equivalent to 40 mg atomoxetine. ATASTRAT® 60 mg (hard capsules). Reg. No.: 52/1.2/0980. Composition: Each 60 mg
hard capsule contains 68,567 mg atomoxetine hydrochloride equivalent to 60 mg atomoxetine. ATASTRAT® 80 mg (hard capsules). Reg. No.: 52/1.2/0981. Composition: Each 80 mg hard capsule contains 91,422 mg atomoxetine hydrochloride equivalent to 80 mg atomoxetine.
Pharmacotherapeutic group: Psychoanaleptics, centrally acting sympathomimetics. ATC Code: N06BA09.
For full prescribing information refer to the Sandoz Professional Information approved by the South African Health Products Regulatory Authority.
Sandoz SA (Pty) Ltd, Reg. No. 1990/001979/07. Waterfall 5-lr, Magwa Crescent West, Waterfall City, Jukskei View, Gauteng, 2090. Tel: +27 (11) 347 6600.
SANCAL Customer Call Centre: +27 (0)861 726 225 SAN.ATA.2021.09.02.
REPORT
NON-MEDICAL USE
OF STIMULANTS
PRESENTATION BY DR FRANCOIS ESTERHUIZEN
Renata Schoeman
D r Francois Esterhuizen is a child and We are living in a society that
adolescent psychiatrist, in private practice demands a lot from us, with
since 2004. He currently sees in-patients specifically increased pressure
at Akeso (Arcadia) and Denmar hospitals. on young people. While their
He also does session work at the Department of frontal lobes are not yet fully
Psychiatry at Steve Biko Hospital. developed, they are met with
unrealistic expectations in terms
DURING THIS PRESENTATION, DR ESTERHUIZEN of performance, appearance
PROVIDED AN OVERVIEW OF THE MORE and to have the perfect live
RECENT STUDIES OF NON-MEDICAL USE portrayed on social media. Very
OF STIMULANTS (NMUS) TO FACILITATE little research is available on NMUS
AN UNDERSTANDING OF THE PROFILE OF in the South African context and Renata Schoeman
YOUNG PEOPLE INVOLVED IN NMUS AND this presentation focussed primarily on research
THEIR MOTIVATION FOR DOING SO. conducted amongst American college students
(18 to 25 years).
An overview of some of the more recent studies of
NMUS will be provided. THE MAJORITY OF STUDIES ALSO FOCUSED
ON AMPHETAMINE USE.
DEFINITIONS OF TERMS THE PROFILE OF THE NMUS STUDENT
Non-medical use refers to the use of a prescribed The Monitoring the Future Study
medication in a manner that was not intended (www.monitoringthefuture.org) provides valuable
by the prescribing medical professional or using information about the profile of NMUS adolescents.
it without a prescription. Diversion refers to the This is an ongoing study of the behaviours,
action of distributing medication prescribed to one attitudes, and values of Americans from
individual, by this individual, to another. adolescence through adulthood regarding use
of illicit drugs and NMU of prescribed medication.
INTRODUCTION Each year, a total of approximately 50 000 8th,
10th and 12th grade students are surveyed (12th
The effect of stimulants (methylphenidate and graders since 1975, and 8th and 10th graders
amphetamines) extends far beyond concentration, since 1991). McCabe (2013) investigated the
reducing hyperactivity and impulsivity. lifetime prevalence of medical and non-medical
use of stimulants in adolescents and assessed
IT ALSO CAN PROVIDE WAKEFULNESS Substance Use Behaviours (SUB) in relation to
AND ALTER ATTENTION, ELEVATE MOOD medical and NMUS respectively. A representative
AND INCREASE OPTIMISM, REDUCE sample of 4 572 individuals (mean age of 18
APPETITE, AND PRODUCE PLEASURE. years) completed a self administrated paper and
pencil questionnaire.
40 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
REPORT
ONE IN SIX HIGH SCHOOL STUDENTS benefits (getting high, enhanced wakefulness
HAD EXPOSURE TO STIMULANTS IN SOME to party longer and increased sociability). Ford
WAY. et al (2014) also conducted research to examine
whether measures associated with Aker’s social
In this study group, 9.5% of participants participated learning are related to NMUS for academic
in the medical use of stimulants, while 9.5% reasons. An anonymous pen and paper survey was
participated in non-medical use (84.6% were non- conducted amongst 549 undergraduate students
users). Of the 9.5% of medical users, 59.3% only used from a public university. Participants were asked
the stimulants as prescribed, while in 22.9% the how many friends engaged in NMUS, whether it is
medical use became non-medical use. Only 17.8% acceptable for students to engage in NMUS and
engaged in NMUS prior to medical use. NMUS were whether a stimulant is an effective study aid.
seen more in higher grades (more in 12th and 10th
than 8th grade). This study highlights that substance FINDINGS WERE SUPPORTIVE OF THE
use behaviour is the same amongst non-users and SOCIAL LEARNING MODEL: STUDENTS
medical users of stimulants. SUPPORTED NMUS, THEY BELIEVED THAT
Ford et al (2016) used data from the 2013 National STIMULANTS ARE AN EFFECTIVE STUDY
Survey on Drug Use and Health. The purpose of their AID, AND THEY WERE AT HIGHER RISK
study was to compare college students and their FOR NMUS IF FRIENDS WERE ENGAGING
non-college peers in terms of NMUS. A total of 18 IN NMUS.
142 respondents (18 to 25 years) participated in the
study. IS NMUS EFFECTIVE FOR COGNITIVE
ENHANCEMENT?
THE ODDS OF NMUS WERE INCREASED Cognition can be defined as the mental process by
FOR FULL-TIME AND PART-TIME STUDENTS, which humans acquire, understand and interpret
BEING UNMARRIED, ENGAGING IN knowledge they are exposed to. There is some
HEAVY DRINKING, MARIJUANA OR OTHER evidence for enhanced declarative memory, as
DRUG USE, AND BEING CAUCASIAN. well as consolidation of memory, but the effect
on executive functions (e.g., working memory and
These findings were affirmed by Messina et al (2014) cognitive control) is not clear (Smith and Farah,
in a sample of 1016 university students. Once again, 2011).
alcohol and other substance misuse were elevated
in the NMUS group. THERE IS ALSO AN INVERTED U CURVE
OF NEUROTRANSMITTER ENHANCEMENT
IT IS INTERESTING TO NOTE THAT THE ON COGNITIVE FUNCTIONING: TOO
COMMON DENOMINATOR IN THE MUCH OR TOO LITTLE DOPAMINE WILL
STUDIES WERE PERSONALITY TRAITS OF LEAD TO DECREASE IN COGNITIVE
IMPULSIVITY AND SENSATION-SEEKING, FUNCTIONING.
AS WELL AS PERFECTIONISM.
Cropsey et al (2006) used a balanced placebo
The students engaging in NMUS also had higher design study to evaluate expectation related to
rates of inattention and hyperactivity – which could medication effects vs medication’s real effects. They
indicate undiagnosed ADHD. Another interesting conducted a 4-week study in which participants
finding is the inverse correlation between grade were exposed to four scenarios: receiving placebo
point average and NMUS. and told it is placebo, receiving placebo and
In another study by Mcabe et al (2012), the past told it is medication, receiving medication and
year prevalence of NMUS was 7.2% with the main told it is placebo, and receiving medication and
motives for engaging in NMUS being weight loss told it is medication. Participants either received
and enhanced energy, staying awake or getting Adderall 10mg or placebo, followed by a two-hour
high, experimentation and affect regulation. neurocognitive assessment. Regardless of whether
However, other surveys (e.g., Weyland et al, 2013 participants received placebo or medication,
and Lakhan et al, 2012) indicated that enhanced participants who believed they received
focus and concentration was a motivating factor, medication rated their performance better and
although most motives for use related to social had improved actual test performance. However,
with medication the real improvements were small
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 41
REPORT
and specific to attention and long-term memory, IMPROVEMENTS IN COGNITION IN
but not to complex tasks. It was also demonstrated INDIVIDUALS WITH ADHD MUST BE SEEN
that the placebo effect accounted for the improved THROUGH THE LENS OF NORMALISATION
cognitive performance. AND NOT ENHANCEMENT.
In an online survey of 40 undergraduate students,
Ilieva IP et al (2013) examined the stimulant use While lesser cortical thinning, as well as
effect on specific cognitive and non-cognitive normalization of cerebral blood flow, in treated
motivational functions. See figures 1 and 2. versus untreated patients with ADHD have been
described, the effect of long-term use on the non-
Participants experienced overall enhancement ADHD brain is not known.
of both cognitive and motivational functions. The potential perceived benefits need to be
However, the enhancement effect was stronger in balanced with the potential risks of NMUS.
the motivational category. Although the benefits
on attention rated numerically higher, there were SIDE-EFFECTS OF USE INCLUDE HEADACHE,
no significant differences between attentional STOMACHACHE, IRRITABILITY, DYSPHORIA,
benefits, energy, alertness, and motivation. APPETITE SUPPRESSION, INSOMNIA, AND
DIZZINESS.
Clinically significant side-effects (moderate
with pronounced symptoms, or major with life-
threatening symptoms) have been reported in 35%
of NMUS in adolescents. The Drug Abuse Warning
Network (DAWN) reported an increase in NMUS
ER visits from 5212 (2005) to 15585 (2010), and an
increase in adolescent poison control calls from
30% (1998) to 43% (2005). This places substantial
burden on health care facilities.
WHAT MEASURES SHOULD WE IMPLEMENT TO
REDUCE NMUS? (Faraone et al, 2020)
1. Know the profile: adults 18 to 25 years of age,
university students (especially medical students
and those staying in a hostel), higher level
students (12th vs 8th grade), Caucasian, male,
academic difficulties, history of substance use
disorders, more ADHD symptoms being present
(cannot rule out malingering) and the presence
of eating disorders
2. Know your patient (and family): dynamics in
family and pressure to perform, family history of
ADHD and substance dependence and -abuse
3. Discuss and educate scholars and students
on diversion. Do they feel pressure to share
their medication? Challenge their unrealistic
expectations of performance enhancement. If
in hostels, lock medication away.
4. Prescribing long-acting stimulants or non-
stimulants, rather than short-acting formulations
Renata Schoeman is a psychiatrist in private practice; Associate Professor, Leadership, University of Stellenbosch Business
School. Correspondence: [email protected]
42 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
REPORT
ADHD
AND EDUCATION
Tawni Voges
T he role of educators and the educational portion of special schools into
environment for children with ADHD is resource centres. These resource
incredibly important. While medical centres, together with inclusive
professionals and parents can support education outreach teams,
children both medically and at home, a child provide additional support for
will spend a large portion of their time at school children in both ordinary and full-
and in the classroom. Within this setting, ADHD service schools.
can potentially negatively impact functioning
academically, socially and emotionally leading Prior to the implementation of
to poor school outcomes, low self-esteem, lack of inclusive education, children with
confidence and difficulties maintaining friendships. additional learning needs were
Four speakers with varied experience in education, accommodated at schools which Tawni Voges
psychology and occupational therapy explored
pertinent topics and provided guidance on catered to their needs. For example, children with
supporting children with ADHD in an educational ADHD would attend a school for specific learning
setting. disabilities, while a child with a physical disability
INCLUSIVE VERSUS SPECIALISED EDUCATION would attend a school equipped to support
FOR PUPILS WITH LEARNING DISORDERS physical barriers to learning.
Ms Berenice Daniels, Director of Inclusive and
Specialised Education Support for the Western HOWEVER, WITH THE ADVENT OF
Cape Educational Department presented a INCLUSIVE EDUCATION THE DEPARTMENT
discussion on inclusive education versus specialised OF BASIC EDUCATION HAS UNDERTAKEN
education for pupils with learning disorders. TO STEP AWAY FROM THIS SEGREGATED
Inclusive education has been an area of focus MODEL OF EDUCATION IN ORDER TO
for the Department of Education since 2001, and PROMOTE SOCIAL INCLUSION.
refers to the implementation of education systems
and learning methodologies which acknowledge The policies of inclusive education outline that
and support a broad range of learning needs children who require low-intensity support will
(Department of Education, 2001). attend ordinary schools, children with moderate
support needs will attend full-service schools, and
THE IMPLEMENTATION OF INCLUSIVE those with high-intensity needs will attend special
EDUCATION HAS TAKEN PLACE OVER educational needs schools. A full-service school
VARIOUS PHASES. BETWEEN 2001 AND is a school which is equipped and supported
2006, AUDITS AND ADVOCACY WERE by district support teams in order to cater for the
THE PRIMARY FOCUS. full range of learning needs. It is estimated that
80% of learners will have their needs met in their
Field testing and conversion of existing services into current schools, where they will be supported by
suitable infrastructure was conducted between their teachers through differentiated learning. Ms
2007 and 2009. Conversion involved transforming Daniels highlighted that teachers have received
ordinary schools into full-service schools, and a training in order to equip them to adapt their
teaching methods and classrooms so as to be able
to support children with varied learning needs. This
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 43
REPORT
includes differentiating learning material, methods persistence, commitment, coordination, support,
of presentation, learning activities and organisation monitoring, evaluation, follow-up and leadership”.
of lessons. In order to ensure that educators are Ms Daniels indicated that while considerable
prepared for inclusive education, a project, funded progress has been made, the goals set out in
by the European Union, “Teaching for All” has been 2001 have not yet all been achieved. This year,
implemented in South Africa. Here, the Department 2021, marks the 20th year since the implementation
of Basic Education have collaborated with various of inclusive education and review is scheduled
stakeholders to produce training material for to take place, which will create the opportunity
educators in pre-service training which focuses on to look at what has been accomplished, and
inclusive education practices. assess whether enough resources and services
Outside of the 80% of learners mentioned above, have been put in place to fully support children
15% will remain in their current schools but will with special education needs within an inclusive
receive additional support through the School education framework. Over the past 20 years, what
Based Support Team (SBST) and District Based has become evident, reported Ms Daniels, is that
Support Team (DBST). This may include extra while the Department of Education acts as the
support outside of the normal class time, or support lead agency in addressing school-level barriers
from the DBST and inclusive education outreach to learning, that they are unable to do so alone.
teams. The final 5% of children are those with high There is a need for a learner-centred, multisectoral
intensity needs who will attend special educational approach to care and support. The Department of
needs schools, or who receive individual support Education therefore has the responsibility to create
such as psychological or social work intervention, an enabling environment for multiple stakeholders
provided by the Provincial Based Support Team including teachers, school management, parents
(PBST). and families, local government, Departments of
Health, Transport, Justice, Agriculture and Social
IN ORDER TO IDENTIFY THE CHILDREN Development, as well as the South African Police
WHO REQUIRE ADDITIONAL SUPPORT, THE Service (amongst others) to act in and through
POLICY ON SCREENING, IDENTIFICATION, schools to support learners holistically.
ASSESSMENT AND SUPPORT (SIAS) WAS In closing, Ms Daniels reflected on the fact that
IMPLEMENTED IN 2014. support needs for children with ADHD, have flown
“under the radar” at times, due to the fact that it
This policy provides standardised procedures to is not always as visible as many other learning
screen and identify barriers to learning, assess the barriers. However, she offered her reassurance that
learners support needs and provide the necessary identification and support of learners with ADHD
support in order for learners to achieve to the best is receiving attention through the Department of
of their ability. Ms Daniels explained that this is Education, and the needs of those learners do not
where Goldilocks and The Bear Foundation (www. go unnoticed.
gb4adhd.co.za) has provided support to the REFERENCE:
Western Cape Education Department, through
providing free screening services in schools. Ms Department of Education. (2001). Education
Daniels acknowledged that educators require on- White Paper 6: Special needs education -
going support and training regarding screening and building an inclusive education and training
identification of learning barriers. The assessment system). Retrieved from http://www.education.
of support needs is conducted by the DBST. Once g o v. z a/L i n k C l i c k .a s p x ? f i l e t i c ke t = gV F c c Z L i/
these needs have been assessed, the provision of tI=&tabid=191&mid=484
support is tasked to many different stakeholders ADHD / AUTISM: THE OVERLAP AND
including community-based organisations, DIFFERENTIATING FEATURES
non-profit organisation or professionals in the Dr Merryn Young is a child and adolescent
Department of Health. psychiatrist who works full-time in private. She
previously worked at Valkenberg Hospital where she
MS DANIELS HIGHLIGHTED THE NEED TO assessed criminal capacity. Dr Young began her
FOCUS ON CREATING COLLABORATIVE presentation by expressing her excitement at being
WORKING RELATIONSHIPS BETWEEN able to zoom-in on the overlap and differentiating
THESE STAKEHOLDERS IN ORDER TO features of ADHD and Autism Spectrum Disorder
TACKLE THE MAMMOTH TASK OF (ASD).
SUPPORTING MANY CHILDREN WITH The overlap
ADDITIONAL LEARNING NEEDS. In differentiating between ASD and ADHD, the
initial hurdle, Dr Young explained is the overlap
In reflecting on the process of implementing inclusive between the conditions. Both ASD and ADHD are
education in South Africa, Ms Daniels quoted the neurodevelopmental conditions which appear
late Professor Kader Asmal, saying “I acknowledge in childhood. Furthermore, they share various risk
that budling an inclusive education and training factors such as complicated pregnancy and birth,
system will not be easy. What will be required is
44 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
REPORT
low birth weight, premature birth and low APGAR Differentiating features
scores. In addition, many of the early signs of both In making a diagnosis of ADHD according to
conditions are the same, such as difficulty with the DSM-5, one needs to display six out of nine
self-regulating (including excessive crying, being symptoms of inattention or six out of nine symptoms
easily upset or overstimulated, delayed motor and of hyperactivity and impulsivity to be diagnosed
language development), challenging and defiant with either sub-type. Symptoms of both these
behaviour, struggling with social interactions subtypes need to be evident to make a diagnosis of
and heightened sensory responses. Interestingly, ADHD-Combined subtype. This creates a situation
diagnosing a child with both ASD and ADHD has where a large number of possible combinations
only been permissible since the advent of the DSM-5 of symptoms are possible. To highlight this point,
in 2013. Since then, clinicians have become aware Dr Young referenced Silk et al who used a network
of a significant overlap in these conditions. Dr Young analysis approach to ADHD and calculated
explained that 30-80% of children with ASD also an incredible 116 220 possible combination of
meet the diagnostic criteria for ADHD, while 20-50% symptoms in ADHD.
of children with ADHD also meet the criteria for ASD. Dr Young explained that in ASD, the presentation
of behaviours and symptoms tend to be even
INDIVIDUALS WITH DUAL-DIAGNOSES ARE more diverse across individuals. This is highlighted
LIKELY TO HAVE GREATER IMPAIRMENT. by the name of the condition, Autism Spectrum
RESEARCHERS AND SCIENTISTS HAVE Disorder, which indicates that autism has wide and
BEGUN EXPLORING WHETHER THIS varied presentations which fall on a spectrum. For
MARKED OVERLAP MAY BE DUE TO example, in order to make a diagnosis of ASD, three
SHARED BIOLOGICAL ROOTS. symptoms of deficits of social communication and
social interaction across multiple contexts. These
However, genetic and imaging studies have yielded refer to deficits in social-emotional reciprocity,
a confusing mix of both similarities and differences. deficits in nonverbal communication behaviours
Being able to tease out the two diagnoses is used in social interaction and deficiency in
important because the treatment plan for a child developing, maintaining and understanding
with predominately ASD may be different to that relationships. These types of deficits can present
of someone with predominately ADHD. Dr Young in numerous ways, highlighting the heterogeneity
emphasised the importance of early intervention, of the condition. To emphasise the difficulty in
explaining that intervening while the brain is still identifying the subtle differences between ASD and
developing enables us to leverage neuroplasticity ADHD, Dr Young compared the symptom of “deficits
which creates the opportunity to make a significant in developing, maintaining and understanding
impact. relationships” in a child with ASD, with the impulsive
Heterogeneity behaviour of child with ADHD who finds it very
The second difficulty in diagnosis and managing ASD challenging to inhibit their behaviour in order
and ADHD, is heterogeneity - the quality or state of to meet the expected “socially acceptable”
being diverse in character or content. To demonstrate requirements of a specific situation.
heterogeneity in ADHD and ASD, Dr Young presented a
compelling metaphor: the lemon and lime dilemma. WHILE A CHILD WITH ASD MAY FIND
This is a metaphor she often presents to parents in her IT CHALLENGING TO MAKE FRIENDS
practice. The metaphor is as follows: we all feel as if AND MAINTAIN RELATIONSHIPS DUE
we’d intuitively be able to differentiate a lemon from a TO THEIR LACK OF UNDERSTANDING
lime. However, there are many varietals of lemons that RELATIONSHIPS, A CHILD WITH ADHD
look like limes, and many limes which on the surface, MAY FIND IT DIFFICULT TO SHARE AND
look like lemons. In this instance, heterogeneity takes TAKE TURNS DUE TO IMPULSIVITY, OR BE
the form of varietals of both fruit. Similarly, in clinical EMOTIONALLY DYSREGULATED, LEADING
work, practitioners may feel that they could intuitively TO DIFFICULTY WITH PEERS.
recognise the difference between an individual with
ADHD or ASD. In these examples the underlying cause for
the difficulty in relationships is different, but the
HOWEVER, THE “VARIETALS” IN ASD impairment may look very similar to a parent or
AND ADHD MEAN THAT DIFFERENT clinician.
INDIVIDUALS PRESENT IN DIFFERENT According to Dr Young, one of the key features of
WAYS IN DIFFERENT PHASES OF LIFE. ASD which may aid is differentiating it from ADHD,
is the diagnostic criteria of restricted, repetitive
Even within one of the conditions, the presenting patterns of behaviour, interests or activities. To make
symptoms may look very different in different a diagnosis of ASD, two of the following symptoms
people. For example, in a family where multiple need to be present: a) stereotyped or repetitive
siblings have the same diagnosis of ADHD, the way motor movements, use of objects or speech such
this manifests and/or impairs functioning can be as echolalia or stimming, b) insistence of sameness,
very diverse.
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 45
REPORT
inflexible adherence to routines and ritualised Finally, remember that the label does not change
patterns, c) highly restricted, fixated interests that the individual’s traits. While providing an official
are abnormal in intensity or focus and d) hypo or diagnosis and label is helpful is acquiring medical
hyper-reactivity to sensory input such as sounds, services or concessions at school for example, in
light and textures. essence, the label does not change the individual’s
experiences. Our primary focus, as healthcare
In addressing how we tackle the lemons and limes professionals should be identifying each patient’s
dilemma in ASD and ADHD, Dr Young provided the unique strengths and challenges, and using those
following suggestions: to guide our interventions in order for them to
• Remembering that there are distinct diagnostic flourish.
REFERENCE:
criteria and take time to explore the core
difficulties which the patient is presenting with. Silk, T.J., Malpas, C.B., Beare, R., Efron, D.,
• Be mindful whether their primary impairments are Anderson, V., Hazell, P., … & Sciberras, E.
related to social communications and restricted (2019). A network analysis approach to ADHD
and repetitive behaviour (ASD) or inattention, symptoms: More than the sum of its parts. PLoS
hyperactivity and impulsivity (ADHD). One, 14(1), e2011053. https://doi.org/10.1371/
• Get more information from different sources journal.pone.0211053
such as teachers, parents and any additional CLASSROOM TIPS FOR EDUCATORS RELATING
healthcare professionals who are involved in the TO ADHD
case. Ms Elize Janse van Rensburg is an occupational
• Information can be collected using rating therapist with a special interest in sensory
scales, self-reporting by the patient and integration, paediatric occupational therapy and
objective assessments. Objective assessments neurodevelopment. She is also the co-founder of
could include school observations, semi- ‘Built to Bloom’ which is a company that provides
structured interviews or standard screenings equipment and training to occupational therapists.
such as the Autism Diagnostic Observation Ms Janse van Rensburg opened her presentation
Schedule (ADOS) or the Diagnostic Interview acknowledging that the reality of classroom
for Social Communication Disorders (DISCO) environments is that it is often very challenging to
for ASD. apply individual strategies to support a specific
• Clinical experience of working with individuals child with additional learning or behavioural needs.
with these diagnoses can aid in identifying
the lemons and limes. If you’re unsure, refer to SHE EMPHASISED THAT IN IMPLEMENTING
a more experienced colleague or consult for a CLASSROOM STRATEGIES, IT IS VITAL TO
second opinion. REMEMBER THAT “ONE SIZE DOES NOT FIT
• Explore the fundamental motivation for a certain ALL”, AND THAT DIFFERENT APPROACHES
behaviour. This relates not only to the actual WILL WORK FOR DIFFERENT TEACHERS
diagnosis, but also social and environment AND LEARNERS.
factors which may be playing a role. For
example, parental conflict at home or bullying While words used to described children with
at school ADHD, such as ‘reluctant’, ‘defiant’, ‘intrusive’,
‘dysregulated’ or ‘impulsive’ can serve a useful
The significant take-aways from Dr Young’s purpose in accessing medical services because
presentation are: there are major overlaps in ASD they paint a realistic picture of the impairments
and ADHD, and that in some cases, it will take and challenges that these patients face, Ms
extra effort, investigation and input to discern the Janse van Rensburg, suggests that sometimes a
presence of either condition, or to decide that it is different perspective is necessary. She highlighted
a case with both lemons and limes in the bowl, and for example, that someone who is impulsive, could
that the individual has co-morbid ADHD and ASD. also be viewed as energetic, spontaneous, driven
However, the core symptoms of these diagnoses or inquisitive. By taking this different view of ADHD,
remain in place and these should be used in we can approach these children differently and
diagnosis and treatment planning. In addition, remain mindful of the messages that children are
this is not a process that should be rushed. receiving. It is important to steer away from feedback
which makes children feel ‘bad’ or ‘disobedient’
IT IS NOT NECESSARY TO COME or ‘disruptive’ and focus on the strengths of ADHD
TO A DEFINITIVE DIAGNOSIS IN THE such as creativity or good problem-solving abilities
FIRST SESSION. AS A CLINICIAN, YOU in the classroom environment.
SHOULD SET PARENTAL AND SCHOOL In highlighting the different messages that children
EXPECTATIONS, AND ENSURE THAT THE with and without ADHD receive, Ms Janse van
ROLE-PLAYERS ARE AWARE THAT THIS IS A Rensburg shared a powerful YouTube clip (which
JOURNEY AND THAT THE ANSWERS WILL
BE DISCOVERED OVER TIME.
46 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
REPORT
can be accessed here: https://www.youtube. in the classroom, or conversely be acutely aware
com/watch?v=-IO6zqIm88s) where two children and shameful of their behaviours but unable to
were asked the same questions. The little girl, disinhibit the behaviour due to impulsivity. By
who is diagnosed with ADHD expressed feelings taking this view, we can also re-think behaviour
of uncertainty, feeling bad about herself and low management systems used in classrooms to be
self-esteem. In contrast, the little boy, who does not more inclusive. Ms Janse van Rensburg reflected on
have ADHD was confident and self-assured. This anecdotes from parents of children with ADHD who
video highlights the need for parents, teachers and shared that their children were often discouraged or
healthcare professionals to adapt their responses disadvantaged by the behavioural systems which
to children with ADHD in order to protect their were employed. For example, rewarding positive
confidence, self-esteem and emotional well-being. classroom behaviours such as finishing tasks may
The question, “how do we change the messages be a valuable incentive for a neurotypical child,
that children receive and the perceptions they but for someone with ADHD, this may actually be
have of themselves” is what Ms Janse van Rensberg physically unattainable, and thus reinforce the “I
aimed to answer in her presentation, specifically in am not good enough” narrative. Similarly, when
the classroom setting. The first premise, which she children are punished by having breaktime or
feels is important, was highlighted in this quote from fun activities taken away, their emotional, social,
Dr Ross Greene “Kids do well if they can. And if they sensory and physical needs are not met and this
can’t, it is our job as adults to figure out what is can lead to heightened disruptive behaviour.
getting in the way so we can help”. If we approach
children from this assumption, and try to identify WHAT TEACHERS SHOULD AIM FOR IS
the stressors, unmet needs and skills deficits which TO CONNECT BEFORE YOU CORRECT
are underlying their behaviour, we can change the WHICH MEANS HOLDING THE STUDENT
narrative from “won’t” to “can’t yet”. IN GENUINE POSITIVE REGARD AND
PROVIDING POSITIVE FEEDBACK AND
IN ADDITION TO THE CORE SYMPTOMS ENCOURAGEMENT AS OFTEN AS
OF ADHD INCLUDING INATTENTION, POSSIBLE.
FIDGETING AND IMPULSIVITY AND THE
DIFFICULTIES THEY POSE, IT IS IMPORTANT REGULATION
TO BE AWARE OF SENSORY PROCESSING By creating a safe space, a teacher can create an
AND EXECUTIVE FUNCTIONING DIFFERENCES environment where a child is sufficiently emotionally
WHICH POSE ADDITIONAL CHALLENGES regulated, allowing them to learn and participate.
IN A CLASSROOM. Ms Janse van Rensberg highlighted that regulation
in the classroom can be encouraged through
The first practical strategy to addressing these warm responsive relationships, a supportive
difficulties, is based on paediatric occupational environment, providing co-regulation and teaching
therapist Greg Santucci’s Model of Child self-regulation skills. Regulation can be enhanced
Engagement (MOCE). Ms Janse van Rensburg through the implementation of sensory strategies.
explained that this model can help teachers in Building these skills is beneficial not only to children
encouraging participation in classroom activities, who struggle with sensory processing or integration
and engagement with new learning materials. The difficulties (often apparent in children with ADHD)
model is based on the following principle: in order but for all learners in the classroom who need to
to a child to participate, the need to feel safe and be in a settled state of mind in order to process
regulated. information effectively.
BUILDING TRUST AND SAFETY Sensory strategies make use of all of our senses,
The foundation for engagement is building trust such as taste, touch and hearing. In providing
and safety in the classroom. This can be done by practical example of objects or strategies targeted
prioritising the relationships between the teacher at various senses, Ms Janse van Rensburg offered
and the child. the following suggestions, including options for
lower-resourced communities:
MANY CHILDREN EXPERIENCE SCHOOL
AS DISTRESSING, THEY FEEL PICKED ON Tactile strategies
AND AS THOUGH THEY ARE ALWAYS IN • Specifically designed fidget toys such as ‘Popits’,
TROUBLE.
‘Infinity Cubes’ and ‘Tangle Toys’
Thus, the first step in prioritising the relationship, is • Elastic bands
to reframe the child’s behaviour. This can be done • Prestik
by resisting the urge to view their behaviours as • Velcro attached to the underside of the desk
purposeful or as a personal attack on the teacher. • Top tip: tie fidgets to the table or chair so they
Ms Janse van Rensburg explained that children
may either be completely unaware of their impact don’t fall around or get lost or create situations
where the child needs to search for or fetch the
toy
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 47
REPORT
Vestibular (movement) child is in a state of mind where they are ready to
• Specially designed dynamic seating options learn and participate, explained Ms Janse van
• Changing the position the child is working in e.g. Rensburg. In order to enhance participation three
aspects need to be managed, namely, the child,
kneeling or lying on the mat the environment and the task. Strategies which
• Devise strategies with colleagues where a child can be useful in managing the needs of a child
with ADHD include, managing anxiety through
is able to get up and walk to another classroom adjusting pacing in teaching, making sure the goal
to deliver a “secret message”, and in doing so is achievable, creating structure and predictability,
get the necessary sensory stimulation while breaking tasks into smaller steps, reducing the
feeling valued and important (e.g. “the purple volume of homework, supporting regulation and
folder club” which recently went viral on social managing motivation.
media).
Proprioception and deep pressure MOTIVATION IS A KEY FACTOR FOR
• Weighted lap pads and vests CONCENTRATION, SPECIFICALLY FOR
• Weighted toys which hang around the neck CHILDREN WITH ADHD. EXPLAINING THE
• Weighted backpacks which can be carried RELEVANCE OF A TASK, PLAYING TO
to another classroom, much the same as the A CHILD’S INTERESTS, VARYING TASKS
suggested “purple folder club” above AND EXPECTATIONS CAN ALL ENHANCE
• Cleaning the white board CONCENTRATION.
• Top tip: weighted toys can be easily made by
removing the stuffing of any stuffed animal and Preparatory learning and predictability are
filled with maize or samp. additional helpful tools for children with ADHD. This
Sensory breaks may include offering a child a ‘sneak peek’ of the
• A quiet corner upcoming task and sending lesson plans home
• An opportunity to leave the classroom to to parents in advance. Ms Janse van Rensburg
regulate explained that preparatory learning is shown to
• Top tip: sensory breaks are specifically for increase the success of children with ADHD because
children who require reduced (rather than they may already know an answer (having seen the
additional) sensory input to regulate question before) and feel more confident to take
Oral -sensory part.
• Water in class
• Chewing gum (although controversial in many THE PHYSICAL CLASSROOM ENVIRONMENT
schooling environments) CAN ALSO INFLUENCE A CHILD’S ABILITY
Auditory TO CONCENTRATE AND PARTICIPATE.
• Being aware of the impact of the teacher’s voice
tone and volume Environmental factors which could be addressed
• Music include the temperature of the room, lighting,
• Noise-cancelling headphones for children with distractions such as movement and sounds, hunger
extreme sound sensitivity and thirst and the seating position in the classroom
Visual space (e.g., being seated away from an open door
• Less is usually more or a busy bookshelf).
• Doodling to help with task initiation In closing her presentation, Ms Janse van
Rensburg quoted a mother of a child with ADHD,
Self-monitoring can be helpful for all learners, saying “thank you to the teachers who have
and using metaphors can aid in applying this as taken the time to see the thoughtful boy that
a holistic classroom strategy. Metaphors create a lies behind the impulsivity, the kind heart behind
language for children to express their feelings of the busy and the calm within his wild”. She went
dysregulation. For example, using the metaphor on to reiterate the immense impact that an
of bucket where an empty bucket represents the educator with knowledge of ADHD who is willing
need for additional sensory stimulation, and an to find ways in which to support these children
overflowing bucket expresses the need for a sensory and look beyond the “negative” aspects of their
break or less stimulation. diagnosis, may positively impact a child’s entire
schooling experience and emotional and social
PARTICIPATION wellbeing.
Once trust and safety has been established, and SOCIAL SKILLS TRAINING FOR CHILDREN
regulation strategies and skills are in place, the WITH ADHD: BUILDING BRIDGES FOR SOCIAL
CONNECTION
The final presentation regarding education and
ADHD was presented by Ms Marelé Venter who is
an occupational therapist with 21 years of clinical
48 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
REPORT
experience. She currently working in private regulation, self-monitoring, self-regulation, planning
practice and is also the co-author of “Bully Busters” and follow through, and metacognition which often
which is an anti-bully programme. do not come naturally to children with ADHD.
Humans are social beings who value connectedness. Neuroscience research has shown that brain-
We live in a society which places importance on the based executive functioning skills deficits is what
social aspects of relationships. Unfortunately, many drives the challenging behaviour. In line with the
children with ADHD are perceived as “too loud”, previous presenter, Ms Venter echoed the idea
“rude”, “too rough”, or “weird”. Ms Venter explained that “if they could, they would”. That is to say, that
that by the age of seven or eight, children with ADHD socially challenging behaviour is a reflection of
are often out of sync and lag behind their peers in something a child cannot do because they lack
terms of social know-how. By this age neurotypical the necessary skills, as opposed to something they
children have developed the skills to interpret won’t do or purposefully choose not to do. Is it
social cues and modify their actions to meet with our job as parents, teachers, and professionals to
expected behaviours in various situations. However, investigate the “why?” behind the behaviour.
this remains challenging for children with ADHD. In To describe the social landscape for children
reflecting on her experience working with children with ADHD, together with the processes and skills
with ADHD, Ms Venter described that she often needed to be socially successful, Ms Venter invited
hears the heart-breaking question, “why will no the audience to join her on a imaginary cruise –
one play with me?”. In order support children in a journey to explore social connection in children
these circumstances, it is crucial is to explore the with ADHD.
stories that they are telling themselves, their inner In this nautical metaphor, the social landscape
monologue about their experiences. This is because which children need to navigate can be imaged
the stories we tell ourselves about ourselves shape as an ocean. The ocean has many ships and ports.
our behaviour. The brain is represented by a busy harbour which is
characterised by constantly changing conditions,
CHILDREN WHO ARE EXPERIENCING leading to either smooth sailing or stormy waters.
SOCIAL DIFFICULTIES MAY BEGIN TO Executive functioning is represented by the captain
TELL THEMSELVES “I’M FINE BY MYSELF”, of the ship and is a key aspect of social ability and
“I DON’T CARE IF I HAVE FRIENDS AT shapes the child’s view of themselves or others, in the
SCHOOL”, “SMART CHILDREN DON’T sea of social activity. Executive functioning includes
HAVE FRIENDS” AND “THEY ARE JUST focus and attention, remembering and learning
MEAN”. from past experiences, regulating emotion and
adapting to new situations. It is the Captain’s duty
In doing so, these children create their own to organise the tools that the child needs, as well
narrative about why others are treating them a as train them in the skills and behaviours necessary
certain way. This is a form of self-protection in to navigate the social waters. Furthermore, if the
order to avoid uncomfortable situations. Children captain is ineffective and is unable to co-ordinate
in these situations are also prone to feeling that the crew and activities on the ship, the ship will run
other children are deliberately trying to hurt. This aground.
interpretation of behaviour can subsequently Ms Venter explained that it is tempting to think that
interfere with the processes of forgiveness, making by changing the child’s external environment (what
amends and maintaining friendships. Children is happening on and around the ship) or giving
in these circumstances may also retaliate, walk them a “pass” on social behaviour challenges (i.e.
away or ruminate on negative experiences which make excuses for a captain’s poor leadership), that
exacerbates unhappiness and decreases socially they may outgrow this behaviour. Unfortunately, this
adaptable behaviour. Ms Venter explained a cycle is not the case. As parents, teacher and healthcare
where social exclusion leads to children being out professionals, we need to understand the brain-
of sync with their peers, which lessens their chances based behaviours which are underlying the social
of being socially included in the future. This leads challenges. If we neglect to do this, interventions
to a “play paradox”, where the children who most will have minimal impact on social functioning or
need positive social interaction and friendship are the trajectory of the ship.
constantly left out, and are not able to fill this need.
Just as exploring the stories which children tell IN ORDER TO ASSIST CHILDREN WITH
themselves is important, it is critical to investigate SOCIAL CHALLENGES, IT IS IMPORTANT TO
the story that we as healthcare professionals tell INVESTIGATE WHICH SOCIAL PATTERNS ARE
ourselves about the social behaviours of children LIMITING THEIR SOCIAL OPPORTUNITIES.
with ADHD. We may find ourselves thinking “he never
listens”, “she’s so bossy”, “he’s just quirky” or “she’s The frequency, intensity and duration of these
young, she’ll grow out of it”. However, it vital for us patterns will provide clues as to whether intervention
to take a deeper look at the underlying executive is necessary. Ms Venter provided examples of
functioning deficits and causes of the “difficult” these patterns may look like in children with under-
social behaviour. These executive functioning developed social skills. For example, a child who
include cognitive flexibility, attention, emotional
SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022 * 49
REPORT
is a “Space Invader” will struggle to understand Once we are aware of the skills and behaviours
personal space which leads to them routinely underlying social difficulties, it then becomes the
being intrusive and disruptive. Conversely, “The responsibility of the health professional, emotional
“Avoider” rarely participates in play because they coach, teacher or parent to look at the overall
really struggle to join into play or join a group. picture and teach children the core skills which they
Based on the identified patterns, and having need to not only survive, but to thrive. The core skills
evaluated at the frequency, duration and intensity include a child’s ability to manage emotions rather
of the behaviours, the question then becomes than letting them manage you, to read the room,
– how do we intervene and assist these children? to compromise, to understand social cues and
A proposed strategy, according to Ms Venter, is unspoken rules and be ready to change behaviour
to assist children in developing a bird’s eye view, in response to them, learning to walk in someone
referred to as meta-cognition. Meta-cognition is else’s shows and being empathetic, being flexible
the ability for someone to think about their thinking and adaptive and recognising their audience and
and thus boost social and self-awareness. Early adapting communication to be appropriate.
intervention is crucial building both social and self- In our role as social skills coaches, Ms Venter
awareness which lays the foundation for effective emphasised the importance of creating small
socialisation. In the pre-teen phase, children are manageable skills, which, practice and “mini-
experimenting with their identities and friendships wins” become the touchstone for the confidence
and social ties are more flexible. to try. In this role, we need to listen and respond
in a positive and predictable manner, with a
INTERVENTION AT THIS TIME IS problem-solving approach in order to leading
IMPORTANT, BEFORE ENTERING HIGH a child through the process of developing their
SCHOOL WHERE SOCIAL GROUPS problem-solving skills.
ARE LESS PERMEABLE AND OFTEN
CHARACTERISED BY CLIQUES. OUR AIM IS TO ENABLE CHILDREN TO
GAIN EXPERIENCE IN USING THE BRAIN-
In developing the bird's eye view approach, three BASED PROCESSES THAT DEVELOP
clusters of behaviours (which are components of SOCIAL AWARENESS, SELF-AWARENESS,
executive functioning) can be addressed, namely SOCIAL-REGULATION AND POSITIVE
reading social cues, setting social boundaries and SOCIAL BEHAVIOURS.
developing cognitive flexibility. These skills can
become the “buoys” that help keep children with Create an environment is which this can takes
social difficulties, afloat. Ms Venter explained these place, requires that the “grown-up” listens
cluster based on the description of the behaviour, reflectively and non-judgementally, encourage,
as well as the necessary skills needed to achieve model positive behaviour, set realistic goals and
behaviour. always be a child’s cheerleader by honouring their
In addition, both self-regulation and emotional self-discovery and celebrating every milestone, no
regulation play are important for successful social matter how small.
behaviour. Self-regulation, much like the compass While is it important to assess areas that need
for nautical navigation, helps an individual development, explained Ms Venter, it is equally
navigate stormy seas. Self-regulation requires the important to discover each child’s strengths and
ability to weigh options, calculate risks and benefits interests and processing style, and use this to
of a behaviour and change behaviour accordingly. build an individualised social-skills programme
Ms Venter emphasised, that self-regulation is not intervention.
about exercising more willpower, but is the capacity Ms Venter’s presentation was concluded with
to manage oneself and control impulses through the following thoughts: social skills represent the
better self-awareness, self-monitoring, self-calming bridges between people by offering us a safe,
and adaptive thinking. Emotional regulation refers sturdy and reliable way to connect. Many children
to the use of coping mechanisms to manage with ADHD struggle to build these bridges, and
emotions and behaviour in stormy waters. require an invested individual to provide them
with the tools and materials necessary to do so.
BIG DYSREGULATING EMOTIONS CAN Importantly, our primary focus shouldn’t only better
TRIGGER BEHAVIOURS THAT COMPLICATE social behaviour. We should strive to help children
SOCIAL INTERACTION SUCH AS re-write the narratives they have of themselves, and
AGGRESSIVE BEHAVIOUR OR SHUTTING in doing so re-route the ship to a destination where
DOWN. they feel connected and valued.
Tawni Voges is currently the Operations Manager at The Goldilocks and The Bear Foundation (www.gb4adhd.co,za), an
NGO/PBO that offers free ADHD and mental health screening in underprivileged communities in Cape Town. She recently
completed her Masters in Research Psychology at the University of Stellenbosch, where her focus was on how stigma
associated with ADHD creates barriers to accessing treatment. Correspondence: [email protected]
50 * SOUTH AFRICAN PSYCHIATRY ISSUE 30 2022
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