Susanne Walitza, why do so many schoolchildren take Ritalin?

An old building near Hegibachplatz in Zurich: creaking stairs, large windows and a room decorated with stucco, which is home to the Directorate of the Clinic for Child and Adolescent Psychiatry and Psychotherapy. «A gem,» says Susanne Walitza. «But I don't just use it for myself. We hold our meetings here,» emphasises the professor of child and adolescent psychiatry, running her hand over the white tabletop. She will be giving an interview to Fritz+Fränzi here that day.

Mrs Walitza, how many children and young people are prescribed Ritalin in this country?

It is estimated that five per cent of all children and adolescents in Switzerland are affected by attention deficit hyperactivity disorder, or ADHD for short. Around half of them are treated with the active ingredient methylphenidate, contained in the drug Ritalin, for example. Ritalin is the first choice for treating this disorder with medication.

In 2018, almost twice as many schoolchildren were taking psychostimulants as in 2006. How do you explain this rapid increase?

The increase in prescriptions mainly took place in the years between 2002 and 2010. We assume that the supply situation improved in these years, particularly in the urban centres, and that there have been more child and adolescent psychiatrists, psychotherapists and paediatricians specialising in ADHD since then. There has also been an increase in information about the illness.

So she was destigmatised to a certain extent?

Yes, so that more children were seeing doctors and child and adolescent psychotherapists. After 2010, the numbers stagnated. They are even falling slightly. In other words, I believe we have achieved the necessary level of care. ADHD is a very common and well-researched disorder.

That was inherited in 70 to 80 per cent of cases?

Correct. However, despite the knowledge that ADHD is highly hereditary, we do not have a biological examination method or biomarkers that could replace the complex clinical examination that is indicated when ADHD is suspected. Even if some providers already offer corresponding diagnostic tools: ADHD cannot be detected in the blood or with a brain wave measurement (electroencephalography EEG).

ADHD is a very well researched disorder.

You talk about the symptoms being dependent on the setting. What does that mean?

As I said, we know that ADHD is hereditary. However, the extent to which the disorder manifests itself in individual cases is very much dependent on the environment and society. The more rigid the school system and the more heterogeneous the class, the more difficult it is for the child with ADHD. As we can influence the environmental factors relatively well, they are one of the most important starting points in treatment.

In what way?

This starts with parent counselling and parent training and extends to interventions at school. For example, there is now ADHD-specific further training for primary school teachers, which includes elements such as classroom management and dealing with children with ADHD and their parents. Today we are much more enlightened, have committed parents and teachers and therefore much more potential to utilise the possibilities of treatment - without medication. Only when the situation for the child at school does not improve, the child is the constant scapegoat or becomes depressed because it is falling behind its potential, do experts and parents recommend medication.

«The disease is an invention of the pharmaceutical industry.» This is probably the most widespread criticism of the diagnosis of ADHD. Experts such as the German neurobiologist and brain researcher Gerald Hüther advise parents to do more with their children in nature, to create and experience things together instead of resorting to medication.

I very much welcome it when parents take their children out into nature, into the forest. We now know that urbanisation activates mental disorders. But if a child plays in the forest every day for a month, building huts and so on, they will still have ADHD. In the forest, they don't have these demands that cause the disorder to occur.

The child does not have to sit still and listen for an hour or two.

That's right. In the past, we were constantly on the move and it was an advantage to recognise any potential danger immediately. Today, this is no longer the case as our system is very much geared towards listening. However, in my view, frontal teaching over several hours is not only difficult and less effective for children with ADHD. These demands are also stressful for children with ADHD.

So the social conditions for impulsive, inattentive children were better 40 or 50 years ago.

This may be the case for the mild cases. The severely affected children lag far behind their actual intellectual abilities in terms of performance and social integration. They were then sent to a special school, and that is tragic. But don't get me wrong, I too would argue that we should not prematurely interpret and treat children's very situationally dependent behaviour and their different rates of development - including in terms of concentration and hyperactivity - as a disorder, but rather learn to appreciate them as normal, healthy and diverse behaviours. This view of things means that assessments for ADHD must be carried out in a sustainable, time-consuming and differentiated manner.

Assessments for ADHD must be carried out in a sustained, time-consuming and differentiated manner.

You carry out most of the assessments and treatments at the Department of Child and Adolescent Psychiatry and Psychotherapy at the University of Zurich in the canton of Zurich. Nobody would deny your specialisation. Is care this good everywhere?

There are supply bottlenecks that can lead to undersupply, especially in rural regions. That is true. And there are also black sheep who prescribe medication based on a «glance diagnosis». And in the very worst cases, they prescribe according to the motto «if it works, it was ADHD». This is fatal, as Ritalin is not a diagnostic agent and should not be used to avoid more time-consuming non-medication measures.

What advice do you have for parents who are facing this clarification process?

The child should also be examined at least once by a child and adolescent psychotherapist. In around 70 per cent of cases, there is a comorbid disorder, i.e. a concomitant illness. And a doctor who does not specialise in psychiatry cannot determine in the same way whether the child has other disorders, such as depression, which ultimately exacerbate the ADHD symptoms or are similar to them. This differential diagnosis is important and can only be carried out by a child psychiatrist or psychotherapist. However, if the accompanying disorder is not diagnosed, only the ADHD will be treated in the end.

The general recommendation to date has been to treat only the severe cases

treated with medication. In the new interdisciplinary guideline «Attention Deficit Hyperactivity Disorder in Children, Adolescents and Adults» published by various professional associations, S3 for short, experts are advised to prescribe methylphenidate even in moderately severe cases.

Drug treatment is always indicated if other measures are not sufficient and the child's ability to cope with everyday life is severely impaired by ADHD. This can also be the case with moderate ADHD. The new S3 guideline therefore merely reflects the behaviour that is already common in practice and is supported by a good study situation. In its methodological report, which takes strict quality standards into account, the guideline shows one thing above all: that drug treatment has so far had the best effect of the various interventions.

Nevertheless, you have been researching alternative treatment methods for years.

We achieve the best results with omega-3 fatty acid supplements and neurofeedback. However, even with these two methods, the effect is much less than with medication. With neurofeedback, the child learns to regulate its own brain activity with the help of computer programmes. This is different for children with ADHD than for those who are not affected. The aim is to bring them to a level of activity at which they can concentrate and better control their impulsiveness.

How promising are these alternative measures?

Some children benefit from neurofeedback training. Unfortunately, it has to be said that the results are not as effective as with methylphenidate. The question is: how long can we wait and treat with alternative methods if the situation does not improve significantly? If an ADHD child never has the chance to go to grammar school despite their intellectual potential because they can't concentrate, this is already a burden.

It is even worse if a child has to repeat a class several times.

Or even having to change schools all the time. Stimulants such as methylphenidate have a very good efficacy and side effect profile. If we had that for other mental disorders, we would probably be more than satisfied.

Despite education, these children and the disorder itself are still stigmatised in some cases.

However, the most relevant side effects of Ritalin are still considered to be loss of appetite and sleep disorders.

That is correct, but in my experience this is primarily a question of the correct dosage. You have to dose very carefully and then observe the child's behaviour. When parents tell me: «The child is now much quieter than before», that is a side effect for me. My aim is for the child to be able to say: «Now I'm myself again. I can concentrate again, I can function at school, I enjoy playing with other children again.» Only then will the dose and the therapy be right for me. If side effects occur permanently, the treatment is going wrong.

That sounds reassuring. Nevertheless, many parents are alarmed when ADHD is suspected.

That is understandable. Despite education, these children and the disorder itself are still stigmatised in some cases. One of the reasons for this is the misuse of stimulants such as methylphenidate to improve performance. That really annoys me. When a child suffers from ADHD symptoms, it is also a difficult situation for the parents. It is unacceptable to be looked at the wrong way if you agree to medication.

How should parents react if they observe possible ADHD symptoms in their child?

It depends on the age of the child. Before the sixth birthday, it is not usually clarified. From primary school onwards, you can take a closer look. Firstly, I would wait and observe the child: Can my son or daughter stay with a game for longer? If not, as a mum or dad I would practise this with the child: «Come on, let's both finish this now.» This so-called parent training is the be-all and end-all for hyperactivity and attention deficit disorder. I would do this for a very long time, and if I then realise that my child has a tendency not to see things through to the end, I have to create a setting at home that makes this easier for him.

How does it work?

For example, with the help of a weekly work plan. This records the individual work steps and supports the child in their work.

Does this also apply to school?

Yes, it is advisable to talk to the teachers in order to adapt the environment to the child's needs. For example, it often helps to place the boy or girl close to the teacher. Difficult cases are those in which the symptoms are somewhat apparent, but not enough for a clear diagnosis. These children also need to be catered for. It is generally advisable to structure the child's environment so that they can concentrate better.

Difficult cases are those in which the symptoms are somewhat apparent, but not enough for a clear diagnosis.

And if these measures are not enough?

The next point of contact would then be a specialised paediatrician, a developmental paediatrician or a child and adolescent psychiatrist. In Zurich, the investigations are mainly carried out by the Children's Hospital and by us at the Clinic for Child and Adolescent Psychiatry and Psychotherapy.

How do you proceed?

As I said, the diagnosis is clinical and very complex. We work with a multiaxial classification scheme that covers six areas. For example, the client's exact life circumstances are recorded, intelligence is measured and it is investigated whether there are any organic illnesses that could lead to such symptoms. A very important axis describes the psychosocial conditions: How are things at home? Are there any risk factors? Is a parent affected? Is the child being bullied? Are there other reasons why the child can no longer concentrate? Then, of course, the core symptoms of ADHD must be closely observed, questioned and examined.

Is this done so meticulously everywhere?

In the clinics, we have to take these six axes into account. At the end, we determine the degree of severity, which determines the intensity of treatment. This level must be documented for each patient before and after treatment. Most paediatricians are also committed to a similar approach. But I also realise that it is not always carried out in everyday routine. But it is very important to me. And if we did this and the effort behind it became visible, there would probably be less criticism of drug treatment.