NEW ZOLNOREM 12,5 mg MR. Each modified release tablet contains 12,5 mg zolpidem tartrate. S5 A54/2.2/0178. For full prescribing information, refer to the professional information approved by SAHPRA, June 2023. 1) Kirkwood, C., et al 2007. Zolpidem modified-release in insomnia. Neuropsychiatric disease and treatment, 3(5), pp.521-526.ZMA935/01/2024 www.pharmadynamics.co.za CUSTOMER CARE LINE +27 21 707 7000 A suitable option for patients whose sleep is not maintained by immediate-release zolpidem¹ - Kirkwood et al.
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PUBLISHED IN ASSOCIATION WITH THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS ABOUT ABOUT the discipline the disciplineFORFOR the discipline the disciplineissue 38 • February 2024 ISSN 2409-5699 www.southafricanpsychiatry.co.za REPORTS FROM THE 4TH SOUTH AFRICAN MULTIDISCIPLINARY ADHD CONGRESS C O L L E G E O F PSYCHIATRISTS: UPDATE M A N A G I N G O N L I N E COMPLAINTS AND NEGATIVE REVIEWS 6TH AFRICAN DIASPORA GLOBAL MENTAL HEALTH CONFERENCE: REFLECTIONS
THAT FINAL PIECE HELP THEM TO UNLOCK Unlocking potential S6 CONTRAMYL XR 18 mg (Extended Release Tablets). Reg. No. 49/1.2/1137. Each extended release tablet contains 18 mg methylphenidate hydrochloride. Contains sugar (sucrose). S6 CONTRAMYL XR 27 mg (Extended Release Tablets). Reg. No. 49/1.2/1138. Each extended release tablet 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, 1601. Tel: (011) 451 1300. Fax: (011) 451 1400. www.viatris.co.za. MET-2023-0034 EXP: 04/2025 “ADHD SHOULD NOT BE A BARRIER TO REALISING MY POTENTIAL.”
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 5 NOTE: “instructions to authors” are available at www.southafricanpsychiatry.co.za Features 6TH AFRICAN DIASPORA GLOBAL MENTAL HEALTH CONFERENCE: REFLECTIONS 45 MANAGING ONLINE COMPLAINTS AND NEGATIVE REVIEWS COLLEGE OF PSYCHIATRISTS: UPDATE 51 53 REPORTS FROM THE 4TH SOUTH AFRICAN MULTIDISCIPLINARY ADHD CONGRESS 9 - 43
6 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 CONTENTSFEBRUARY 2024 * PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online. CONTENTS 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: Orange lilies on an orange background, bouquet by 'Illya' on AdobeStock Design and layout: The Source * Printers: Raptor Print 7 FROM THE EDITOR 9 4TH SOUTHERN AFRICAN MULTIDISCIPLINARY ADHD CONGRESS 13 OPENING SESSIONS 16 OCCUPATIONAL THERAPY AND ADHD 20 MEDICATION AND ADHD 22 ALTERNATIVE INTERVENTIONS FOR ADHD 23 PLAY AND THE SOCIAL BRAIN 24 EDUCATION AND ADHD 26 THE UTILITY AND ETHICS OF GENETIC TESTING IN ADHD 27 MARRYING THE DIMENSIONAL VERSUS THE CATEGORICAL APPROACH: ICF 28 GAMING ADDICTION IN ADHD: MANAGEMENT AND TREATMENT 29 ADHD AND SCREEN TIME – THE CHICKEN OR THE EGG 30 THE USE OF OUTCOME-BASED MEASURES FOR NEURODEVELOPMENTAL DISORDERS 32 GUT-BRAIN AXIS IN ADHD 33 IS IT ADHD OR EARLY COGNITIVE DECLINE? 34 CULTURALLY APPROPRIATE EVALUATION FOR ADHD 35 ADHD IN PRESCHOOL CHILDREN IN A LOW SOCIOECONOMIC SETTING 36 COMORBIDITY AND LIFESTYLE 38 PSYCHOSOCIAL INTERVENTIONS 42 NOT SO SMART? “SMART” DRUGS INCREASE THE LEVEL BUT DECREASE THE QUALITY OF COGNITIVE EFFORT 43 LET’S TALK ABOUT SEX IN ADHD 44 SASOP SPECIAL INTEREST GROUP FOR ADHD TRAIN THE TRAINEE WORKSHOP 45 REFLECTIONS ON THE 6TH AFRICAN DIASPORA GLOBAL MENTAL HEALTH CONFERENCE 48 DEPARTMENTS OF PSYCHIATRY NEWS 51 MEDICO LEGAL: MANAGING ONLINE COMPLAINTS AND NEGATIVE REVIEWS 53 COLLEGE OF PSYCHIATRISTS: UPDATE 55 OF TRUSTY BOOTS, FRAYED LACES, AND THE YEAR OF ‘NEW’ 57 HOW TO RESPOND AS A CLINICIAN TO THE PALESTINIAN-ISRAELI CONFLICT 59 WINE FORUM: A SWIGGY SOIREE 61 REVIEW: MOVIES FROM THE ARCHIVES A BEAUTIFUL MIND 62 MOVIES 64 SASOP
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 7 Dear Reader, Greetings and wishing all readers a prosperous and healthy 2024. As part of my new year clean out I decided to upgrade my photo – out with the old and in with the current reality…best to embrace change. In early January 2024 a research article appeared in the BMJ that should give all psychiatrists pause for thought. It reported on the extent of conflict of interests amongst those contributing to the compilation of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). Almost 60% of contributors had between them received over USD 14 million in various forms from the pharmaceutical industry (Davis et al, 2024; BMJ 2024;384:e076902). This is no way implicates the pharmaceutical industry in determining DSM-5 content, however that such conflicts of interest exist certainly raises questions around a potential influence shaping both the diagnostic and treatment landscape. To quote the authors of the study: “To ensure unbiased, evidence based mental health practice, it is important to prohibit industry influence in the Diagnostic and Statistical Manual of Mental Disorders." It would be interesting to find out what the figure is for the more recently published Mental, Behavioural or Neurodevelopmental Disorders (MBND) chapter in the International Classification of Diseases (ICD 11; World Health Organization, 2019). The current issue features Reports written predominantly, but not exclusively, by registrars from the various Departments of Psychiatry around the country who attended the 4th Southern African Multidisciplinary ADHD Congress held in August/September 2023. As always it is a pleasure to have our next generation of young professionals contribute, and a special thanks to Renata Schoeman for her efforts in facilitating and supporting the write ups (aside from convening the Congress). There are additional Reports on other events of interest to the discipline. Our regular features cover medico-legal issues (in relation to use and risks of social media) as well as content on the doctorpatient relationship, a personal view on the current conflict in the Middle East and not forgetting that all work and no play…is not good for the soul – a selection of wine and movies to consider and enjoy. In addition, as always, there is News from Departments of Psychiatry. Of specific relevance to Psychiatrists - there is important information related to members of the Council for the College of Psychiatrists (2023 – 2026) as well as a vision statement from the newly elected President (Prof. Carla Kotze) as well an introduction to the new Board of the South African Society of Psychiatrists (SASOP). We wish both Council and Board members well in undertaking their tasks. And, last but not least –an important update related to the Prescribed Minimum Benefit Definition Guideline for Schizophrenia (PsychMG/SASOP). Hopefully something for everyone. Enjoy. Until next time. FROM THE EDITOR Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading Design and Layout: Rigel Andreoli 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 "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 38 2024 For further product information contact PHARMA DYNAMICS Email [email protected] CUSTOMER CARE LINE +27 21 707 7000 www.pharmadynamics.co.za BRIVOR 5, 10, 20 mg. Each film coated tablet contains vortioxetine hydrobromide equivalent to 5, 10, 20 mg vortioxetine respectively. S5 A55/1.2/0105, 6, 7. DULTA 30, 60 mg. Each tablet contains 30, 60 mg duloxetine respectively. S5 A46/1.2/0889, 890. NAM NS3 18/1.2/0126, 0127. DYNA SERTRALINE 50, 100. Each tablet contains 50, 100 mg sertraline respectively. S5 A43/1.2/0339, 0340. NAM NS3 14/1.2/0627, 0628. EXLOV XR 50, 100 mg. Each extended-release tablet contains desvenlafaxine benzoate equivalent to 50, 100 mg desvenlafaxine respectively. S5 A51/1.2/0009, 0010. ILLOVEX XR 37,5, 75, 150, 225, 300 mg. Each extended release film coated tablet contains venlafaxine hydrochloride equivalent to 37,5, 75, 150, 225, 300 mg venlafaxine respectively. S5 A48/1.2/0910, 0911, 0912, 0913, A53/1.2/0467. PRODYNA 150, 300 mg XR. Each tablet contains 150, 300 mg bupropion hydrochloride respectively. S5 A54/1.2/0181,0182. SERRAPRESS 20 mg. Each tablet contains 20 mg paroxetine. S5 A38/1.2/0069. NAM NS3 08/1.2/0101. ZYTOMIL 10, 20 mg. Each film coated tablet contains 10, 20 mg escitalopram respectively. S5 A42/1.2/0912, 0914. NAM NS3 10/1.2/0479, 0481. For full prescribing information, refer to the professional information approved by SAHPRA. NSCRA941/02/2024 respectively. S5 A46/1.2/0889, 890. NAM NS3 18/1.2/0126, 0127. Each tablet contains 20 mg paroxetine. S5 A38/1.2/0069. NAM NS3 08/1.2/0101. Each tablet contains 50, 100 mg sertraline respectively. S5 A43/1.2/0339, 0340. NAM NS3 14/1.2/0627, 0628. tablet contains venlafaxine hydrochloride equivalent to 37,5, 75, 150, 225, 300 mg venlafaxine respectively. S5 A48/1.2/0910, 0911, 0912, 0913, A53/1.2/0467. Each extended-release tablet contains desvenlafaxine benzoate equivalent to 50, 100 mg desvenlafaxine respectively. S5 A51/1.2/0009, 0010. bupropion hydrochloride respectively. S5 A54/1.2/0181,0182. Each film coated tablet contains vortioxetine hydrobromide equivalent to 5, 10, 20 mg vortioxetine respectively. S5 A55/1.2/0105, 6, 7.
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 9 I t is estimated that 17% of children and adolescents face mental health challenges in low- and middle-income countries. Half of all mental health disorders develop before the age of 14. However, only 1% of all psychiatric services are dedicated to child and adolescent mental health. International studies estimate the prevalence of ADHD as five percent in school-aged children, with 65% of patients having symptoms that persist into adulthood. LACK OF AWARENESS OF ADHD AND OTHER MENTAL HEALTH DIFFICULTIES, OVERBURDENED HEALTHCARE SERVICES, AND THE STIGMA SURROUNDING MENTAL HEALTH, FURTHER IMPEDES THE EARLY IDENTIFICATION OF, AND INTERVENTION FOR ADHD AND COMORBID DISORDERS. The 4th Southern African Multidisciplinary ADHD Congress, held as a virtual event from 30th August to 2nd September 2023, succeeded in its aim to bring together psychiatrists, paediatricians, general practitioners, psychologists, and occupational therapists – the whole team involved with the optimal management of ADHD across the lifespan. 411 participants from 12 countries (South Africa, UK, USA, Australia, Canada, Namibia, the Netherlands, New Zealand, Ghana, Romania, Sweden, and Taiwan) from various healthcare professions, allied healthcare professions, as well as education, the media, and even individuals with lived experiences, participated in the congress. The congress was hosted by the University of Stellenbosch Business School, in partnership with the Goldilocks and the Bear Foundation. A wide variety of topics were covered and truly enhanced all participants’ knowledge of ADHD. A big word of appreciation to our platinum sponsors (Dr Reddy’s and Adcock Ingram), our silver sponsor (Viatris), and to Londocor for all their logistical assistance. We are looking forward to welcoming you to the 5th Southern Africa Multidisciplinary ADHD Congress, 4 to 7 September 2024! Renata Schoeman is the Head of Health Care Leadership MBA Associate Professor: Leadership Stellenbosch Business School. Correspondence: [email protected] ADHD CONGRESS 2023 Renata Schoeman SOUTHERN AFRICAN MULTIDISCIPLINARY ADHD CONGRESS 30TH AUGUST – 2ND SEPTEMBER 2023 4 Renata Schoeman TH
10 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 ADHD CONGRESS 2023 4TH SOUTHERN AFRICAN MULTIDISCIPLINARY ADHD CONGRESS PROGRAMME 14:00 - 16:10 SCIENTIFIC SESSION 1: 1st 1000 days Chair: Lesley Carew 14:00 - 14:10 Official Welcome and Opening 14:10 - 14:15 Introduction of speakers 14:15 - 14:50 The First 1000 days: considering early behavioural dysregulation in clinical settings 14:50 - 14:55 Q & A 14:55 - 15:30 Infant Mental Health: predictors of ADHD 15:30 - 15:35 Q & A 15:35 - 16:05 Prems/Low birth weight infants with hyperactivity 16:05 - 16:10 Q & A 16:10 - 16:35 Comfort Break / News from the sponsors 16:35 - 18:00 SCIENTIFIC SESSION 2: 1st 1000 days Chair: Kedi Motingoe 16:35 - 16:40 Introduction of speakers 16:40 - 17:15 Toddlers on the spectrum 17:15 - 17:20 Q & A 17:20 - 17:55 ADHD in Preschool children in a Low Socio-economic setting 17:55 - 18:00 Q & A 08:00 - 09:00 ACINO SWISS SYMPOSIUM Chair: Rochester Shen Introduction of speaker Rochester Shen Resilience in ADHD Jan Buitelaar (The Netherlands) 14:00 - 16:05 SCIENTIFIC SESSION 3: Education Chair: Gail Scher 14:00 - 14:05 Introduction of speakers Gail Scher 14:05 - 14:40 Inclusive education: the pros, the cons, and the law Jean Fourie 14:40 - 14:45 Q & A 14:45 - 15:20 Consessions: is it indicated for ADHD? Gina Rencken 15:20 - 15:25 Q & A 15:25 - 16:00 A success story: catering for neurodiverse children Henk Arangies 16:00 - 16:05 Q & A 16:05 - 16:30 Comfort Break / News from the sponsors 16:30 - 17:55 SCIENTIFIC SESSION 4: New developments Chair: Frans Korb 16:30 - 16:35 Introduction of speakers Frans Korb 16:35 - 17:10 Gaming addiction in ADHD: management and treatment Hugo Theron 17:10 - 17:15 Q & A 17:15 - 17:50 Marrying the dimensional versus categorical approach: Sven Bölte (Sweden) the ICF 17:50 - 17:55 Q & A WEDNESDAY 30 AUGUST 2023 THURSDAY 31 AUGUST 2023
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 11 ADHD CONGRESS 2023 08:00 - 09:00 PHARMA DYNAMICS SYMPOSIUM Chair: Eva Minkov Introduction of speaker Eva Minkov Tracto app: Empowering caregivers to support paediatric Karla Pretorius outcomes 14:00 - 16:05 SCIENTIFIC SESSION 5: Hot topics Chair: Sebo Seape 14:00 - 14:05 Introduction of speakers Sebo Seape 14:05 - 14:40 The brain-gut axis in ADHD Suntheren Pillay 14:40 - 14:45 Q & A 14:45 - 15:20 Is it ADHD or early cognitive decline? Jane Indergaard (USA) 15:20 - 15:25 Q & A 15:25 - 16:00 Culturally apropriate evaluations for ADHD Kwabena Kusi-Mensah (Ghana) 16:00 - 16:05 Q & A 16:05 - 16:30 Comfort Break / News from the sponsors 16:30 - 17:55 SCIENTIFIC SESSION 6: Psychopharmacology Chair: Suntheren Pillay 16:30 - 16:35 Introduction of speakers Suntheren Pillay 16:35 - 17:10 An update on Psychopharmacology for ADHD Greg Mattingly 17:10 - 17:15 Q & A 17:15 - 17:50 An update on drug interactions in ADHD Eric Decloedt 17:50 - 17:55 Q & A 08:30 - 09:30 DR REDDY'S SYMPOSIUM Chair: Kiolan Naidoo Introduction of speaker Kiolan Naidoo The role of combination therapy in ADHD - stimulant and Fanie Meyer non-stimulant 09:30 - 10:00 Comfort Break / News from the sponsors 10: 00 - 11:25 SCIENTIFIC SESSION 7: Hot topics Chair: Nerica Ramsundhar 10:00 - 10:05 Introduction of speakers Nerica Ramsundhar 10:05 - 10:40 Not so smart "smartdrugs" David Coghill (Australia) 10:40 - 10:45 Q & A 10:45 - 11:20 Let's talk about sex (in ADHD) Karen Vukovic 11:20 - 11:25 Q & A 11:25 - 12:00 Comfort Break / News from the sponsors 12:00 - 13:25 SCIENTIFIC SESSION 8: New developments Chair: Renata Schoeman 12:00 - 12:05 Introduction of speakers Renata Schoeman 12:05 - 12:40 The use of outcome based measures Stephen Faraone (USA) 12:40 - 12:45 Q & A 12:45 - 13:20 ADHD and screentime: the chicken or the egg Brendan Belsham 13:20 - 13:25 Q & A 13:25 - 14:00 Comfort Break / News from the sponsors 14:00 - 16:25 SCIENTIFIC SESSION 9: PARALLEL SESSIONS SESSION 9.1: Occupational therapy Chair: Gina Rencken FRIDAY 1 AUGUST 2023 SATURDAY 2 SEPTEMBER 2023
12 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 ADHD CONGRESS 2023 14:00 - 14:05 Introduction of speakers Gina Rencken 14:05 - 14:35 ADHD in infancy and toddlerhood - navigating early Emma Wijnberg intervention, developmental strenghts and challenges through sensory integraton and family intervention 14:35 - 15:05 Sensory integration in ADHD Riekert Swart 15:05 - 15:35 Praxis, executive functioning, and the school-aged child Elize Janse van Rensburg with ADHD 15:35 - 16:05 Navigating adult occupations: support and intervention Ray Anne Cook for people with ADHD 16:05 - 16:25 Discussion SESSION 9.2: Alternative interventions Chair: Jannie van der Westhuizen 14:00 - 14:05 Introduction of speakers Jannie van der Westhuizen 14:05 - 14:35 The "herbal" route: CAMs and ADHD Renata Schoeman 14:35 - 15:05 The "fungal" route: psilocybin and ADHD Lesley Carew 15:05 - 15:35 Play and the social brain in ADHD Adri van der Walt 15:35 - 16:05 Virtual reality therapy Anita MarinescuConstantin (UK) 16:05 - 16:25 Discussion SESSION 9.3: Exercise and diet Chair: Bonginkozi Mafuze 14:00 - 14:05 Introduction of speakers Bonginkosi Mafuze 14:05 - 14:35 Children with diabetes type 1 and the problems that arise Elizabeth Fernell (Sweden) when ADHD is not identified 14:35 - 15:05 Obesity and ADHD Andre Venter 15:05 - 15:35 Eating disorders, ADHD and diet Tanya Huber 15:35 - 16:05 Exercise in the management of ADHD James Burger 16:05 - 16:25 Discussion SESSION 9.4: Psychosocial interventions Chair: Anton Kruger 14:00 - 14:05 Introduction of speakers Anton Kruger 14:05 - 14:35 Coaching for ADHD Adela Baker (USA) 14:35 - 15:05 Parental support in ADHD Karla Pretorius 15:05 - 15:35 The influence of ADHD on relationships Melane van Zyl 15:35 - 16:05 Living with ADHD Margaux Joffe (USA) 16:05 - 16:25 Discussion 16:25 - 17:00 Comfort Break / News from the sponsors 17:00 - 19:00 SESSION 10 - ETHICS, PRIZES, ENTERTAINMENT and CLOSING Chair: Renata Schoeman 17:00 - 17:15 Goldilocks and The Bear Foundation Miché Moodley, Marguerette Osborne 17:15 - 18:00 The utility and ethics of genetic testing in ADHD Chris Verster 18:00 - 18:40 Entertainment - Trans Africa Safaris Jennifer Paterson 18:40 - 19:00 Prizes and Closing Renata Schoeman SATURDAY 2 SEPTEMBER 2023 (CONTINUED)
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 13 REPORT – ADHD CONGRESS 2023 O P E N I N G SESSIONS Janine Rodrigues OFFICIAL WELCOME & OPENING South Africa’s 4th multidisciplinary congress was opened by a representative of the Stellenbosch business school, Dr Armand Bam, (Head: Stellenbosch Business School Social Impact; Senior Lecturer (Business in Society) · Stellenbosch Business School) the proud hosts of this year’s exciting program. He acknowledged their awareness of thoseplaced at the margins of our society and their role as a business school in contributing towards breaking down the barriers of exclusion of these individuals through greater inclusion in teaching, research and learning domains. He closed with 3 thought provoking challenges posed to all listeners: 1. Are we innovating or imitating in ADHD management and research? 2. Is the pursuit of productivity harming individuals with ADHD in the business environment? With the growing demands for efficiency and multi tasking, are we excluding neurodiverse talents that individuals with ADHD may bring? 3. Are we as business schools addressing the right issues in ADHD research and business education? Are we tackling the route causes of challenges such stigma, workplace inflexibility and access to appropriate accommodations? INTRODUCTION OF SPEAKERS LESLEY CAREW IN INTRODUCING THE FIRST SPEAKER, LESLEY CAREW SHARED HOW THE FIRST 1000 DAYS WAS CONCEPTUALISED BY RENATA SCHOEMAN AND HAS BEEN AN IDEA THAT HAS BEEN DEVELOPING AND GROWING SINCE THE LAST ADHD CONGRESS CONCLUDED. With this in mind, it was fitting that the congress was kicked off by the passionate as well as highly qualified in the field, an international speaker from Florida, Mary Margaret Gleason. The focus of her talk was the 1st 1000 days, but more specifically from a clinical perspective where she shared that her drive for academia is based on the patients she sees daily with her focus on mental health promotion, prevention and early intervention to paediatric primary settings. THE FIRST 1000 DAYS: CONSIDERING EARLY BEHAVIOURAL DYSREGULATION IN CLINICAL SETTINGS PRESENTED BY MARY MARGARET GLEASON The aim of this talk was to cover aspects of behavioural dysregulation in ADHD including the differential diagnosis, relevant elements of its assessment in young children and the approach to formulating a treatment plan. The symptoms that a child comes in with, in this case behaviour dysregulation can be conceptualised in many different layers. This was depicted with an image which places the infant at the centre, surrounded by the various layers that need to be considered in assessment of a young child which include prenatal environment, parent-child relationship, family, caregiving support networks, childcare, health care and lastly community and employers. Factors related to the development of behavioural regulation from infancy to toddlerhood were considered. THE MOST IMPORTANT AREA THAT WE AS HEALTHCARE WORKERS CAN INFLUENCE IS THE CAREGIVING RELATIONSHIP. The importance of a caregiver’s emotional availability and ability to be sensitive, responsive and nurturing as well as to model calm responses and assist the young child in naming the emotional state is identified as an important factor in child learning to regulate their behaviour. An aspect which was emphasised as impacting on this ability of the caregiver, is the presence of perinatal depression in the caregiver. In considering the Janine Rodrigues
14 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 differential diagnosis of behavioural dysregulation, the notion of normal development needs to be considered. Other interesting considerations that may not always be front of mind include trauma or stress and adversity as well as physical pain, which the child may not be able to verbalise but all of which can manifest with behaviour dysregulation. The usual considerations include developmental conditions, mood or anxiety disorders and genetic conditions. Lastly the caregiver child relationship needs to be considered in understanding if the child’s emotional needs are being met so that they are able to organise their emotional responses appropriately. THE CONCEPT OF A MULTI-AXIAL APPROACH TO EARLY CHILDHOOD MENTAL HEALTH PROBLEMS WAS DISCUSSED AND THIS TIES IN WITH THE IDEA OF CONSIDERING YOUNG CHILDREN IN DIFFERENT LAYERS. Overactivity disorder of toddlerhood was also discussed. An important cconcept highlighted naming of the condition and the importance of this because by the time you give the child this ‘label’, they probably have many other more negative labels. Labelling the condition appropriately helps the child to access appropriate treatment instead of maintaining their previous attained labels of ‘the bad child’ or the ‘naughty child that no one likes’. Take home messages in terms of assessing these young children include the importance of delving into symptoms experienced in detail, identifying risk factors and to examine every child for features of non-accidental injury. Important in the assessment is observation of not only the child’s behaviour and its congruency with the caregiver description of the child but also the attachment behaviours which include whether the child seeks comfort from the caregiver in the room. Attachment can also be assessed by considering how the parent talks about the child in the room and understanding that this is the lens the parent sees the child and their behaviour through on a daily basis. Important aspects identified as part of the approach to supporting behavioural regulation rather than treating the problem and these aspects include reducing extreme adversity, keeping young children safe and supporting emotional regulation skills. With the first line treatment of ADHD in children under 6 years includes parent management and behavioural intervention, the concept of promoting positive behaviours was emphasised. This was a good reminder of simple parent counselling that can be done in our resource limited context during the consultation. It was interesting that teaching mindfulness and relaxation to young children can be beneficial as part of the management approach. Overall, this was an insightful presentation, highlighting important concepts to consider when assessing the young child with behavioural dysregulation. INFANT MENTAL HEALTH: PREDICTORS OF ADHD PRESENTED BY KEDI MOTINGOE Kedi Motingoe took us through the 2nd session of the day with her talk on infant mental health. She built on many of the topics introduced in the previous talk, with a more detailed focus on how important the early days of life really are and how experiences during this time can impact on the later development of ADHD. She highlighted that the presentation of psychiatric disorders in infancy is extremely complex. She also emphasized the importance of identifying those at higher risk of developing ADHD as earlier appropriate intervention can lead to prevention. Much like the previous talk, it was emphasised that the problem is unlikely to be found in the child, the mother or the father but rather in the parent child relationship system. INFANT MENTAL HEALTH CONSIDERS STRONGLY CONSIDERS THAT EARLY LIFE EXPERIENCE LARGELY SHAPES THE BRAIN. An infant’s capacity to regulate their emotions, form secure relationships and explore the environment depends largely on adequate nurturing in early life. This was elaborated on later in the talk, emphasising that a stress ridden society such as our own, is associated with decreased levels of maternal warmth. Listeners were also reminded that the father may have as much of a role to play as the mother does. Overactivity disorder of toddlerhood was described as a condition of hyperactivity as seen in children younger than 3 years of age. Symptoms can start as early as 18 months old however the diagnosis can only officially be made at the age of 2. In a comparison table that was shared, it is clear that the factors that differentiate OADT from ADHD is an age between 2 and 3 years and the lack of an inattentive symptom category. It was also interesting to note that a OADT diagnosis should not be made in a setting of inadequate parental structure and oversight. THE ATTACHMENT RELATIONSHIP WAS AGAIN EMPHASISED AND DEPICTED IN AN IMAGE OF A DISTRESSED, SEEMINGLY OVERWHELMED MOM WITH THE BABY LOOKING TO MOM FOR COMFORT OF HER OWN DISTRESS. The impact of a mom who is unable to model behaviour or comfort her child, has a large impact on the ability for the child to learn how to regulate their own emotions, and hence behaviour in the future. Another interesting concept addressed was that of screentime being a form of neglect. REPORT – ADHD CONGRESS 2023
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 15 Janine Rodrigues is a 4th year Psychiatry registrar, University of the Witwatersrand. Correspondence: [email protected] REPORT – ADHD CONGRESS 2023 Screen use by the child as well as by the caregiver can negatively impact the interaction between mother and child. It becomes challenging for a young child to develop the skills to regulate their impulses because they are flooded with fast paced and bright imaging. The way the condition was described was appearing as though there is ‘no harmony in the dance between caregiver and child’. In terms of management, the approach was divided into promotion, prevention and lastly intervention. Promotion was highlighted as one of the most important areas of focus, and it was emphasised that advocacy is the responsibility of every mental health practitioner. ADHD PHENOTYPE IN INDIVIDUALS BORN PRETERM PRESENTED BY NERICA RAMSUNDHAR Nerica Ramsundhar guided us through the next topic of ADHD and prematurity. It was highlighted that the natural tendency to celebrate the increased survival of premature newborns has been seen over the past several decades. This celebration failed to address the increased associated consequences and we are now dealing with the consequences that manifest as the child progresses through the lifespan. The idea is that if we can detect those at risk of later developing ADHD, we could support them before we get to the stage of making a diagnosis. The talk aimed to discuss identification of an ADHD phenotype in the premature newborn, how to recognise the premature child at risk, and what could be implemented to modify their developmental trajectory. THE PRETERM CLASSIFICATION IS USED TO IDENTIFY WHICH PRETERM INFANTS ARE MOST AT RISK OF DEVELOPING N E U R O D E V E LO P M E N TA L A N D NEUROLOGICAL COMPLICATIONS. The gestational age is used to classify the infant as extremely preterm (E.P) being less than 28 weeks, very preterm (V.P) being 28 - 32 weeks, and moderate preterm divided into early moderate preterm (EMP) being 32 - 34 weeks and late moderate preterm (LMP) being 34 – 37 weeks. It then further places EP and VP into a ‘high risk’ category and EMP and LMP into an ‘at risk’ group. This categorical approach assists us to identify those who are most at risk of complications such as epilepsy, cerebral palsy, sensory impairments, cognitive and neurobehavioural issues. Of importance is that EP was associated with a 4 times higher prevalence of ADHD compared with controls, and EMP associated with a 2-3 times increased risk. VP and EP was also found to be associated with some internalising conditions such as anxiety and depression and could be indicative of higher risk towards developing ADHD. Interestingly the VP group had a 10 times higher rate of developing autism spectrum disorder compared with at term counterparts. In the late preterm group, there is risk of speech, motor and cognitive delays however some have a catch up at 12 months. Those that do not catch up need closer monitoring for complications. When comparing prem ADHD versus term ADHD, it was found that the prem group showed a unique ADHD profile with a pattern of predominant inattentiveness, less comorbidity (specifically conduct disorder), more cognitive impairment, less genetic influence, female predominance as well motor difficulties being a strong early sign of ADHD. The neurofunctional assessment (NFA) can be done at 3 months to detect abnormalities that were prognostic of developmental delay. THE NFA ALSO IDENTIFIED EARLY DEVELOPMENTAL FLAGS PREDICTIVE OF DEVELOPING ADHD AND INCLUDED LOWER ATTENTION AND REGULATION, HIGHER EXCITABILITY, POORER QUALITY OF MOVEMENT, LESS ORIENTATION TO STIMULI AND PERSISTENCE OF PRIMITIVE REFLEXES. Another marker is the motor milestones achieved at 24 months with delay being associated with later ADHD. A table detailing the risk factors for ADHD in the premature population in the categories of environmental, obstetric, neonatal and early development factors. Of particular interest is the use of antenatal steroids in late and moderate prems. This is postulated to be due to the link between ADHD and sepsis involving the inflammatory cascade. The approach to intervention focused mainly on prevention of risk factors including preventing teenage pregnancy, encouraging more judicial use of antenatal steroids, collaboration between paediatricians and obstetricians when making decisions regarding steroid use and prevention of sepsis. OTHER ASPECTS OF INTERVENTION INCLUDE MORE KANGAROO CARE OF THE NEWBORN, ENCOURAGEMENT OF BREASTFEEDING AND EARLY TIMEOUS MANAGEMENT OF NECROTISING ENTEROCOLITIS AND NEONATAL SEPSIS. The take home message was that early identification and early intervention ultimately leads to a better prognosis in that you are able to take advantage of neuroplasticity for a better neurodevelopmental outcome.
16 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 Miché Moodley is a registered Psychometrist (Independent Practice) currently employed by the Goldilocks and The Bear Foundation. She conducts screening for ADHD and other mental health issues. She also conducts educational assessments for children to assess for learning barriers. Miché is passionate about child and adolescent mental health and believes that efficient and effective interventions at a young age are key to ensure the holistic wellbeing of future generations. Correspondence: [email protected] Miché Moodley OCCUPATIONAL THERAPY AND ADHD Miché Moodley REPORT – ADHD CONGRESS 2023 ATTENTION DEFICIT HYPERACTIVITY DISORDER IN INFANTS AND TODDLERS: NAVIGATING EARLY INTERVENTION, DEVELOPMENTAL STRENGTHS AND CHALLENGES THROUGH SENSORY INTEGRATION AND FAMILY INTERVENTION T his topic was presented by Occupational Therapist, Ms. Emma Wijnberg. Ms Wijnberg began by stating that Attention Deficit Hyperactivity Disorder (ADHD) is often associated with older children, but it can have foundations in early childhood. She then highlighted the need for early recognition and intervention as it is crucial for healthy development. What is noteworthy is that clinical guidelines typically diagnose ADHD from age 4 onwards, recent studies suggest that symptoms can manifest earlier. Ms Wijnberg then went onto discussing research in the US, which revealed that 9.4% of children had an ADHD diagnosis, including 2.4% aged over 2 years. Furthermore, The American Academy of Paediatrics (AAP) expanded its guidelines in 2011 to include pre-schoolers and teenagers aged 4-18, highlighting the importance of early detection. Structural brain differences exist in ADHD from birth, particularly in the prefrontal cortex and basal ganglia, which are crucial for executive functioning and impulse control. EARLY INTERVENTION CAN HARNESS NEUROPLASTICITY IN THE DEVELOPING BRAIN, POTENTIALLY MITIGATING ADHD'S EFFECTS. Diagnosing ADHD in toddlers under 4 years is challenging as typical behaviours like high energy, excessive talking, and distraction are developmentally appropriate. However, distinguishing ADHD from typical toddler behaviour requires attention to specific signs. Early indicators of ADHD include difficulties in regulating emotions, particularly a poor response to stress and a tendency to react with unpleasant emotions. Research found that infants with issues in crying, sleeping, or eating beyond the first 3 months were more likely to experience attentional difficulties later. Ms Wijnberg then went onto highlighting various factors that could aid in the management of ADHD symptoms: NUTRITION Nutrition plays a role in ADHD management. Neurotransmitters like dopamine and norepinephrine, critical for attention and impulse control, are imbalanced in ADHD. A balanced diet, avoiding processed carbohydrates and sugars, can help stabilize blood sugar levels. Omega-3 and fish oil supplements are effective in treating ADHD, as are iron and zinc supplements for addressing deficiencies. EXERCISE Regular exercise benefits children with ADHD by improving attention and academic performance. Outdoor activities and unstructured play are particularly effective. The American Academy of Paediatrics recommends at least one hour of moderate to vigorous exercise daily for children and adolescents. SLEEP Adequate sleep is essential for children with ADHD. Inadequate sleep exacerbates ADHD symptoms and affects overall functioning. A structured bedtime routine, limited screen time before bed, and avoiding vigorous exercise or melatonin use before sleep are essential for quality sleep.
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 17 REPORT – ADHD CONGRESS 2023 SCREENTIME Excessive screentime is linked to various issues, including poor sleep quality, mental health problems, lower academic achievement, reduced physical activity, and developmental delays in children and teenagers. Preschool children with over 2 hours of screentime daily are more likely to exhibit inattention. Sensory integration, the brain's ability to process sensory information, is vital for infants and toddlers' development.Sensory integration difficulties can lead to emotional dysregulation issues, poor peer engagement, and impaired motor skills. Creating sensory-friendly environments and consulting with occupational therapists to develop tailored sensory diets can help. Sensory integration plays a crucial role in managing ADHD. It intertwines with brain areas like the limbic system (emotions) and the reticular formation (attention and sleep). SENSORY ISSUES IN ADHD MAY MANIFEST AS HYPERSENSITIVITY OR HYPOSENSITIVITY TO STIMULI, AFFECTING ATTENTION AND REGULATION. TAILORED SENSORY ACTIVITIES, LIKE WEIGHTED VESTS AND AUDITORY CUES, CAN HELP CHILDREN WITH ADHD. In summary, ADHD in infants and toddlers presents unique challenges due to developmental variability. Early intervention is vital, focusing on identifying early indicators, nutrition, exercise, sleep, and sensory integration. By addressing these aspects, we can better support children's healthy development and potentially mitigate the impact of ADHD. SENSORY PROCESSING DIFFICULTIES IN CHILDREN WITH ADHD FEATURES The presenter was Dr. Riekert Swart, a paediatrician in private practice. His presentation focused on the co-occurrence of sensory processing difficulties in children with ADHD features. His presentation was based on research conducted from his Masters Thesis which helped to shed light on the need for early assessment and intervention. Dr Swart highlighted that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 TR) does not classify sensory processing disorder as a psychiatric disorder, but it is observed in some neurodevelopmental disorders like autism. This led to his research, in which he aimed to assess the prevalence of sensory processing difficulties and inattention/hyperactivity features in children in Grade R and Grade 1 without necessarily diagnosing them with ADHD or sensory processing disorder. Dr Swart explained that ADHD is a prevalent neurodevelopmental disorder in South Africa, affecting 8-10% of children. The DSM-5 criteria is used for diagnoses and children may exhibit predominantly hyperactive/impulsive symptoms, inattention symptoms, or a combination of both. Dr Swart also introduced the concept of sensory integration theory by Dr. Jane Ayres, emphasizing that sensory integration occurs throughout childhood. He also discussed Sensory Processing Disorder and highlighted that it is often not diagnosed in early childhood. He referenced the Zero to Threes Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC0-5), which includes sensory processing symptoms for ages 0-5, focusing on sensory responsiveness and abnormalities that affect a child’s daily functioning in various domains. Moving on to his recent study, Dr Swart explained the methodology. The study involved children in Grade R and Grade 1 in Middelburg, Mpumalanga, in 2022. Parents who were concerned about their children’s ADHD symptoms were invited to participate. Demographic questionnaires, the Sensory Processing Measure Home Form, and Conners 3 Parent Short Form were used for data collection. THE STUDY'S FINDINGS REVEALED THAT A SIGNIFICANT NUMBER OF CHILDREN MET THE CRITERIA FOR SENSORY PROCESSING DIFFICULTIES AND INATTENTION/ HYPERACTIVITY SYMPTOMS. Specifically, 82 children (80.39%) had sensory processing difficulties, 80 (78.43%) had inattention and/or hyperactivity symptoms, and 60 (58.82%) exhibited both sensory processing difficulties and hyperactivity/impulsivity. Dr Swart pointed out that the majority of children with sensory processing difficulties were male, aged 6 years, in Grade R, reflecting the demographic makeup of the study group. The sensory processing dysfunction was particularly evident in vision, hearing, and body awareness. For children with inattention and/or hyperactivity and impulsivity, the majority were also males in Grade R, with high scores indicating these symptoms. Dr Swart’s presentation referenced international papers that supported his findings, highlighting the co-occurrence of sensory processing disorder and ADHD. He emphasized the importance of assessing children diagnosed with ADHD for sensory processing disorder and initiating sensory integration therapy. He also mentioned the need for further research in cases where parents may not express concern about their child’s symptoms. In conclusion, Dr Swart’s presentation shed light on the relationship between sensory processing difficulties and ADHD in children, even though sensory processing disorder is not officially recognized in the DSM-5. His study underlined the
18 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 significance of considering sensory processing issues in children with ADHD and the potential benefits of sensory integration therapy in their treatment. PRAXIS AND EXECUTIVE FUNCTIONING IN THE SCHOOL-AGED CHILD WITH ADHD The presenter was Mrs Elize Janse van Rensburg, an occupational therapist. Her presentation explored the relationship between praxis and executive functioning in school-aged children with ADHD. She began by highlighting that a significant percentage (50-89%) of children with ADHD also experience motor coordination and praxis difficulties. Praxis is defined as the neurocognitive process underlying the planning and execution of skilled adaptive interaction with the physical world. Mrs Janse van Rensburg highlighted that praxis consists of several components, including ideation (thinking about possible interactions with objects), planning (enabling adaptive interaction), and execution (the motor expression of ideation and planning). She stated that it relies on sensory input, body schema development, and motor memory. Furthermore, feedback during and after actions contributes to the praxis loop and helps build the body schema and motor memory. Mrs Janse van Rensburg then delved into the brain structures involved in praxis, which include the frontal and limbic areas for ideation, the premotor and sensory motor areas for planning and execution, and the posterior parietal area for sensory input. A UNIQUE PERSPECTIVE ON PRAXIS IS ITS ROLE IN ORGANISING BEHAVIOUR IN BOTH TEMPORAL AND SPATIAL DIMENSIONS. AS INDIVIDUALS GROW, THEIR SPATIOTEMPORAL HORIZONS EXPAND, ALLOWING THEM TO NAVIGATE THROUGH TIME AND SPACE MORE EFFECTIVELY. PRAXIS PLAYS A CRUCIAL ROLE IN THIS PROCESS. Mrs Janse van Rensburg further went onto discussing the various disorders of praxis, including: somatodyspraxia, visiodyspraxia, ideational dyspraxia, and bilateral integration and sequencing issues. Research supports the existence of these disorders, and recent neuroscience studies have confirmed the brain areas involved in praxis. Executive functioning challenges frequently associated with ADHD was explored. These include: planning, self-control, and working memory while executive functions include: working memory, cognitive flexibility, initiation, monitoring, emotional regulation, and inhibitory control. It highlights the interplay between dyspraxia and executive function. For example, difficulties in starting or ending activities due to poor praxis can impact the ability to shift between tasks. Both praxis and executive function are processed in cortical and subcortical structures, and studies have linked executive function skills with motor performance. RESEARCH INDICATES THAT SENSORY PROCESSING DIFFICULTIES ARE ASSOCIATED WITH LOWER EXECUTIVE FUNCTION IN CHILDREN WITH ADHD, SUGGESTING A CONNECTION BETWEEN SENSORY PROCESSING, EXECUTIVE FUNCTION, AND ADHD SYMPTOMS. WHILE MOTOR COORDINATION DIFFICULTIES IN CHILDREN WITH ADHD MAY IMPROVE WITH AGE, EXECUTIVE FUNCTION CHALLENGES TEND TO INCREASE AS ENVIRONMENTAL DEMANDS RISE. The presentation concludes by emphasizing that many children with ADHD have both dyspraxia and executive function challenges. It suggests intervention strategies that include sensory perception, praxis, and executive function assessments, prioritizing outcomes, considering environmental demands, and tailoring interventions accordingly. The presentation suggests various strategies for assisting children with ADHD who have praxis and executive function challenges, including sensory integration, breaking tasks down to decrease executive function demand, and clinical reasoning. Ayres Sensory Integration (ASI) is recommended as a treatment modality, as it has been found effective in treating praxis disorders and executive function challenges in children with ADHD. ASI focuses on challenging motor control, supporting intrinsic motivation, providing sensory opportunities, and maintaining an optimal level of alertness. In summary, this article highlights the interplay between praxis and executive functioning in children with ADHD, emphasizing the importance of comprehensive assessments and tailored interventions to improve their functional abilities NAVIGATING ADULT OCCUPATIONS: SUPPORT AND INTERVENTION FOR PEOPLE WITH ADHD The presenter was Ms. Ray Anne Cook, an occupational therapist. She began the presentation by discussing the strengths and challenges adults with ADHD face in the workplace. ADULTHOOD - CHALLENGES VERSUS STRENGTHS Ms. Cook highlighted that before being diagnosed with ADHD, adults (aged 18 onwards) often experience failures, internalize negative views, and self-blame, which can hinder their functioning. However, after diagnosis, they tend to move beyond self-guilt and develop a more positive view of themselves, seeing the positive aspects of ADHD.
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 19 REPORT – ADHD CONGRESS 2023 CHALLENGES FACED BY ADULTS WITH ADHD Adults with ADHD often face challenges such as: difficulty meeting deadlines, vocational struggles, anger issues, addiction, relationship and social strain, comprehension problems, a family history of ADHD, commitment to therapy, and boundaries in therapy. These challenges can significantly affect their occupational performance. STRENGTHS OF ADULTS WITH ADHD: Despite these challenges, individuals with ADHD possess numerous strengths, including: attunement to nature, personal sensitivity, creativity, inventiveness, energy, enthusiasm, spontaneity, hyperfocus on tasks of interest, resilience, problemsolving skills, and the ability to identify patterns in chaos. MS. COOK NOTED THAT MANY ADULTS WITH ADHD ARE HIGH ACHIEVERS WITH ADVANCED DEGREES AND SUCCESSFUL BUSINESSES. HOWEVER, THEY OFTEN HAVE TO WORK HARDER TO ACHIEVE THEIR GOALS. Ms. Cook further noted that these strengths need support and harnessing rather than criticism. NAVIGATING PREVIOUS YEARS: When working with adult clients with ADHD, Ms. Cook stated that it's essential to consider their last 18 years. This includes when they were diagnosed, their comorbidities, previous interventions, and coping mechanisms. Coping mechanisms, such as low self-esteem or guilt, can significantly impact an individual’s occupational performance. INTERVENTIONS: Ms Cook suggested several strategies for evaluating and intervening in adults with ADHD. These include an in-depth developmental history, sensory reactivity assessment, executive functioning evaluation, and a review of the individual's daily schedule. Evaluations should be conducted over multiple sessions to gain a comprehensive understanding of the client. EVALUATION/INTERVENTION COMBINATION: Ms Cook further recommended that a combination of evaluation and intervention strategies should take place. This involves using feedback forms, conducting interviews, involving a team, using standardized assessments and questionnaires, and planning sessions to address functional difficulties. THE INTERVENTION SHOULD TAKE A BALANCED APPROACH, AIMING TO RESTORE FUNCTION AND IMPROVE OCCUPATIONAL PERFORMANCE. SOME GENERAL TIPS FOR ALL OCCUPATIONS: Understanding ADHD is of importance, using tactile organizers for time management, having clocks everywhere, employing time management techniques like the Pomodoro method, writing down thoughts and questions, and using sticky notes are all helpful strategies. CO-REGULATORS, WHETHER HUMAN OR SPIRITUAL, CAN ASSIST IN TASK COMPLETION. DELEGATING TASKS THAT THE INDIVIDUAL MAY DISLIKE AND USING SENSORY LADDERS FOR SELFAWARENESS ARE ALSO RECOMMENDED. Occupational Work: In the workplace, it's crucial to identify when and where you are most productive, leverage your strengths, and adapt your workspace and tasks accordingly. Consider your relationships, seating arrangements in meetings, and focus techniques. Meetings: Adults with ADHD should consider their preferences for Zoom or face-to-face meetings, note-taking methods, seating arrangements, and focus aids like fidget toys. Work: Organizing work into smaller chunks, coping with deadlines, and having an organized workspace are essential for productivity. Templates can help streamline written tasks. Relationships (Parenting, Partner, Friends): Maintaining healthy relationships involves, not relying on your partner as a parent but as a coregulator, setting boundaries on hobbies and screen time, providing routine and structure in parenting, and being a good listener and friend. Home Maintenance: Managing finances, seeking household help if needed, maintaining routines, and scheduling tasks are vital for home maintenance. Health Maintenance: Managing eating habits, decreasing sugar and caffeine, getting adequate sleep, making time for sports without overdoing it, and aligning sports activities with your motivation style are important for health maintenance. Ms. Cook referenced Lawlis' sport audit. To Restore Function: Check for sensory integration and motor skills, as well as reflexes, and consider therapies like listening therapy such as: Tomatis and rhythmic training, which can improve central nervous system function. IN SUMMARY, ADULTS WITH ADHD FACE CHALLENGES BUT ALSO POSSESS UNIQUE STRENGTHS. Effective interventions and support systems can help them navigate these challenges and maximize their potential in various aspects of life, including work, relationships, and health
20 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 MEDICATION AND ADHD Ntombizakithi Mayisela REPORT – ADHD CONGRESS 2023 PSYCHOPHARMACOLOGY AND ATTENTION DEFICIT HYPERACTIVITY DISORDER T he importance of treating Attention Deficit Hyperactivity Disorder (ADHD) is a topic not often discussed. This session (presented by Greg Mattingly) highlighted some very important facts about the burden of ADHD in our society. The mortality rate of patients with ADHD is higher than in the general population for a variety of reasons. One of the core symptoms of ADHD, impulsivity, can lead to increased rates of accidents such as road traffic accidents, for example, due to impulsive, careless driving. Children with ADHD often have higher rates of hospitalisation due to accidents related to rough play and impulsivity. ADHD is often accompanied by numerous comorbidities. The comorbidities that are common with ADHD include depression, anxiety and substance use disorders which can also potentially increase mortality rates. This is another important reason to treat ADHD as well as identify and treat co-morbidities. The presenter of this session also highlighted barriers to diagnosis of ADHD. Patient factors such as an increased IQ can mask the symptoms of ADHD as the patient will not necessarily be struggling academically and symptoms may not be detected in the school setting. Societal factors such as stigmatisation and embarrassment may also play a role. Practitioner factors such as misdiagnosis due to presenting symptoms overshadowing the diagnosis e.g. patients often present with behavioural problems such as temper problems and addiction which then become the main concern and therefore the diagnosis of ADHD is missed. When choosing the appropriate medication for a patient with ADHD, this should be a patient specific decision. Patients have different needs and different lifestyles. Their need for symptom control may vary depending on scholastic demands and occupational needs. THERE ARE TWO MAIN GROUPS OF DRUG CLASSES AVAILABLE FOR THE TREATMENT OF ADHD: STIMULANTS AND NON-STIMULANTS. STIMULANTS INCLUDE METHYLPHENIDATE AND AMPHETAMINES. METHYLPHENIDATE BLOCKS REUPTAKE OF NOREPINEPHRINE AND DOPAMINE AT THE SYNAPSE AND AMPHETAMINE BLOCKS THE REUPTAKE OF NOREPINEPHRINE AND DOPAMINE INTO THE PRESYNAPTIC NEURON AND INCREASES THE RELEASE OF THESE MONOAMINES INTO THE EXTRANEURONAL SPACE. These drugs are available in a number of preparations for convenience and requirements of the patient i.e. immediate release formulations as well as osmotic release oral system (OROS) extended- release formulations. Short acting formulations on their own are usually less ideal due to increased frequency of doses required well as the peaks and troughs that patients experience when they feel medication taking effect Ntombizakithi Mayisela
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 21 REPORT – ADHD CONGRESS 2023 and wearing off. The OROS formulations can deliver steady doses throughout the day and patients may only need to take them once a day. It is also acceptable to give a patient a combination of long acting and short acting treatments depending on their needs. Stimulants have potential for abuse therefore caution should be practised when prescribing to patients. NON-STIMULANTS SUCH AS ATOMOXETINE CAN ALSO BE USED TO TREAT ADHD. THIS DRUG IS A SELECTIVE NOREPINEPHRINE (NE) REUPTAKE INHIBITOR AND IS THOUGHT TO WORK BY INCREASING NOREPINEPHRINE AND DOPAMINE WITHIN THE PREFRONTAL CORTEX TO IMPROVE ADHD SYMPTOMS. THE DRUG IS USUALLY LESS EFFECTIVE AT TREATING ADHD SYMPTOMS BUT IS A GOOD ALTERNATIVE FOR PATIENTS WHO HAVE INTOLERABLE SIDE EFFECTS TO STIMULANTS. DRUG INTERACTIONS IN ATTENTION DEFICIT HYPERACTIVITY DISORDER PRESENTED BY ERIC DECLOEDT It is known that patients with Attention Deficit Hyperactivity Disorder (ADHD) often present with other comorbidities. These comorbidities cannot be left untreated therefore these patients may be taking multiple drugs. Patients with ADHD may also have other unrelated illnesses that need to be treated. This results in a potential for drug-drug interactions that clinicians need to be aware of. Pharmacokinetics describes the way in which a drug is metabolised in the body and includes processes such as absorption, distribution and elimination. Pharmacodynamics describes how a drug works in the body to exert a therapeutic effect. Drugs have to go through different processes in the body to be effective and then they also have to be eliminated. THEY NEED TO BE LIPID SOLUBLE TO BE ABSORBED INTO THE GASTROINTESTINAL SYSTEM AND NEED TO BE WATER SOLUBLE TO BE EXCRETED BY THE KIDNEYS. Certain drugs induce enzymes and other drugs inhibit enzymes used for the metabolization of different drugs. These various processes demonstrate how different drugs may interact with one another. Not all drug interactions are clinically relevant. Most are theoretical and do not cause a great enough effect to cause clinical concern. Drugs that may cause concern when prescribed together in the context of ADHD are selective serotonin reuptake inhibitors (SSRIs) prescribed for depression and anxiety (common comorbidities in ADHD), anticonvulsants, and antihypertensives. SSRIS AND STIMULANTS, WHEN PRESCRIBED TOGETHER CAN INCREASE THE RISK OF SEROTONIN SYNDROME. SSRIs work by blocking re-uptake of serotonin at the synapse therefore increasing serotonin levels. Stimulants act by increasing dopamine and norepinephrine which increase serotonin by an indirect downstream mechanism therefore increasing risk of serotonin syndrome. Some stimulants can also inhibit the metabolism of SSRIs therefore also increasing the risk of serotonin syndrome. An example of such a stimulant is the prodrug lisdexamfetamine. ATOMOXETINE IS A CYP2D6 (LIVER ENZYME) INHIBITOR. CYP2D6 IS RESPONSIBLE FOR METABOLISING VARIOUS DRUGS INCLUDING SSRIS. THEREFORE, IN THEORY, ATOMOXETINE AS A CYP2D6 INHIBITOR COULD AFFECT THE METABOLISM OF SSRIS. THIS HAS, HOWEVER, NOT BEEN SHOWN TO BE CLINICALLY SIGNIFICANT. Anticonvulsant drugs can potentially decrease the effectiveness of methylphenidate. Some anticonvulsants such as carbamazepine, phenobarbitone and phenytoin induce liver enzymes, particularly cytochrome P450 enzymes. These liver enzymes play a significant role in metabolising methylphenidate. The anticonvulsant’s inducing effect on these enzymes results in faster metabolization of methylphenidate therefore decreasing its concentration in the blood and making it less effective for treating ADHD symptoms. The dose of methylphenidate used may have to be increased. Stimulants increase norepinephrine by inhibiting its reuptake therefore having the potential to increase the blood pressure in patients taking them. In patients with pre-existing hypertension, stimulants may make it harder to manage. This may potentially affect the way in which antihypertensives are prescribed. Ntombizakithi Mayisela is a 4th year Psychiatry registrar, University of Cape Town. Correspondence: zakithi333@ gmail.com
22 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 ALTERNATIVE INTERVENTIONS FOR ADHD Tshepiso Paliweni-Zwane REPORT – ADHD CONGRESS 2023 THE THREE Gs TO AVOID IN PSYCHIATRY I n this session, presented by Renata Schoeman, I learnt about herbal products that ADHD patients may access but with the problem drug interactions with the prescribed medication. GINSENG: A problematic formulation is the Panax Ginseng which increases the sensitivity of dopamine receptors. This leads to improvement in energy and inattentiveness in ADHD people. Physically, it reduces the blood sugar and cholesterol while promoting relaxation and reducing stress. UNFORTUNATELY, THERE ARE SIDE EFFECTS LIKE AN INCREASE IN BLOOD PRESSURE, AND IT MAY CAUSE STEVENS - JOHNSON SYNDROME (ESPECIALLY IF IN COMBINATION WITH LAMOTRIGINE WHICH MAY BE USED FOR EPILEPSY OR AS A MOOD STABILIZER). GINGKO BILOBA: This herbal product increases the brain fertilizer “Brain derived neurotrophic factor” and is an anxiolytic. Unfortunately, it also has side effects like increasing the risk of serotonin syndrome if taken together with stimulants, as well as carrying a risk of inducing seizures and bleeding tendencies. GUARANA: This is a stimulant packed with caffeine that helps with weight loss noting that binge eating disorder, as an impulse control disorder, may be comorbid or even part of the family history for someone with ADHD. The other benefits are improving patient energy, libido, as well as anti-inflammatory and antioxidant properties. Unfortunately, side effects include inducing anxiety, hypertension and cardiac arrythmias. THE FUNGAL ROUTE In this session, presented by Lesley Carew, it was noted that the brain is developing until the age of 25 years . Hence the new focus on psilocybin as an alternative treatment for ADHD should be viewed with caution. Psychiatric patients are investigating natural alternatives because the current psychopharmacological therapy has many side effects. Unfortunately, young people look at ChatGPG to search for data but this is not a scientifically peer reviewed resource with reliable sources. It was interesting to learn that when using microdoses of psilocybin, it can have a positive impact on three key areas of activity in the brain i.e. the prefrontal cortex, the default mode network and the task positive mode (TPM). Psilocybin decreases default mode network activity which is the daydreaming part of the brain while increasing the TPM which helps with engaging in goal directed activities while improving connectivity between these two areas. UNFORTUNATELY, THE EVIDENCE ABOUT CLINICAL UTILITY IS STILL IN ITS INFANCY . There are many exclusion criteria prior to considering this drug for ADHD such as a personal history of borderline personality disorder, schizophrenia, bipolar disorder, pregnancy, current use of stimulants stimulants or antidepressants (due to the risk of serotonin syndrome). The administration of this drug needs to be undertaken in a safe space due to anxiety and psychosis that can occur with exposure. Tshepiso Paliweni-Zwane Tshepiso Paliweni-Zwane is a 4th year Psychiatry registrar at the University of Pretoria. Correspondence: [email protected]
PLAY AND THE SOCIAL BRAIN Tshepiso Paliweni-Zwane REPORT – ADHD CONGRESS 2023 I In the first 5 years of life, noted the presenter Adri van der Walt, children learn the theory of mind and understand others’ behaviour. Play helps with cognitive development and life skills development. Unstructured play can assist the child with activating the entire neocortex and helps them to be more self-directed, attend to other children’s needs, push limits and establish what may be dangerous but can it beneficial for ADHD children? When looking at the general benefits of play, children who play are often better students and it improves their physical growth and resilience, but the ADHD population has less prefrontal control and more impulsivity so structured play where rules are applied - as in sports - may be beneficial. Children who participate in karate and structured play may may have a reduction in impulsivity. ADHD affects emotional regulation and negatively impacts relationships hence children experience social rejection, with inattention to other’s needs. Hyperactivity and impulsivity make it difficult to get along with peers. In animal studies social deprivation in the early years usually leads to more violence and aggression towards peers. In human studies children who experienced a lot of isolation manifest with signs of ADHD. FEAR OF INJURY AND LIMITED FREEDOM OF MOVEMENT FRUSTRATES PLAY FOR THE CHILD AS WELL AS INTERACTIVE PLAY. DURING COVID-19 RESTRICTIONS IMPAIRED PLAY AND LIMITED CHILDREN SOCIALISING. OCCURRED. Evidence shows that early introduction of medication reduces the neuroplasticity of the brain and medication side effects can lead to social withdrawal. Play therapy, however, in younger children seems to be limited in the real time impact on the children. Tshepiso Paliweni-Zwane Tshepiso Paliweni-Zwane is a 4th year Psychiatry registrar at the University of Pretoria. Correspondence: [email protected] VYVANSE® offers sustained improvement in adult attention deficit hyperactivity disorder (ADHD) symptoms for up to 14 hours 1 NO ONE SEES HER ADHD BUT EVERYONE SEES HER SUCCESS NO ONE SEES HER ADHD BUT EVERYONE SEES HER POTENTIAL References: 1. Wigal T, Brams M, Gasior M, Gao J, Squires L, Giblin J, for 316 Study Group. Randomized, double-blind, placebo-controlled, crossover study of the efficacy and safety of lisdexamfetamine dimesylate in adults with attention-deficit/hyperactivity disorder: novel findings using a simulated adult workplace environment design. Behav Brain Funct. 2010;6:34. Available from: http://www.behavioralandbrainfunctions.com/content/6/1/34 [Accessed 18th August 2021]. 2. Pennick M. Absorption of lisdexamfetamine dimesylate and its enzymatic conversion to d-amfetamine. Neuropsychiatr Dis Treat. 2010;6:317-327. 3. Frampton JE. Lisdexamfetamine: A Review in ADHD in Adults. CNS Drugs 2016: 30(4):343-54.DOI 10.1007/s40263-016-0327-6. 4. Adler LA, Dirks B, Deas PF, Raychaudhuri A, Dauphin MR, Lasser RA, et al. Lisdexamfetamine Dimesylate in Adults With Attention-Deficit/ Hyperactivity Disorder Who Report Clinically Significant Impairment in Executive Function: Results From a Randomized, Double-Blind, Placebo-Controlled Study. J Clin Psychiatry. 2013;74(7):694-702. 5. VYVANSE® 30,50,70. SAHPRA approved professional information. Takeda (Pty) Ltd. 24 July, 2020. 6. Coghill DR, Caballero B, Sorooshian S, Civil R. A Systematic Review of the Safety of Lisdexamfetamine Dimesylate. CNS Drugs 2014;28:497–511. VYVANSE® is the FIRST prodrug stimulant 2,3 • Offers improvement in real-life executive function deficits and self-reported quality of life 3,4 • Convenient once-daily dosing with a well-established safety profile 3,5,6 S6 VYVANSE® 30. Each capsule contains 30 mg lisdexamfetamine dimesilate. Reg. No: 48/1.6/0407. S6 VYVANSE® 50. Each capsule contains 50 mg lisdexamfetamine dimesilate. Reg. No: 48/1.6/0408. S6 VYVANSE® 70. Each capsule contains 70 mg lisdexamfetamine dimesilate. Reg. No: 48/1.6/0409. For full prescribing information, refer to the Vyvanse Professional Information as approved by SAHPRA. Takeda (Pty) Ltd, Reg. No.: 1982/011215/07, Building A, Monte Circle, 64 Montecasino Boulevard, Fourways 2191. Tel: +2711 514 3000. Marketed by Acino Pharma (Pty) Ltd. Reg. No: 1994/008717/07. No 106, 16th Road, Midrand, 1686, Gauteng, South Africa. (011) 516 1700. www.acino.co.za C-APROM/ZA/Vyv/0039.
24 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 EDUCATION AND ADHD Emily Machai REPORT – ADHD CONGRESS 2023 INCLUSIVE EDUCATION PRESENTED BY JEAN FOURIE I nclusive education aims at ensuring all children of school going age, who experience barriers to learning including those who are disabled or have a learning disorder of any form, will be able to access education equal to their peers. It also entails that ordinary schools and Education Development Center schools can respond to the needs of all the learners. With ADHD in particular, children struggle with inattentiveness and/ or hyperactivity and/ or impulsiveness. In South Africa by law, legislated in 1996 by the South African Schools Act, public schools must admit all learners and must attend to their educational needs without any unfair discrimination. Some of the challenges faced currently with inclusive education are: • Lack of resources • Inadequate training of teachers • Heavy workload- overcrowding in classrooms. • Lack of parental participation Despite the challenges regarding inclusive education, some pros and cons have been highlighted. Some pros emphasized included: • Higher expectations- in an inclusive class the same goals are set for all students. It may take time for others to achieve the set goals or may have to be applied in different ways for some students, but the end goal is the same. • Good self-esteem – if children with ADHD are placed in a separate class, they might view themselves in a negative way while others are “good” since they didn’t get separated. • Diverse friendships can be formed. Inclusive classes allow the children to be together. Those with ADHD can still be part of ordinary school and are not isolated. • Allows teachers to think out of the box. Not one size fits all. • Parental involvement may assist the parents with better understanding of the illness and assist with methods to help the child at home with homework. Some of the cons raised were: • An inclusive classroom works when there are enough resources available for teachers and staff to provide tailored teaching for each child with special needs. • If there are not enough resources available, children with ADHD may still be forced to learn like the rest of the class. They might find themselves left behind with the curriculum. • Teachers are forced to learn about different disabilities/ learning disorders and how to manage each. This is why availability of resources is very important. • LACK OF PARENTAL INVOLVEMENT. FOR KIDS WITH ADHD, SOME METHODS OF TEACHING DONE IN CLASS MAY NEED TO FURTHER BE IMPLEMENTED AT HOME FOR THEM TO BE SUCCESSFUL. FOR INSTANCE, CERTAIN ROUTINES DONE AT SCHOOL MIGHT NEED TO BE FOLLOWED UP AT HOME. • Other “normal” kids may get bored if they finish or understand the work quicker than the rest. Emily Machai
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 25 REPORT – ADHD CONGRESS 2023 Some of the resources needed are teaching tools for learners and teachers, teachers need to be trained to learn how to deal with different disabilities. The success of inclusive learning is based on the support of teachers, the school, from the government and parents. CONCESSIONS IN ADHD PRESENTED BY GINA RENCKEN Concessions are also known as accommodations for children or students with barriers, to help or enable the student to perform closer to their potential in tests and examinations. Different types of concessions can include: o Additional time o A reader to read all text in an examination to the learner. o Handwriting accommodations o Computer assistance o Medication or food intake o Rest Breaks- learner is not required to be at their desk. CONCESSIONS ARE A VALUABLE TOOL AND RESOURCE IN THE MANAGEMENT OF ADHD IN A CLASSROOM SETTING. ASSESSMENT INTEGRITY MUST BE MAINTAINED, AS WELL AS NO UNFAIR ADVANTAGE TO LEARNERS. In learners with ADHD, accommodations can be: • Extra time to complete class work and test. • Break method: taking a rest is very important in ADHD learners. The method typically recommends setting a timer for 25 minutes and taking a 5 min break. The time can be altered according to the child’s needs. • Seating placement in the classroom: the hallmark signs of ADHD is being easily distracted and struggling to sit through long classes; making sure they’re not seated in a high traffic and possibly distractive areas like next to the door or windows, or heating /air conditioning. • Having a special role during class: this can help offset the negative attention due to their misunderstood behaviours. Steps required to qualify: • A full psycho educational assessment showing at least an average intellectual ability, with significant long-term learning disability. • A comprehensive clinical history is required. • Relevant medical reports which include diagnosis and intervention strategies and professional strategies • Reports from experts (occupational therapists, psychologists) should also be included. • Teachers or school reports Clinicians should be wary of learners or students presenting for a first time who want accommodations to be made for them, yet they managed to achieve well in school activities before. It should be clearly stated that concessions should be temporary and other interventions for the underlying difficulty should still be implemented. NEURODIVERSE LEARNING PRESENTED BY HENK ARANGIES (The presenter shared his personal experience on how he was able to change “mainstream” learning into neurodiverse learning ) Neurodiversity posits that brain differences are normal and acceptable, rather than deficits. The natural neurological difference between how a person’s brain functions and processes information represents neurodiversity. With this in mind, it is important and possible for learners with neurodiversity to learn in a diverse way. DIVERSE METHODS OF LEARNING MAY BE UNCONVENTIONAL MAINSTREAM LEARNING. IT ALSO IMPLIES THAT LEARNERS ARE INDIVIDUALIZED AND THEREFORE LEARN AT THEIR PACE! Setting up individualized learning in neurodiversity may include: • Staff training – everyone must be on the same page and understand goals set for the school: share success stories. • Build and expand technology and classroom infrastructure. This can be sitting around the table instead of individual desks. • Create an e- curriculum: some learners learn better online. • Creative timetable: include multiple short breaks, • Create healthy living.: healthy snacks during lunch break and include exercise. • Involve families. Emily Machai is a 4th year Psychiatry registrar at the University of the Free State. Correspondence: [email protected]
26 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 THE UTILITY AND ETHICS OF GENETIC TESTING IN ADHD Marguerette Osborne REPORT – ADHD CONGRESS 2023 Dr. Verster provided a very insightful and informative presentation on the utility of ethics of genetic testing in attention-deficit/ hyperactivity disorder (ADHD) and what this looks like in South Africa. Literature on the usefulness of genetic testing in ADHD is relatively limited and therefore combined with the cost, it can be argued that it does not have a place in the South African context. Dr. Verster argues that there are various reasons why one should be careful of genetic testing: because genetic testing is part of what is called precision medicine, although there is no denying that precision medicine has a place in the medical world of 2023. What is precision medicine? It is an approach to disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle. It allows for more accurate predictions regarding treatment, and prevention strategies for a specific disease and which method will work best for which group of people. THIS IS IN CONTRAST TO A ONESIZE-FITS-ALL APPROACH, IN WHICH DISEASE TREATMENT AND PREVENTION STRATEGIES ARE DEVELOPED FOR THE AVERAGE PERSON WITH THAT DISORDER. ADHD is a complex and heterogeneous neurodevelopmental condition. Unfortunately, curative treatments are lacking. There are multiple options for symptom control, but at this stage, we cannot say that we can cure it. Late or uncertain diagnoses will delay treatment and that in itself leads to various comorbid issues, which possibly could be prevented by earlier intervention and diagnosis. Polygenic Risk Score (PRS) looks at how a person’s specific risk compares to others with different genetic constitutions. It does not give us a baseline or timeframe for the progression of a disease. This is compared to absolute risk, which shows the likelihood of a disease occurring. In ADHD, PRS has shown some predictive value in symptom severity and comorbidity and may in the future predict the persistence of symptoms. There are some more penetrant rare genetic mutations in a specific subgroup of patients but the accuracy of this is still relatively limited and requires replication of these studies to be conducted to prove the exact value thereof. ADHD remains a highly heritable disorder with a complex genetic architecture, and most cases seem to be due to multiple variants of limited effect size which interact with multiple environmental factors. Given this polygenic nature of ADHD, we unfortunately at this stage have to say that genetic testing with ADHD is still limited specifically relating to diagnosis or predictive assessments. There is also very limited data or literature available on the topic at this stage. Pharmacogenetics is the study of genetic variability in medication response both relating to efficacy and tolerability. There have been numerous studies looking at stimulant responses specifically on genes relating to the catecholamine functions. Ethical Issues: High-cost intervention: Limited current utility. Informed consent and data sharing: All the information needs to be available, and patients and family members must understand the implications of the process so that they can make informed decisions. Privacy and discrimination: For instance, if you get a new job should you make this report available to them that states that you have a predisposition for ADHD? This could potentially lead to discrimination. Commercialisation and conflict of interest: This will be always present, especially when taking into consideration the role of capital in advancing technologies. One needs to be careful in balancing the clinical utility and marketing forces. Long term effects: We may not yet fully understand the long-term effects of precision treatments on ADHD. One has to be aware that at this stage the testing might be focused on specific aspects of ADHD only and does not necessarily consider the broader psychosocial environmental factors. One has to constantly be aware of the ethical implications. Marguerette Osborne Marguerette Osborne is currently employed at Goldilocks and The Bear Foundation and administers psychometric assessments and assists with various other functions at the Foundation Correspondence: [email protected]
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 27 REPORT – ADHD CONGRESS 2023 M A R R Y I N G T H E D I M E N S I O N A L VERSUS THE CATEGORICAL APPROACH: ICF PRESENTED BY SVEN BOLTE Ipeleng K Mahapa-Musekene T he use of the International Classification of Functioning (ICF) in managing ADHD supports the emphasis on individual abilities, disabilities, and the impact of the specific context on individual functioning. This view on the impact of ADHD is meaningful for many reasons. Firstly, functioning is usually looked at as less stigmatising compared to diagnosis; the ICF offers a framework that can be used to assess strengths in addition to impairments. In addition, the functional problems are mostly the reason for the index consultation and an important focus for interventions. These functional aspects are likely to be more tangible and meaningful to individuals with ADHD, their families and society rather than diagnosis and psychopathology. Describing an individual’s functioning can also be useful in identifying real-life challenges, guiding treatment planning, and enhancing communication between individuals with ADHD and their environment and with professionals. More importantly clarifying the functioning of affected individuals has the potential to improve the calculation of health-related service cost. Finally, the ICF highlights the possible influence of the environment—positive and/or negative— on an individual’s outcome. Understanding this modifying role of environmental factors provides the basis for possible adaptation of specific factors to improve outcome. EVEN WITH ALL THESE POSITIVE ELEMENTS, APPLYING THE ICF IN DAY-TODAY SETTINGS CAN BE CHALLENGING. THE ICF IS LESS WELL KNOWN AND HAS NOT YET BEEN WIDELY ACCEPTED BY PROFESSIONALS AND RESEARCHERS IN THE ADHD COMMUNITY. Moreover, its exhaustive comprehensiveness can make its use in daily practice difficult and timeconsuming. In practice, only a fraction of the ICF categories are needed when evaluating functioning of individuals with specific health conditions. The development of ICF Core Sets involved a rigorous scientific procedure aimed at reducing the number of ICF categories to those that are most significant for a given condition. This procedure comprises of four international, multiperspective preparatory studies. ICF Core Sets have been developed for diagnoses such as cerebral palsy, depression, and bipolar disorder, but not yet for any DSM-5 defined neurodevelopmental disorder. The Center of Neurodevelopmental Disorders at Karolinska Institutet (KIND), in collaboration with the ICF Research Branch, a cooperation partner within the WHO Collaboration Centre for the Family of International Classifications in Germany (at DIMDI), and the European Network for Hyperkinetic Disorders (EUNETHYDIS), initiated the development of ICF Core Sets for ADHD and autism which will be more diagnosis specific, which are more operationalised for different age groups. REFERENCES: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, 5th ed., text revised. World Health Organisation- International Classification of Functioning, Disability and Health (ICF) framework Ipeleng K Mahapa-Musekene is a 4th year Psychiatry registrar University of Limpopo. Correspondence: [email protected] Ipeleng K MahapaMusekene
28 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 GAMING ADDICTION IN ADHD: M A N A G E M E N T A N D T R E AT M E N T PRESENTED BY HUGO THERON Ipeleng K Mahapa-Musekene I mpulsivity can be defined as acting without forethought, the inability to postpone reward with preference for immediate reward over delayed but more beneficial reward or lacking the will power to not give into temptations. Compulsivity is characterized by an inability to adapt behaviour even after a negative outcome or feedback, or the inability to terminate ongoing actions. When impulsivity results in the inability to stop initiating actions, compulsivity is the inability to terminate those actions. Neuroanatomically these systems engage on different loops. Impulsivity is associated with the brain circuit that involves the ventral striatum, the thalamus, the ventromedial prefrontal cortex, and anterior cingulate cortex. Compulsivity is in the dorsal striatum, thalamus, and orbitofrontal cortex. Impulsive acts can eventually become compulsive acts when neuroplastic changes occur. ADDICTION IS A GOOD EXAMPLE OF HOW AN IMPULSIVE ACT CAN BECOME COMPULSIVE. THE IMPULSE TO TAKE A SUBSTANCE INITIALLY LEADS TO GREAT PLEASURE BUT NOT ADDICTION. IF THE ACT OCCURS FREQUENTLY, COMPULSIVITY CAN OCCUR THAT IN TURN DRIVES THE INDIVIDUAL FROM SEEKING PLEASURE TO SEEKING RELIEF FROM DISTRESSING SYMPTOMS ASSOCIATED WITH WITHDRAWAL. Not everyone who uses substances gets addicted, similarly, with gaming addiction. Not everyone who plays internet games will become addicted. Some games are more intriguing than others. Some individuals maybe more impulsive by nature or have a more dysfunctional reward system. Impulsive traits and a dysfunctional reward system may confer a propensity towards excessive internet gaming, and when one plays internet games frequently, impulsive gaming can recruit the involvement of the habit system perhaps in some individuals more readily than others. This then triggers neuroplasticity in the compulsivity circuit. This, hypothetically, is the way gaming can become an addiction. There is not much evidence related to gaming addiction management. Psychological techniques related to substance addiction are a topic under research. Cognitive and behavioural therapy could show some efficacy. The rewarding effects of internet usage, the cognitive attitudes towards responsibility of one’s behaviour, and the subsequent reinforcement after internet usage can all contribute to the use of internet gaming. So, behavioural techniques such as limited internet usage, monitoring data usage, switching off the internet at certain hours can assist in improving usage of the internet and potentally assist in gaming addiction. Having strict rules on usage of gadgets can also be of use. Looking at the sociocultural view on internet usage, especially in recent COVID times, screen time has exponentially increased as people had to socialize virtually. In limiting screen time, one could attempt to control the use of internet. Management of comorbid ADHD should improve the impulsivity, and theoretically reduce the propensity to develop addiction. Management of comorbid conditions in gaming disorder is imperative. There are no pharmacological modalities for gaming addiction. REFERENCES: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, 5th ed., text revised. Kaplan & Sadock's Synopsis of Psychiatry 12th Edition is written by Robert Boland; Marica Verdiun; Pedro Ruiz and published by Wolters Kluwer Health. Ipeleng K Mahapa-Musekene is a 4th year Psychiatry registrar at the University of Limpopo. Correspondence: [email protected] Ipeleng K MahapaMusekene
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 29 REPORT – ADHD CONGRESS 2023 ADHD AND SCREEN TIME – THE CHICKEN OR THE EGG PRESENTED BY BRENDAN BELSHAM Nelao Mhata T here is a surge in the diagnosis of ADHD. It has been observed that there has been at least a doubling of ADHD diagnoses as well as prescribing of ADHD medications in different countries. In parallel to this, is the increase in screen time among toddlers and children that has been exacerbated by Covid-19, and continued to be high even post Covid. There is a correlation between ADHD symptoms and excessive screen time use. Further, questions have risen whether screen time predisposes to the diagnosis of ADHD or if an ADHD diagnosis predisposes a child to increased screen time, or if there is a shared vulnerability? A STUDY IN EARLY TV EXPOSURE IN CHILDREN LESS THAN 3 YEARS OLD FOUND AN INCREASED RISK OF ATTENTIONAL DIFFICULTIES DURING SCHOOL, BUT FROM 4 YEARS OLD, THIS EXPOSURE WAS NOT ASSOCIATED WITH A HIGHER RISK. THE TYPE OF CONTENT AND SCREEN SPEED ALSO MATTERS. THE FIRST 1000 DAYS ARE IMPORTANT BECAUSE OF BRAIN DEVELOPMENT, AND CERTAIN MILESTONES. The brain responds to how it’s used, and intensive touchscreen use has been found to cause expansion of cortical representation for fingers and thumbs i.e. it can reorganize the somatosensory cortex. There is a fear this happens at the expense of other cognitive skills. Children with excessive screen use were found to have poor development of language, poor emotional attachment and it can lead to poor emotional self-regulation. Impact of excessive screen time includes: - Excessive screen use reduces opportunity for sleep. - Sleep deprivation in turn causes inattention. - Impacts emotionally - Increased snacking and eating whilst watching tv, and decreased physical exercise may increase the risk of obesity. Obesity and ADHD have a bidrectional relationship Development of ADHD has been correlated with amount of screen time use at different ages, hence one wonders about late onset ADHD and if exposure to electronic media may be contributing to emergence of ADHD later in life. Excessive screen time increases ADHD due to direct mechanisms and indirect mechanisms such as: - obesity. - ADHD makes screen activity attractive. - There is immediate reward from screen time or in gaming since children with ADHD struggle with delayed gratification. - High stimulation nature of gaming - ADHD patients are reward dependent hence the strong association between ADHD, substance use and gaming. ADHD has been found to predict problematic screen time use. ADHD and screen time use possibly also share the same biological vulnerability i.e. linked to similar brain regions such as frontal lobe and anterior cingulate lesions. MANY CHILDREN WITH ADHD HAVE PARENTS WITH ADHD, HENCE SOME HAVE INADEQUATE PARENTAL CONTROL. Therefore, one needs to treat both the chicken and the egg. Manage both the excessive screen time use and educate parents. Treat the child’s ADHD as well as intervene with the parents, because evidence is that adult ADHD impacts parenting skills. Parents need to implement boundaries around screen time, and internet usage decreases with ADHD treatment. Hence, there is a need to consider both the infant and caregiver’s screen time e.g. a mother on her phone during a family meal has a negative impact on the child and there is a link between insecure disorganized attachment and ADHD symptoms. Nelao Mhata Nelao Mhata is a 4th year Psychiatry registrar at the University of KwaZulu Natal. Correspondence: [email protected]
30 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 THE USE OF OUTCOMEBASED MEASURES FOR NEURODEVELOPMENTAL DISORDERS PRESENTED BY STEPHEN FARAONE Nelao Mhata B enefits of outcome-based measures include identifying non-responders early, engaging patient and family and supporting interdisciplinary communication. The International Consortium for Healthcare Outcome Measurement (ICHOM) is based in many different countries and creates a set of measurement outcomes for neurodevelopmental disorders (NDD). IT ALSO DEVELOPS STANDARDIZED MEASUREMENT TOOLS HENCE THERE IS A VALUE-BASED CARE WHICH HELPS TO SERVE THE BEST INTERESTS OF THE PATIENT. Their goal is to make the tools global, but this is currently challenging because they are not validated in all countries. Their principles for the set development include: - Outcomes defined around a medical condition. - Patients who are directly involved in capturing symptoms, and quality of life. ICHOM is made up of working clinicians who are members and experts in making sets and involved in the ADHD world. They conduct multiple meetings via Zoom discussing different measures and outcome domains, brainstorming, voting upon to finally choose a set and then define different domains. There is also a patients’ advisory group, who give their input and other professional input is also requested. The neurodevelopmental scope: - Include diagnoses i.e. ADHD, Communication disorders, motor disorders etc. - Age between 3 to 20 years old - Relevant treatments modalities NDD set outcomes: - Areas to address for ADHD included ADHD symptoms; but for each of the other disorders, other measurement outcomes were identified i.e. for Specific Learning Disorder they identified reading accuracy, comprehension etc. - For ADHD, they assessed 64 outcome measures and they had to go through them to come up with outcome measures. Inclusion criteria for outcome measures: - Need to fit in the measuring model - Has to be validated - Has to have content validity - Needs to be reliable - Needs to be easily interpreted by clinician - Has to be licensed - Tools need to cover age that was being looked at - Other reports – such as from teachers NDD TOOL SELECTION: ADHD – Patient reported outcome measures included -SNAP-IV, ADHD rating scale, VADRS Impact, functioning, and quality of life outcomes – KIDSCREEN was the best to use for QOL Other domains associated with ADHD – i.e. fot depression / mood symptoms the RCAD was used. Results: - 40 participants, 73% had ADHD Patient validation survey - 70% of the participants endorsed the outcomes that were suggested Survey for Health Care Professionals (HCP) involved with patients Nelao Mhata
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 31 REPORT – ADHD CONGRESS 2023 - 32 participants - 70% of the HCPs also endorsed the suggested outcome measures Strengths - Working group – had 2 patient representatives, so there was input from patients - External validation from service users and experts - High rates of endorsement Limitations - Limited to age of 3 to 20 years because adult measures are not similar to children measures - Heterogeneity of NDD, does not allow in depth evaluation of disorders - One case, outcome measure was not identified Future research: - NDD Working Group (WG) will update the set as advances in measurements are made, but dramatic change is not expected to occur as these measures have been around for some time - Hopefully data reported from the set will become a useful tool for researchers and guide further research In summary: NDD sets from ICHOM Project - Feasible across many cultures - Free measurements - Low administrative burden - Can be implemented electronically - Measurements don’t require clinicians to spend time with patients - They are all patient reported – hence it’s a useful adjunct to the clinical interview - THE NDD SET PRIORITIZES SELF OR CARE GIVER REPORT, AS TEACHERS REPORT CAN BE DIFFICULT TO OBTAIN To overcome barriers - Train and educate clinicians. - Integrate them into health records - Engage patients and caregivers - Continuous research and validation of tools Future of Measure based tools in NDD - Tools need to be integrated with telehealth platforms. - Real time data analytics using machine learning tools. - Predictive modelling to predict patient outcomes. - Enhance patient-clinician collaboration. Nelao Mhata is a 4th year Psychiatry registrar at the University of KwaZulu Natal. Correspondence: [email protected] Life Path Health is a group of private mental health hospitals with inpatient facilities in the Western Cape, Soweto and Kwazulu-Natal. We assist psychiatrists in launching their private practices to meet the high demand for quality mental health care in South Africa. To find out more, please contact COO Dr Karen Olckers at [email protected] www.lifepathgroup.co.za
32 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 GUT-BRAIN AXIS IN ADHD Princess Nhlapo T he talk by Suntheren Pillay offered valuable insights into the intriguing relationship between gut health and Attention Deficit Hyperactivity Disorder (ADHD). Dr. Pillay began by explaining the concept of the gut-brain axis and its relevance to ADHD as follows: • Gut-Brain Axis: The gut-brain axis is a bidirectional communication system between the gastrointestinal tract and the brain. It involves complex interactions between the gut microbiota (the community of microorganisms in the digestive system), the immune system, and the central nervous system. EMERGING RESEARCH HAS HIGHLIGHTED THE ROLE OF THIS AXIS IN INFLUENCING VARIOUS ASPECTS OF MENTAL HEALTH, INCLUDING MOOD AND BEHAVIOUR • Microbiota Composition: Some studies have shown differences in the composition of gut microbiota in individuals with ADHD compared to those without the condition. It is believed that an imbalance in gut bacteria, known as dysbiosis, might contribute to ADHD symptoms. Factors like diet, antibiotic use, and lifestyle can influence microbiota composition. • Inflammation and the Immune System: The gut is a significant site of interaction between the immune system and the microbiota. Dysregulation of the immune response and chronic inflammation are associated with various neurological and psychiatric conditions, including ADHD. Gut dysbiosis can potentially trigger an inflammatory response that affects brain function. • Neurotransmitters and Metabolites: Gut bacteria can produce neurotransmitters and metabolites that influence brain function. FOR EXAMPLE, CERTAIN BACTERIA CAN PRODUCE NEUROTRANSMITTERS LIKE SEROTONIN AND DOPAMINE, WHICH PLAY A ROLE IN MOOD REGULATION AND ATTENTION. CHANGES IN THESE NEUROTRANSMITTER LEVELS CAN POTENTIALLY IMPACT ADHD SYMPTOMS. • Dietary Factors: Diet is known to influence both gut health and ADHD. Some dietary patterns, such as high-sugar and processed food diets, have been associated with an increased risk of ADHD symptoms. Conversely, diets rich in fibre, omega-3 fatty acids, and probiotics (beneficial bacteria) may have a positive impact on gut health and potentially improve ADHD symptoms. The talk delved into recent research findings, citing studies that suggest a potential link between gut microbiota composition and ADHD symptom severity(Sukmajaya et al., 2021). Dr. Pillay presented compelling evidence showing alterations in gut bacteria among individuals with ADHD, sparking interest in the role of microbiota in the disorder. Dr. Pillay concluded the talk by highlighting the potential therapeutic implications of targeting the gut microbiota in ADHD management. While further research is needed, the idea of using probiotics or dietary interventions to modulate gut health is gaining traction. Dr Nhlapo is a 4th year Psychiatry registrar, University of the Witwatersrand. Correspondence: [email protected]
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 33 REPORT – ADHD CONGRESS 2023 IS IT ADHD OR EARLY COGNITIVE DECLINE? Princess Nhlapo T he talk by Jane Indergaard offered a thoughtprovoking exploration of the challenges in distinguishing between these two conditions which aimed to shed light on the diagnostic complexities faced by clinicians and researchers. Dr. Indergaard began by defining ADHD as a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity. Early cognitive decline, on the other hand, refers to a decline in cognitive abilities that occurs earlier in life than typical age-related changes. The talk delved into the diagnostic challenges posed by overlapping symptoms, such as forgetfulness and distractibility, which can be observed in both conditions. Dr. Indergaard highlighted the importance of a thorough assessment and consideration of various factors in making an accurate diagnosis. MANY OLDER ADULTS WITH ADHD WERE NOT DIAGNOSED DURING CHILDHOOD OR ADOLESCENCE. ADHD WAS NOT AS WIDELY RECOGNIZED IN THE PAST, AND DIAGNOSTIC CRITERIA HAVE EVOLVED OVER TIME. CONSEQUENTLY, INDIVIDUALS WITH UNDIAGNOSED OR UNTREATED ADHD MAY REACH ADULTHOOD WITHOUT A FORMAL DIAGNOSIS. ADHD symptoms can change as individuals age. While hyperactivity may diminish in adulthood, difficulties with attention, organization, and time management often persist. Older adults may experience increased forgetfulness, difficulty multitasking, and challenges with completing tasks efficiently. While there is no definitive causal relationship established, several mechanisms have been proposed to explain the potential association between ADHD and neurocognitive disorders: • Common Genetic Factors: There is evidence to suggest that both ADHD and certain neurocognitive disorders have a genetic component. Some genes associated with ADHD have also been implicated in neurocognitive disorders. It's possible that common genetic factors or genetic variations may contribute to an increased risk for both conditions in some individuals.(Grünblatt et al., 2023) • Neurobiological Factors: Both ADHD and neurocognitive disorders can involve abnormalities in brain structure and function. For example, in ADHD, there may be differences in the size and connectivity of certain brain regions, particularly those related to attention and executive functions. Neurocognitive disorders, on the other hand, are characterized by progressive brain changes and neurodegeneration. It is possible that shared neurobiological factors or vulnerabilities contribute to the association between these conditions. • Aging Effects: As individuals with ADHD age, they may experience changes in cognitive function that are typical of the aging process. These age-related cognitive changes can sometimes mimic or overlap with symptoms of certain neurocognitive disorders, leading to diagnostic challenges. It's important to note that while these mechanisms offer insights into the potential association between ADHD and neurocognitive disorders, more research is needed to establish clear causal links and better understand the nature of this relationship. Not all individuals with ADHD will develop neurocognitive disorders, and many factors, including genetics, lifestyle, and the presence of comorbid conditions, can influence an individual's risk. Early diagnosis and appropriate management of both ADHD and neurocognitive disorders are crucial for optimizing outcomes and quality of life. Dr. Indergaard's talk on distinguishing between ADHD and early cognitive decline underscored the complexities faced by clinicians and researchers. Accurate diagnosis and appropriate interventions are crucial in ensuring the well-being of individuals affected by these conditions. Further research in this area is essential for improving diagnostic accuracy and treatment strategies. Dr Nhlapo is a 4th year Psychiatry registrar, University of the Witwatersrand. Correspondence: [email protected]
34 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 C U L T U R A L L Y APPROPRIATE EVALUATION FOR ADHD Princess Nhlapo T he talk on the "culturally appropriate evaluation for ADHD" by Kwabena KusiMansh offered valuable insights into culturally appropriate evaluations of ADHD playing a pivotal role in ensuring accurate diagnoses and tailored interventions for individuals from diverse cultural backgrounds. The talk highlighted how cultural norms and values can significantly influence how ADHD symptoms are perceived and reported. For instance, in some cultures, hyperactivity and impulsivity may be seen as normal behaviour in children. UNDERSTANDING THESE CULTURAL VARIATIONS IS CRUCIAL TO AVOID MISDIAGNOSIS OR UNDERDIAGNOSIS. Cultural competence involves being aware of one's biases and beliefs and adapting assessment strategies to align with the cultural background of the individual. This approach fosters trust and collaboration, increasing the accuracy of ADHD evaluations(Kusi-Mensah et al., 2022). Practical Guidelines for Culturally Appropriate ADHD Evaluations • Culturally Tailored Assessment Tools: Utilize assessment tools that have been adapted or validated for specific cultural groups, if available. • Language Access: Ensure that assessment materials and discussions are conducted in the individual's preferred language, utilizing interpreters when necessary. • Cultural Sensitivity: Be aware of cultural nuances, such as communication styles, familial roles, and taboos related to mental health. • Collaboration: Engage with culturally competent professionals who can provide insights and help navigate cultural considerations. Dr. Kusi-Mansh highlighted the importance of culturally appropriate evaluations of ADHD to ensure accurate diagnoses and effective interventions. By recognizing cultural factors, adopting cultural competence, and following practical guidelines, healthcare professionals can provide more comprehensive and meaningful assessments for individuals from diverse cultural backgrounds, ultimately improving their overall well-being. REFERENCES Grünblatt, E., Homolak, J., Babic Perhoc, A., Davor, V., Knezovic, A., Osmanovic Barilar, J., Riederer, P., Walitza, S., Tackenberg, C., & Salkovic-Petrisic, M. (2023). From attention-deficit hyperactivity disorder to sporadic Alzheimer’s disease—Wnt/mTOR pathways hypothesis. Frontiers in Neuroscience, 17. https://doi.org/10.3389/fnins.2023.1104985 Kusi-Mensah, K., Nuamah, N. D., Wemakor, S., Agorinya, J., Seidu, R., Martyn-Dickens, C., & Bateman, A. (2022). A Systematic Review of the Validity and Reliability of Assessment Tools for Executive Function and Adaptive Function Following Brain Pathology among Children and Adolescents in Low- and Middle-Income Countries. In Neuropsychology Review (Vol. 32, Issue 4, pp. 974–1016). Springer. https://doi.org/10.1007/s11065- 022-09538-3 Sukmajaya, A. C., Lusida, M. I., Soetjipto, & Setiawati, Y. (2021). Systematic review of gut microbiota and attention-deficit hyperactivity disorder (ADHD). In Annals of General Psychiatry (Vol. 20, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s12991- 021-00330-w Dr Nhlapo is a 4th year Psychiatry registrar, University of the Witwatersrand. Correspondence: [email protected]
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 35 REPORT – ADHD CONGRESS 2023 ADHD IN PRESCHOOL CHILDREN IN A LOW SOCIOECONOMIC SETTING PRESENTED BY DR HELEN CLARK Sandisiwe Dyonase Adiagnosis of ADHD should be made only after a comprehensive assessment by a specialist with expertise in ADHD. Appropriate psychological, psychosocial and behavioural interventions should be put in place. THE PRESCHOOL ADHD TREATMENT STUDY (PATS; GREENHILL ET AL, 2006) It was the first randomized clinical trial- evaluating the use of methylphenidate in preschool children with ADHD and it was a double- blind placebo controlled parallel study. FINDINGS OF THE STUDY: Use of methylphenidate: o Was safe and generally well tolerated o More adverse events than older children Specific adverse events: o Irritability o Emotionality o Appetite loss o Trouble sleeping o Skin picking o Becoming worried No discontinuation for cardiovascular reasons Initial growth rate slowing SYMPTOMS OF ADHD (ALSO SEE DSM 5-TR CRITERIA) o Running, jumping and climbing o Always on the go o Never sits still o Noisy o Aggression o Tantrums o Loses and break things o Getting expelled from school ADHD can be diagnosed from the age of 3. It can either be hyperactive or inattentive or combined subtype. RISK FACTORS o Persistently high levels of adverse circumstances in pregnancy and birth e.g. maternal stress o Family dysfunction, instability and violence. o Poverty o Physical, emotional, sexual abuse and neglect o Multiple changes of caregivers in early life o Multiple negative life events o Parental mental illness o Refugee status o Too early school placement COMORBIDITY o Oppositional defiant disorder o Conduct disorder o Autism spectrum disorder o Speech delay o Global developmental delay o Anxiety and related disorders o Attachment difficulties MANAGEMENT Medication options 1. Methylphenidate 5mg @ 7h00am, 11h00am, 15h00pm. It can be titrated up depending to the response 7.5mg 2. 10mg @07h00am 11h00am, 15h00pm 3. Psychoeducation 4. Parent training programs 5. Alternative strategies/additional options ADVERSE EVENTS: o Insomnia o Appetite suppression o Raised blood pressure and pulse rate o Growth deceleration o Rebound phenomena o Prolonged periods of emotional instability o Irritability CONCLUSION IT IS IMPORTANT WHEN WORKING WITH THIS GROUP OF CHILDREN TO UNDERSTAND NOT ONLY THE CORE ADHD AND COMBINED DIAGNOSES, BUT ALSO THE REAL CHALLENGES EXACERBATING THEIR PRESENTATION AND COMPRISING THEIR CARE. There is a real risk to not intervening. It is the responsibility of the doctor to use the limited resources in the best and safest way possible towards enhancing the development and safety of these special children. Sandisiwe Dyonase is a 3rd year Psychiatry registrar at the University of Pretoria. Correspondence: [email protected] Sandisiwe Dyonase
36 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 C O M O R B I D I T Y AND LIFESTYLE Phumla Gasa CHILDREN WITH DIABETES TYPE 1 AND PROBLEMS THAT ARISE WHEN ADHD IS NOT IDENTIFIED PRESENTED BY ELIZABETH FERNELL Diabetes is known to be one of the most chronic conditions in children with type one diabetes being higher in children and young adults. In this population autoimmune, environmental and genetic factors contribute to its development. The known knowledge- As diabetes is common in children, this has led to research around around its association with attention deficit and hyperactivity disorder (ADHD) a neurodevelopmental disorder that also has genetic and environmental factors linked to it. Findings in a paper titled - “Children and adolescents with type 1 diabetes and high Hb1Ac: a neurodevelopmental perspective” (Nylander et al) showed that: high HbA1c was seen more often in adolescent diabetes patients with neurodevelopment disorders. This finding was seen in children/adolescents between the ages of 12-16 years of age, with memory and learning problems being high. THE PROPOSED EXPLANATION FOR THIS IS THAT NEURODEVELOPMENTAL DISORDERS MIGHT PRECEDE THIS POOR METABOLIC CONTROL AND EARLY DETECTION OF NEURODEVELOPMENTAL DISORDERS MIGHT ALLOW PATIENT SPECIFIC TREATMENT TO BETTER CONTROL THIS RISK. Looking at ADHD specifically and type 1 diabetes, when addressing a management plan for this co morbidity, special attention needs to placed on these children due to the nature of the disorder (ADHD) and challenges these individuals face based on ADHD symptomatology. This has been echoed by the research by Ida Lindblad et al, “Adolescents with type 1 diabetes mellitus and attention deficit/hyperactivity disorder require specific support from healthcare professionals”. The complexities that arise in both diagnoses and the difficulties faced in the control and management of both conditions has led to the need to be able to create a fine balancing act between the management of ADHD symptoms and achieving better diabetes control. O B E S IT Y A N D A D H D PRESENTED BY ANDRE VENTER Obesity is a known health risk that can cascade to the development of multiple medical problems and cause co-morbidities. High levels of obesity have been seen in children. With ADHD being a neurodevelopmental disorder, a disorder encountered in the developmental period in children, it is important to understand the influence both these conditions - obesity and ADHD have on each other. RESEARCH HAS SHOWN THAT THE PHENOTYPE OF OBESITY AND ADHD HAS A GENETIC LINK. Looking at obesity related factors that have been seen to manifest as ADHD: binge eating (associated impulsivity, dopamine dysregulation and its effects on executive functioning leading to food addiction); excessive day time sleepiness (hypoarousal/ excessive day time sleepiness in obesity- sleepy children could be more hyperactive/ impulsive as a strategy to stay awake and the late sleep phase nature of ADHD can dysregulate appetite hormones leading to overeating). Other common factors between obesity and ADHD include altered reinforcement patterns leading to ‘reward deficiency syndrome’ which can result in unnatural means of reinforcement; brain factors and BDNF; chronic inflammation associated with obesity and its impact on brain functions and also on ADHD and executive function are other links between the two conditions. Flipping the coin, Karhunen et al found the link between obesity and ADHD to be bidirectional. ADHD impact on obesity included: impulsivity and deficient inhibitory control may lead to disorganised eating pattens, inattention could also result in difficulties in following a routine eating pattern Phumla Gasa
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 37 and eating could be used to remedy boredom or to cope with the awareness of inadequacies in attention. A sedentary lifestyle and increased time spent on ‘leisure’ activities such as screen time also adds to the impact of ADHD on obesity. The factors noted above have led to the need to address the impact of both the conditions on each other and although complex, treatment needs to focus on addressing both conditions with equal priority for the successful management of obesity and ADHD. It is important to make sure that psychoeducation forms the basis of the management plan. EATING DISORDERS, ADHD AND DIET PRESENTED BY TANYA HUBER The impact of diet on ADHD is topical, with popular culture or media advocating for multiple food restrictions, foods to avoid and dietary supplements. Is the association between diet and ADHD such an obvious factor that should be followed as a script or is there more literature which can add to influence our views? LITERATURE HAS SHOWN THAT THERE IS LACK OF EVIDENCE ON CERTAIN DIETARY RESTRICTIONS AND THIS COULD INSTEAD CONTRIBUTE TO NUTRITIONAL DEFICIENCIES. THERE ARE ALSO ADDED CHALLENGES TO ADHERING TO A STRICT DIET. ADVOCACY FOR ADDED SUPPLEMENTS LIKE FREE FATTY ACIDS HAS BEEN SEEN TO BE LACKING BASED ON ADHD ALONE AND MAY RESULT IN DRUG INTERACTIONS. The symptomatology of ADHD and challenges an individual faces with this disorder can influence eating patterns, so to can the medication used to treat ADHD. Ultimately the disorder itself and the pharmacological management of the disorder can result in disorganised eating patterns. Equipping individuals with better tools, such as a ‘buddy’ to assist with ongoing support, support groups, guidance on certain apps and teaching better eating habits (meal planning, simple recipes etc) can assist with diet and minimise disordered eating patterns. EXERCISE IN THE MANAGEMENT OF ADHD PRESENTED BY JAMES BURGER There are many benefits of exercise on mental and physical health. Exercise has been shown to assist with cognition, improve motor skills and co ordination, as well as assist in improving the side effects of medication, namely of ADHD and in the management of comorbidities associated with ADHD. For this reason it is important understand the reason for and the benefits of exercise and why they need to be include in the management plan for children and adolescents with ADHD. ADHD is a neurodevelopmental disorder and can have negative effects on a child’s executive function and other aspects of cognition. Research by Lasse Christiansen et al suggested that the effects of exercise on cognition (and on general child heath) makes it a safe and easily accessible alternative adjuvant treatment option in children with ADHD. Recommendations on the specificities of the exercise such as mode of exercise have not yet been clear. Besides cognition, the general symptoms of ADHD and comorbid mood and anxiety problems have been shown to improve with exercise according to preliminary evidence. As with all treatment modalities, exercise does not come without its ‘side effects’ and risks such as resulting injuries, muscle soreness and possible concussions when looking at high impact modes of exercise. The general rule of “start low and go slow” that is used with pharmacotherapy in Psychiatry, should also be applied when implementing exercise in the treatment plan. CHOICES SHOULD BE PATIENT CENTRED LOOKING AT THE INDIVIDUAL’S NEEDS AND CAPABILITIES SO AS TO HELP WITH MOTIVATION IN ORDER TO MAKE EXERCISING A LIFESTYLE CHOICE. The ‘FITT’ principle: frequency, intensity, time, type can assist in guiding the exercise choices. The World Health Organisation recommends that a child (3-4 years of age) being active for at least 3 hours per day with 1 hour of that time spent on vigorous activity through the day or (5-17 years of age) 1 hour per day of moderate to vigorous exercise including aerobic activity. IN BOTH AGE GROUPS DECREASING SCREEN TIME AND AVOIDING A SEDENTARY LIFESTYLE IS RECOMMENDED. When using exercise as an adjuvant treatment choice, some practicalities in prescribing in ADHD include considerations such as: team vs individual forms of exercise, allowing variation in choices to prevent boredom, use for socialising and assisting with prosocial behaviour and most of all it has to be enjoyable to the individual. Due to the challenges faced in the South African setting other things to consider include accessibility, affordability and safety concerns. With all the increasing interest in looking at exercise and ADHD, medication/ pharmacotherapy is still needed in the treatment plan and just like any adjuvant therapy, exercise works in combination with the existing treatment plan. REPORT – ADHD CONGRESS 2023 Phumla Gasa is a 4th year Psychiatry registrar at the University of KwaZulu Natal Correspondence: [email protected]
38 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 PSYCHOSOCIAL INTERVENTIONS Kgapuru Mashishi COACHING FOR ADHD PRESENTED BY ADELA BAKER (ADHD COACH - USA) B enefits of outcome-based measures include identifying non-responders early, engaging patient and family and supporting interdisciplinary communication. The International Consortium for Healthcare Outcome Measurement (ICHOM) is based in many different countries and creates a set of measurement outcomes for neurodevelopmental disorders (NDD). ADHD coaching is a relatively new field that has become more prominent recently in other parts of the world. Coaching complements medication and other non-pharmacological interventions, it does not replace medication. Working with an ADHD coach allows you to explore your strength and opportunities in spite of your ADHD diagnosis. In this session the importance of ADHD coaching was discussed. ADHD coaching is conducted by a trained and qualified professional who assists individuals to come up with ways to deal with their day to day activities and responsibilities that might be impacted by ADHD. It is a tool that can be used with medication to help get the patient organized and reach their goals. It is a practical intervention that specifically targets the core impairments of ADHD such as planning, time management, goal setting, organization and problem solving. It addresses the academic, emotional, vocational and interpersonal difficulties. Teenagers and adults that are diagnosed with ADHD can benefit from the ADHD coaching. IN THESE SESSIONS, PATIENTS ARE PROVIDED WITH EDUCATION ABOUT ADHD, LEARN HOW THEIR BRAIN WORKS, WHAT KIND OF SUPPORT THEY MIGHT NEED AND SELF-ADVOCACY. An ADHD coach helps their clients to learn practical skills and to initiate changes in their daily lives, supporting clients by providing feedback, encouragement and practical suggestions to address specific challenges as well as supporting them and holding them accountable for following through on their goals The duration of the coaching differs based on the coach and the client, however it mostly takes approximately 12 weeks attending hourly sessions on a weekly basis. The coach also does check-ins in between the sessions to follow up on what was agreed upon in the last session. These sessions can be conducted in person, online, or by phone Most ADHD coaching is based on Cognitive Behavioural Therapy(CBT), it assists patients to be mindful, and it also discusses issues around the importance of exercise, sleep and diet in the management of ADHD. ADHD COACHING IS A COLLABORATIVE PROCESS, SO IT IS IMPORTANT TO FIND THE RIGHT MATCH. IT CAN BENEFIT THE INDIVIDUAL TO ACHIEVE PHYSICAL AND EMOTIONAL IMPROVEMENT, INTELLECTUAL GROWTH AND EDUCATIONAL DEVELOPMENT ETC. Benefits of ADHD coaching include: • Understanding ADHD- This includes being educated about the ADHD symptoms and the impact they they have on goal setting- This helps people to identify and prioritize their needs and improve quality of life • Self- advocacy- People with ADHD may need to advocate for their needs especially in the school and workplace • Relationships- Coaching might help individuals Kgapuru Mashishi
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 39 REPORT – ADHD CONGRESS 2023 to learn valuable skills that can impact their relationships positively The sessions will include education on ADHD, incorporate new skills, improve emotional problems, personalized strategies, genuine support network and realizing self-awareness It Is also important to find an ADHD Coach that has suitable credentials, who is trained and qualified as this will ensure that patients sought the most appropriate service. The credentials can be looked up on coach federation and ADHD coaches. USING ADHD COACHES THAT ARE NOT TRAINED CAN HAVE A NEGATIVE IMPACT IN THE INDIVIDUAL'S LIFE PARENTAL SUPPORT IN ADHD PRESENTED BY KARLA PRETORIUS (REGISTERED COUNSELLOR AND A MENTOR) Attention Deficit Hyperactivity Disorder(ADHD) is a neurodevelopmental disorder with persistent, impairing inattentive, disorganized, hyperactive and impulsive behaviour behaviour. THIS SESSION ON PARENTAL SUPPORT IN ADHD WAS VERY INTERESTING BECAUSE MOST OF THE TIME WHEN ADHD IS DISCUSSED, EMPHASIS IS PUT ON PHARMACOLOGICAL MANAGEMENT OF ADHD. The session highlighted the importance of parental support in dealing with a child with ADHD in order for the child to improve their attentiveness, focus, be less impulsive and hyperactive. There were key elements that were discussed as part of what parents can do to assist their children. There are seven (7) key elements that can be used in effectively supporting an ADHD child: A. VISUAL CLUTTER Due to the fact that patients with ADHD have poor focus, poor attention and are easily distracted, ensuring that the room is clear of unnecessary items is important. • Parents should ensure that there is no clutter or unnecessary visual stimuli on the child’s working station. • There should be clear boundaries for each work or play station. • Use transition cues to move from one activity to the other B. VISUAL SUPPORT • Make use of a visual schedule, where you put all the to do list for the day including things as small as when to have meals. • Visual schedules provide clear expectations, promote predictability, promote structure and clear boundaries • A visual choice board can be used by putting real photos of items the child likes so that the child can visualize what they will gain/get after completing a certain task. • These boards should be placed where the child can see them and they should be categorized such as games, snacks, sensory etc. C. TRANSITION CUES • USE EITHER VISUAL, AUDITORY OR TACTILE CUES TO ALERT THE CHILD THAT THEY NEED TO MOVE FROM ONE ACTIVITY TO THE NEXT. THIS CAN ALSO BE USED DURING SCHOOL TESTS AS CHILDREN WITH ADHD SOMETIMES TAKE LONGER ON ONE QUESTION AND FIND IT DIFFICULT TO MOVE ON. • Visual cues can include cards or specific visual patterns. • Auditory cues can include things like a timer or a specific sound. • Tactile cues can involve giving a child a tap on the shoulder to indicate that it’s time to move to the next activity. D. LOW AROUSAL TONE • Speaking with a low arousal tone can reduce anxiety and help a child to relax and express themselves confidently. • Use short and concise language when giving instructions E. CHILL SPACE • This is a much needed calming and safe space for a child to receive sensory input. • Things that can be included in this space include: - Visual: Fairy lights - Auditory: Music, Headphones to block out noise - Tactile: Different textures - Smell: Certain smells that the child loves - Taste: The type of food your child loves - Proprioception: Stress balls • The space should be easily accessible for the child and be able to be used without supervision
40 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 F. FUNCTIONAL ROOMS • Child needs to know the purpose that each room serves i.e. study or play room. G. SENSORY SUPPORT • Using other sensory inputs to assist your child to complete a task. • This can include things like writing out prompts, use of yoga balls and sensory mats. THE INFLUENCE OF ADHD ON RELATIONSHIPS PRESENTED BY DR. MELANE VAN ZYL People who are diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) are inattentive, easily distractible, impulsive, have emotional dysregulation, communication difficulties and difficulty with organization and planning. The importance of this talk was to highlight how these symptoms of ADHD can affect patients’ relationships and what can be done to make improvements. IMPROVING RELATIONSHIPS OF PEOPLE LIVING WITH ADHD REQUIRES THEM TO UNDERSTAND THE ROLE THAT ADHD PLAYS IN THEIR RELATIONSHIP. THIS INVOLVES IDENTIFYING HOW THE SYMPTOMS OF ADHD INFLUENCE THEIR INTERACTION WITH OTHERS. This session discussed how Dialectical Behavioural Therapy (DBT) can assist patients with ADHD in improving their relationships. Emotional dysregulation is not included as a core symptom of ADHD however, most patients with ADHD have emotional dysregulation and DBT is a form of therapy that focuses on emotional regulation. DBT has four (4) modules namely: Mindfulness, Distress Tolerance, Emotional Regulation and Interpersonal effectiveness. IN DBT FOR RELATIONSHIPS, YOU NEED TO BE CLEAR OF WHAT IS THE IMPORTANT OUTCOME YOU WANT TO ACHIEVE FROM THE CONVERSATION WITH OTHERS. An abbreviation of DEAR MAN GIVES FAST SKILL was used. It is an interpersonal effectiveness skill that can be useful in improving communication and managing interpersonal relationships. This set of skills are used to effectively communicate your needs, wants and feelings in a clear and concise manner. The skill further assists individuals to communicate more effectively without being aggressive or passive. DEAR MAN is used to get what you want, and it is an acronym for: • Describe: You need to clearly describe what the situation is and always stick to the facts at hand. Avoid using judgmental language. • Express: Express how you feel about the situation and stay away from accusatory language or attacking the other person. • Assert: Be assertive by asking for what you want clearly, avoid making vague or unrealistic demands. • Reinforce: Explain the positive effects of getting what you want and how your situation will improve if the request is granted. • Mindful: Be mindful of what you say and of your goal to be achieved throughout the conversation and avoid being distracted. • Appear Confident: Make use of a confident tone when speaking. • Negotiate: Be open to negotiate and compromise, get the other person’s opinion and find a solution that works for both parties. Use GIVE in trying to maintain relationships, which is an acronym for: • Be Gentle: Be respectful when engaging with others. • Act Interested: Listen and show interest in what others are saying and don’t interrupt them. • Validate: Validating others opinions and feelings by showing them that you understand their feelings is important • Use an Easy manner: Use non-threatening language and humor to engage with others Use FAST in maintaining self-respect and it stands for: • Be Fair: Be fair to self and others. • No Apologies: Do not apologize for being yourself unless you are in the wrong. • Stick to Values: Stick to your own values. • Be Truthful: Do not exaggerate the situation unnecessarily. The way that DEAR MAN GIVES FAST SKILL can be applied in everyday life is in a variety of settings including personal and professional relationships.
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 41 Kgapuru Mashishi is a Medical Officer at the University of the Witwatersrand. Correspondence: kgapurumashishi@ gmail.com REPORT – ADHD CONGRESS 2023 LIVING WITH ADHD PRESENTED BY MARGAUX JOFFE (CERTIFIED ACCESSIBILITY PROFESSIONAL AND DISABILITY INCLUSION CONSULTANT - USA). MS MARGAUX JOFFE IS A FOUNDER AND EXECUTIVE PRODUCER OF KALEIDOSCOPE SOCIETY WHICH IS A SOCIETY THAT SUPPORTS WOMEN WITH ADHD Living with Attention Deficit Hyperactivity Disorder (ADHD) can be very difficult, as the symptoms can make everyday activities more challenging. Psychiatrist William Dodson estimates that by age 12, children with ADHD receive 20 000 more negative messages from parents, teachers, and other adults than their friends or peers who do not have ADHD. MOST OF THE LITERATURE TALKS ABOUT WHAT PEOPLE LIVING WITH ADHD STRUGGLE WITH AND NOT WHAT THEY ARE GREAT AT. THIS TALK WAS VERY IMPORTANT IN HIGHLIGHTING SOME OF THE STRENGTHS OF PEOPLE LIVING WITH ADHD. People living with ADHD have common ADHD strengths such as: • Hyper-focus; • Creativity; • Empathy; • Curiosity; • Strong Sense of Justice; • Sense of Humour; and • Problem Solvers. Another important topic discussed was ADHD and employment barriers. 60% of adults with ADHD are more likely to be fired from their jobs and are estimated to earn less than those without ADHD. Shame and stigma prevents many from accessing treatment and support Some of the challenges that employees with untreated ADHD struggle with in the workplace are: Poor productivity • Due to the poor concentration, inattentiveness and poor organization & planning, people living with ADHD find it difficult to meet deadlines and be productive. • Memory challenges, time management and procrastination can also affect their productivity. Impulsiveness and loss of household income • Due to their impulsiveness, they may terminate work prematurely which leads to loss of income. • They also tend to be dismissed by employers due to their impulsiveness, emotional outbursts and difficult relationships. Stigma • Social rejection by peers, bullying and loss of promotions are some of the factors that can make people living with ADHD reluctant to access treatment. • They struggle with shame and guilt. Loss of Employment: • Employees with untreated ADHD are 30% more likely to have employment issues, 60% more likely to be fired from a job or three times more likely to quit a job impulsively. • Other issues include high absenteeism and making errors, and this can cause consequences including suspensions and termination. Teamwork: • Certain symptoms such as disorganization, poor planning and time management can make it difficult for people with ADHD to work in a team • IMPULSIVE BEHAVIOUR SUCH AS BLURTING OUT THINGS WITHOUT THINKING OF CONSEQUENCES • People with ADHD also have rejection sensitivity which makes them particularly sensitive to criticism • Due to their emotional dysregulation they might lose their temper and fight with coworkers • They also have problems with their supervisors due to their poor planning skills, time management and failure to follow through on commitments The session also discussed the power of peer support for ADHD. • Peer support assists in dispelling the stigma, creating belongingness, building of confidence, self-acceptance and healing. • Some of the things that can be done to assist people with ADHD is to be more empathetic and not judgmental, give positive feedback and strength based approach. • Understanding what interests people with ADHD will assist in understanding them better. • By providing clear structure, not deviating from the plan and clear priorities, people will lessen their anxiety around what needs to be done. • At the workplace having a team and supervisor who are open to learning and accepting people living with ADHD can have a positive impact.
42 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT – ADHD CONGRESS 2023 NOT SO SMART? “SMART” DRUGS INCREASE THE LEVEL BUT DECREASE THE QUALITY OF COGNITIVE EFFORT PRESENTED BY DAVID COGHILL Linda Mesani P revious studies have mentioned that medical students, and individuals in various sectors, especially the financial sector have a tendency to use cognitive enhancers. Medical students reported using cognitive enhancers at least once in their lifetime, with first use reported to be during college or medical school years. In the financial sector, some individuals admitted to using cocaine, methylphenidate etc. Those in asset management were more likely to report use of cocaine as a cognitive enhancer. They used these in the work place. Individuals in the commercial banking sector reported use of methylphenidate, modafinil or amphetamines as cognitive enhancers. The individuals who use these drugs are of the belief that these drugs assist them to concentrate better and become more productive. This session was about the efficacy of smart drugs on healthy individuals. It was based on a study that was published in various prestigious publications such as The Guardian, New Scientist, National Geographic and The Economist. The study was a randomised double-blinded, placebo-controlled trial. Individuals were given a single dose of either: a placebo or one of 3 stimulant drugs- methylphenidate, modafinil and dexamphetamine. Individuals were stratified between the placebo and the stimulants. They were then given the knapsack task to complete. The aim was to assess the impact of smart drugs on complex decision making, using the knapsack task. It was observed that the individuals on the stimulants appeared as though they were working harder. They made more moves compared to those on placebo. The moves were made faster as well. When productivity was assessed, the individuals on the placebo were found to be more productive than those on stimulants. Productivity was defined as gain in value per move. So even though the individuals on the stimulants appeared to be working hard and making more moves, and at a faster pace, there was actually no value in the moves they made. The individuals on placebo were more productive, thus made more moves with value, compared to those individuals on stimulants. There was especially negative productivity in individuals on dexamphetamine and methylphenidate. IT WAS THUS ESTABLISHED THAT IN THE INDIVIDUALS ON STIMULANTS, THERE WAS ACTUALLY LOSS OF PRODUCTIVITY. THE INDIVIDUALS HAD A SUBJECTIVE SENSE OF ACCOMPLISHMENT, AND WERE MOTIVATED TO WORK, BUT THIS DID NOT OBJECTIVELY RESULT IN PRODUCTIVITY. INSTEAD, THERE WAS A LOSS IN PRODUCTIVITY. Therefore, the stimulant drugs prescribed for ADHD, have no effect in healthy individuals. They do not increase performance. I found this session to be very informative, engaging and stimulating. I often get requests for prescriptions for Ritalin by university students and parents, who all believe that this helps with concentration, especially during exam time. So, this topic was quite relevant and informative. It debunked the prevailing belief that cognitive enhancers are helpful and efficient in enhancing one’s concentration and efficiency during studying in preparation for examinations or tests. I will use this study in deterring my healthy patients in their request of scripts for Ritalin. Linda Mesani Linda Mesani is a 4th year Psychiatry registrar, University of the Free State. Correspondence: [email protected]
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 43 REPORT – ADHD CONGRESS 2023 LET’S TALK ABOUT SEX IN ADHD PRESENTED BY KAREN VUKOVIC Linda Mesani T his session was about the impact of ADHD on relationships. The most common problems reported were with regards to relating. Individuals with ADHD had problems with communicating with their partners, such as being unable to sustain conversations, forgetting the topic at hand, blurting out things without thinking, inability to handle frustration and mood dysregulation. There are also conflicts with regards to non-completion of tasks and untidiness. These result in conflict and dissatisfaction within the relationship. ANOTHER WAY THAT ADHD CAN CAUSE CONFLICT IN RELATIONSHIPS IS THE FACT THAT, IT CAUSES AN INCREASE IN AGGRESSION. THIS CAN RESULT IN VIOLENCE, INCLUDING SEXUAL VIOLENCE. ADHD impacts the intimacy aspect of relationships as well. The core features of ADHD such as hyperactivity, impulsivity and inattention negatively impact intimacy. With inattention, individuals tend to be distractible, and lose focus during intimacy. With impulsivity and hyperactivity, the individuals tend to focus more on instant gratification and exhibit sensation seeking behaviour and risky behaviour. These result in low sexual satisfaction and even low selfesteem. There could be more sexual activity and masturbatory behaviour. These may be incorrectly used by the individuals, as ways to cope with the symptoms of ADHD. Partners of those with ADHD feel unsatisfied and unloved in the relationship. Males tend to masturbate frequently, but become less active in their relationships. Females tend to be physically harsh and too sexually demanding to their partners. They may also be easily bored and inattentive. Both genders may have sexual aversion. Females may have excitatory and orgasmic problems, while males may have orgasmic problems and premature ejaculation. Males may also have negative emotions after sex. There may be other sexual disorders such as, sadomasochistic desire, paedophilic desire and transvestic desire and activity. In children, ADHD in associated with neglect and abuse. It is also associated with conduct disorder. In adolescents, ADHD may result in risky sexual behaviours, such as early sexual debut, unprotected sex resulting in teenage pregnancies and acquiring STDs. Women with ADHD and history of sexual abuse often have aggression, bulimia and borderline personality disorder. They may also have lower paying jobs. This is in contrast to those with ADHD, without a history of sexual abuse. Sexual abuse on its own is associated with irritability, impulsivity and thrill seeking. This then compounds on the core symptoms of ADHD. Sexual abuse is increased in ADHD children with inattention type. The medication for ADHD may also result in undesired side effects, such as hypersexuality, excessive masturbation, spontaneous erections and ejaculations. Priapism may also be a side effect of the medication. There are some studies that report that some patients ~ 25% discontinue the use of Atomoxetine because of the undesired side effects, especially low sexual desire SOME STUDIES REPORT THAT THE MEDICATION MIGHT ACTUALLY IMPROVE SEXUAL FUNCTIONING. Before this session, I had actually never considered the impact of ADHD in relationships. This is an aspect that we tend to shy away from during history taking. Patients may present with anxiety or depressive symptoms that may actually stem from this, hence we miss the precipitating and maintaining factors. This was an eye-opening session. Linda Mesani Linda Mesani is a 4th year Psychiatry registrar, University of the Free State. Correspondence: [email protected]
44 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT SASOP SPECIAL INTEREST GROUP FOR ADHD TRAIN THE TRAINEE WORKSHOP Jannie van der Westhuizen On the 21st October 2023, a Train-theTrainee workshop for psychiatry registrars took place at the Birchwood Conference Centre in Johannesburg. The purpose of the Train-the-trainee workshop was to provide training to senior registrars in diagnostic and management aspects of ADHD. Twenty-one registrars attended the workshop. They were mainly from academic centres in the Eastern Cape, Gauteng, and Limpopo. Drs Jannie van der Westhuizen and Frans Korb presented the course material. The following topics were covered: neurobiology, diagnosis, pharmacological and non-pharmacological interventions for ADHD. Relevant neuropsychology, comorbidity, and psychotherapeutic interventions, as well as lifestyle management were also covered. It was very inspiring to experience these young colleagues’ enthusiasm and willingness to learn. They all gave excellent feedback. Feedback included the following: “The workshop was hugely beneficial, not only in preparing for FCPsych, but also in preparation for practice both in public and private sector”. “I found this training very useful and helpful, to not only assist with managing ADHD, but to psycho educate parents and patients about the condition.” “I think I have learnt more during this workshop about ADHD than I have going through a textbook.” The registrars described it as comprehensive, informative, practical, fun, and specifically experienced it as interactive. The presenters were also complimented for their style of presenting, and willingness to be “approachable”. More than one person commented that they understood the broader concept of the condition better, especially in the light of discussions around comorbidities. OVERALL, EVERYBODY SHOWED HUGE APPRECIATION AND GRATITUDE FOR THE OPPORTUNITY. A very special thank you to Prof Renata Schoeman for all her hard work organising this event. And a special thank you to Acino Takeda for their ongoing support through this generous educational grant. Jannie van der Westhuizen has worked as a psychiatrist in private practice in George since 1998. He obtained his MMed in Psychiatry from the University of Pretoria where he then worked as a consultant and lecturer in Child and Adolescent Psychiatry at the University of Pretoria and Weskoppies Psychiatric Hospital Complex. Correspondence: [email protected] From left to right: Yellow: Dr Jannie vd Westhuizen, Dr Frans Korb, Bongnkosi Mafuze, Obinna Nwabu Blue: Joyce Matodzi , Chiomu Onyia, Moipone Mojela, Salminah Lebotsa (orange shirt), Khomotso Modiba, Ipeleng Mahapa, Zamalubi Dlamini, Nonhlanhla Ntumbe Green: Nikhil Nowbath, Iviwe Gqirana, Lerato Masenya, Matuka Banyana, Nosihle Gumede, Lynette Moodley, Godfrey Dludla Red: Ashvena Gajathar, Lenora Samuel, Muthumuni Nemavhola, Janine Rodriques, Imi Magwabeni, Lisha Narayan
SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 45 REPORT R E F L E C T I O N S O N T H E 6TH AFRICAN DIASPORA G L O B A L M E N T A L HEALTH CONFERENCE Precious Dimba “Africa Unite”. Those were my thoughts as we closed off the 6th African Diaspora Global Mental Health Conference in Cape Town on the 19th November 2023. This two day conference left me with a great sense of respect and awe for Africa and its people. In fact, as Dr. David Henderson eloquently put it: “We will be all right.” If the conference was any reflection of the future of our great continent, we truly will be all right. Though it is well known that Africa has many challenges, it was wonderful to share a room with an inspiring group of people who want to improve the mental wellbeing of our people. The theme for this year’s conference was: Mental Health Impact of Climate Change and Environmental Stressors. With the various climatic changes being experienced all over Africa, from floods to droughts, heatwaves, wildfires and various others, the theme seemed fitting. THESE NATURAL DISASTERS OF VARIOUS MAGNITUDES HAVE LEFT MANY OF OUR PEOPLE DISPLACED, AND WITH SERIOUS FOOD AND WATER SHORTAGES. THIS, IN TURN, HAS HAD SERIOUS MENTAL HEALTH IMPLICATIONS. THE CALL FOR AFRICANS TO COME TOGETHER WITH SOLUTIONS COULD NOT BE LOUDER. We spent two days listening to how colleagues from various parts of Africa and the world are trying to solve the various mental health issues encountered in different parts of our continent. We also had an opportunity to hear from emerging young researchers about their work looking at climate change, its impact on Africa and on mental health. We also got insights into the work the Africa Global Mental Health Institute (AGMHI) does through its working groups. The panel discussions on mental health funding and bidirectional learning opportunities in the global mental health space were of most interest to budding researchers and young mental healthcare practitioners such as myself. There are many things that stood out for me during this conference. For one, I saw the value of research. Research allows us to describe the problems we have, as well as the magnitude of those problems, so that we can find fitting and appropriate solutions to those problems. I was encouraged by the amount of research happening around Africa and the world. Secondly, solutions and interventions to the many problems we are facing as a continent need not be grand. They can be simple and still be effective, and can make use of resources that we already have access to. I WAS TRULY INSPIRED BY THE WORK DONE BY DR. JOHN PARKER AND THE SPRING FOUNDATION AT LENTEGEUR HOSPITAL. PROF. ANGELA OFORI-ATTA ALSO TOLD US ABOUT HER WORK WITH PSYCH CORPS GHANA AND HOW THEY WERE ABLE TO EXPAND ACCESS TO MENTAL HEALTHCARE IN GHANA USING THIS SIMPLE AND UNIQUE SYSTEM. Precious Dimba
46 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 REPORT We also had a unique opportunity to see mental illness through the lens of a colleague living with a mental illness. Dr. Samke Ngcobo’s account of her journey made me stop and think of how I practice psychiatry, how my patients experience me as their treating doctor, and how they experience the mental healthcare system as a whole. THIS WAS TRULY A UNIQUE EXPERIENCE – ONE THAT LEFT ME WITH A DEEP SADNESS FOR ALL THAT IS GOING ON IN AFRICA, BUT ALSO RENEWED HOPE OF A BRIGHT AND PROSPEROUS FUTURE. I also felt challenged, not only in my practice of psychiatry but also in what my contribution to our continent and world will be. Truly if Africa can unite, great things can happen. Precious Dimba is currently a second- year psychiatry registrar at the University of KwaZulu-Natal (UKZN). Post matric, she went on to do her undergraduate medical degree at the University of Cape Town (UCT). Her interest in psychiatry started in her undergraduate years at Valkenberg Hospital and blossomed during her MO time in psychiatry at King Dinuzulu Hospital Complex (KDHC) in Durban, KZN. It was also during her time at KDHC when she obtained her Diploma in Mental Health through the Colleges of Medicine of South Africa (CMSA). At present, Dr. Dimba is also doing her MMed in Psychiatry through UKZN. Her research is looking at food security and quality of life in females with a mental illness at KDHC in KZN. Correspondence: [email protected] Dr. John Parker giving a tour of the Spring Foundation at Lentegeur Hospital Prof. Angela Ofori-Atta Attendees
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NEWS This year, the Psychiatric Genetics Group of the BrainBehaviour Unit (BBU), UCT Neuroscience Institute, has continued to go from strength to strength. In addition to welcoming three new Msc Med Neurosci candidates (Anje Grobler, Mia Lombard and Pheziwe Mshunqwane), a number of our group members have excelled in 2023. Tsaone Charlotte Chalumbila (PhD candidate) participated in the Equinox Conference (September 2023), at which she presented her doctoral work, “Investigating transgenerational effects of maternal psychological distress through infant gene expression profiles in a South African birth cohort study”. She also presented a poster of this work at STELLAR PSYCH GEN IN 2023! BY SHAREEFA DALVIE AND NASTASSJA KOEN 48 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 DEPARTMENTS OF PSYCHIATRY ART FOR MENTAL HEALTH EXHIBITION OPENING OTHER NEWS In commemoration of Mental health month, the Department of Psychiatry hosted their second annual “Art for Mental Health” exhibition at the Wits Adler museum. Entitled “Kintsugi & Ikigai-the pursuit of happiness” the opening event was held on the 10th of October, World Mental Health Day, featuring work from Department staff, students and alumni. The guest speaker was Sandra MaythamBailey, whose main medium of work is sculpture. She delivered an amazing talk reflecting on the theme. This year, a silent auction was held online. Proceeds from funds that were raised were awarded to the Department of Psychiatry at Chris Hani Baragwanath Academic Hospital’s (CHBAH) initiative- a Christmas party for orphans from the Bethany and Bethesda home in Soweto • 3 consultants (Drs Poliah, Nel and Minty) attended the first women’s mental health conference in Melbourne, Australia. • Dr Sotobe Mose a subspecialist trainee from the Division of Neuropsychiatry attended the Neuropsychiatry congress in Prague. • Prof Cora Smith retired after many years at the Department of Psychiatry. • Dr Tiaan Schutte has been awarded the subspecialty of Addictions Psychiatry (“grandfathered”) by the Health Professionals Council of South Africa. We look forward to more developments from this new subspecialty at Wits. • The Division of Child & Adolescent Psychiatry also has two new fellows-Dr G Sefala and Dr A Porter Sandra Maytham Bailey
NEWS the World Congress of Psychiatric Genetics (WCPG) in October 2023 in Montreal, Canada; and received an Early Career Investigator Program (ECIP) Award, from the International Society of Psychiatric Genetics, to attend this congress. Dr Shareefa Dalvie and A/Prof Nastassja Koen (CoHeads, Psychiatric Genetics Group) organised and chaired the symposium, “The Contribution of African Genomics Research to Innovation in Psychiatry” at the International Congress of Human Genetics (ICHG) in Cape Town (February 2023). In addition, Shareefa presented a poster at ICHG entitled “Does childhood adversity influence immune-related gene expression?”. She also presented her work on “PRS Associations with Subcortical Volumes, Cortical Thickness and Surface Area in ENIGMA-OCD” at the SOBP Annual Meeting in San Diego, USA (April 2023). Anje Grobler (MSc candidate) has been elected as the incoming Chairperson of the UCT Cortex Club for 2024. The Cortex Club is a student-run Neuroscience Society that deals with cutting-edge topics and challenging issues in neuroscience. A/Prof Nastassja Koen (Co-Head, Psychiatric Genetics Group) was awarded a NRF Research Excellence Award for Early Career/Emerging Researchers (Life Sciences), as well as a UCT College of Fellows Young Researcher Award 2023. A/Prof Nastassja Koen receives a NRF Research Excellence Award (left) and a UCT College of Fellows Young Researcher Award (right) Dr Lerato Majara (Prior Co-Head, Psychiatric Genetics Group) attended the 75th celebration of the American Society of Human Genetics (ASHG) in Washington DC, USA (November 2023). At the awards ceremony, her paper, “Low and differential polygenic score generalizability among African populations due largely to genetic diversity” (DOI: 10.1016/j. xhgg.2023.100184), was selected as one of two Outstanding Early Career Publications in the journal, Genetics and Human Genomics Advances (HGG) (award made to senior author, Dr Alicia Martin). Lerato – together with Dr Olivia Wootton (PhD candidate) and Prof Dan Stein – also presented, “Towards integration of clinical neuroscience and global mental health research in the South African context” at the NIMH’s Research Domain Criteria (RDoC) Framework in Global Mental Health Research Webinar (September 2023). Lihle Moyakhe (PhD candidate) presented a poster of her doctoral work, "Using polygenic risk scores to find potential links with developmental and mental health outcomes in children: A systematic review" at the ICHG 2023; and was awarded an International Scholar and Cultural Exchange Program (ISCEP) scholarship to attend the International Statistical Genetics (ISG) workshop, in Boulder, Colorado (March 2023). She also presented a poster of her work, “Epigenetic age, child development and mental health in a South African cohort” at the WCPG in October 2023, and received an ECIP Award to attend this congress. Dr Mary Mufford (Postdoctoral Fellow) published her work, “The genetic architecture of amygdala nuclei” in Biological Psychiatry (DOI: 10.1016/j. biopsych.2023.06.022). She also presented this work, and her work on “Amygdala nuclei volumes associated with PTSD and related measures in ENIGMA-PTSD” at the Society of Biological Psychiatry (SOBP) Annual Meeting in San Diego, USA (April 2023), for which she was one of the international early career travel awardees. As a Research Fellow in the Harvard T.H. Chan School of Public Health/Stanley Centre’s Global Initiative for Neuropsychiatric Genetics Education in Research (GINGER), she also attended the WCPG and presented a poster on “The psychometric properties of the UBACC in the NeuroGAP-Psychosis study”. Dr Olivia Wootton (PhD candidate) was awarded a travel bursary to attend the Wellcome Connecting Science Genomics of Brain Disorders Conference (May 2023) for her work entitled, “Characterising the shared genetic influences between schizophrenia and reaction time variability”. Additionally, she was a finalist for the Hugh Gurling Award at the WCPG (October 2023) where she presented her work, “Using genetically informed cognitive dimensions to explore phenotypic heterogeneity in schizophrenia”. See our departmental newsletter for more information on these achievements http://tinyurl.com/6uh5259d Lihle Moyakhe at the WCPG Dr Lerato Majara at the ASHG meeting (November 2023 SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 49
NEWS Panelists Dr Nomafrench Mbombo, Shana Fife, Liesl Hermanus, Professor Salome Maswime and Jason Marcus (Photo Courtesy of Brenton Geach, UCT) 50 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 "NO MATERNAL HEALTH WITHOUT MENTAL HEALTH" FILM SCREENING AND PANEL DISCUSSION BY SIMONE HONIKMAN ANNUAL DEPARTMENTAL RESEARCH DAY 2023: “ENGAGING COMMUNITIES IN RESEARCH” BY NASTASSJA KOEN The PMHP joined forces with Leah Smith, a doctoral occupational therapy student from the US, to produce an open access film entitled "No Maternal Health without Mental Health". The film aims to support the capacity building of frontline providers in maternity care settings. Crafted through focus groups and consultations with frontline providers and other experts, the film demonstrates skills in the critical intersecting areas in reproductive healthcare: respectful care and mental health support. The PMHP collaborated with the Department of Obstetrics and Gynaecology and the Faculty Transformation and Equity Committee to showcase the film, on November 23, as part of the period of 16 Days of Activism against Gender Based Violence. The event took place at the Neuroscience Institute and included an international audience through a streaming platform. Associate Professor Honikman, PMHP director, presented on the prevalence of depression and anxiety among pregnant women in South Africa, the social determinants of this public health crisis and described the concept of obstetric violence, contextualising this wide-spread human rights abuse as a form of gender-based violence. After a showing of the film, a panel discussion was facilitated by Professor Salome Maswime, head of Global Surgery. Panelists included Dr Nomafrench Mbombo, MEC for Health and Wellness, Jason Marcus, Senior Lecturer in the Department of Obstetrics and Gynaecology, Liesl Hermanus, PMHP Clinical Services Coordinator and Shana Fife, author and woman with lived experience of obstetric violence. Together, they engaged in a robust conversation about the challenges faced by healthcare workers, in addressing the pervasive problems of obstetric violence and bullying among colleagues On Tuesday 22nd August 2023, the Departmental Research Committee (DRC) was delighted to welcome attendees to the first in-person Annual Departmental Research Day since 2019. With the theme, “Engaging Communities in Research”, we celebrated the outstanding and diverse research being conducted by Department members and welcomed a number of esteemed guest speakers. We were also thrilled by the strong attendance this year – with about 120 in-person plus virtual delegates. A/Prof Claire van der Westhuizen (Deputy Director of the Alan J Flisher Centre for Public Mental Health), and her team presented the event’s opening plenary, “Exploring the Question: Community Engagement or a Community of Practice?”. This plenary set an excellent and engaging tone for the remainder of the programme. We then welcomed Dr Natacha Berkowitz, Ms Bulelwa Mtukushe, A/Prof Goodman Sibeko and Ms Siphumelele Sigwebela for a lively and interactive panel discussion (chaired by the DRC’s Prof John Joska). Topics covered included health research at COCT City Health; managing the implementation aspects of multi-site projects; stakeholder engagement and collaboration for technology transfer and task sharing; and working with community stakeholders throughout the research process. Following a delicious brunch and refreshments (catered by the fantastic Magnificent Barista Boys), we then welcomed six researchers from the Department who delivered brief oral presentations of their work. This was an excellent showcase of the breadth of high-quality and highimpact research being undertaken across the Department. We would also like to congratulate Dr Liezel Schlebusch (Centre for Autism Research in Africa) for being awarded this year’s prize for Best Oral Presentation for her work, “Transforming the lives of children with developmental disabilities through a community-based caregiver skills training intervention”. Finally, it was our pleasure to host Prof Salome Maswime (Head of the Global Surgery Division and Chair of UCT’s University of the Future Project) for the closing plenary. This was an outstanding conclusion to the event, providing stimulating and engaging reflections on, “A Model for Community Engagement – Insights from Global Surgery”