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Articles by Dr. Billy Levin


Tuesday, December 05, 2000


Children with a neurological dysfunction are clinically diagnosable, medically treatable and if managed correctly can be given the opportunity to function at a normal level. Without recognition and treatment they appear to be disruptive and disobedient through no fault of their own, and cannot respond to the usual disciplinary means.

Safe medication and effective management are vital issues.


Kinders met 'n neurologiese disfunksie kan klinies gediagnoseer, en medies behandel word. Indien hulle korrek behandel word, word hulle die geleentheid gegun om op 'n normale vlak te funksioneer. Sonder herkenning en behandeling is hulle onwillekeurig geneig tot ontwrigting en ongehoorsaamheid, en kan dus ook nie onderwerp word aan gewone dissiplinere metodes nie.

Veilige medikasie en effektiewe beheer is dus van die grootste belang.


Discipline is vital for children, and children need discipline. Every average parent with good intentions is able to provide adequate discipline to a greater or lesser degree, and equally, the average child is able to benefit from that discipline making the exercise, both for the parents and for the child, worthwhile. There are however, some children who appear to need more discipline than others, and there are some parents whose method of disciplining is not always ideal. As long as both the parents and the child fall into the average acceptable range, there will be ultimate success for both the parents and the child.

What concerns and interest me most, is a small group of children who because they happen to be different from other children, will not benefit from the usual form of disciplining through no fault of there own. They have what we call a cerebral disjunction. In itself the disjunction is not an abnormality, but it does make these children unique. In fact they appear to have a brain that functions differently from other children and require different approaches to achieve success in the domain of discipline. For example, what would happen if a very enthusiastic music teacher tried to teach a child, who was totally tone deaf to sing, and the teacher was unaware that the child had no ear for music. The teacher would enthusiastically attempt to teach, eventually become frustrated, and probably become antagonistic to the child who would not learn. She would blame the child, not knowing that he had an inability to appreciate musical sounds. The child in turn would attempt to try, fail, feel upset, make more effort, still fail, ultimately give up and become antagonistic and resentful to any further tutoring. Picture the scene now - an aggressive teacher demanding, and a resentful antagonistic student - hardly an ideal setting for learning. If the teacher was unaware of the tone deafness and the child never received adequate help, there would be no success.

There is a small group of children unfortunately who do have a learning disability related to brain function. They would fit into this category where the ordinary disciplining would not be successful. The child, through no fault of its own, would not achieve what its parents would want. The situation would be identical to the music teacher and her despondent pupil.

If left unresolved, the child would not learn, the child would stop bothering, and would eventually drop out, and the parents would ultimately give up. This need not be the case if the condition is diagnosed and treated. Before it is recognised there has to be knowledge that the condition exists. It needs to be understood, and thereafter to be treated correctly to bring a situation into focus where the child is able to learn. At that point only, can the parents start applying average disciplining methods and the child will start to benefit from those approaches.

I would like to define the condition as a Neurological Inadequacy due to mainly genetically inherited maturational variations. These are mainly immaturities of the left hemisphere of the brain, but occasionally excessive development of the right hemisphere. When the left hemisphere is immature we have an "attentional deficit" disability without hyperactivity (Learning Problem). With right hemispheric dominance, due to excessive development, we have an "attentional deficit" with hyperactivity (Behavior Problem). The right hemisphere is a doing, practical and temperamental brain which is also musical and artistic. The left brain has to do with language, concentrates on verbal input, sequences things and is organised. This would imply that to learn adequately you have to have a left brain that matures so that it can listen, put things into a sequence, first think before it acts, and focus attention on the spoken word. Without these facilities learning is difficult. Couple that to the fact that if the right brain dominates, the child is hasty, tends to do without thinking, is very much more visual, and invariably, temperamental. This genetic pattern might in time improve as maturity takes place, but by the time the child acquires the talents that he needs he has already lost out. He now has to recoup and catch up in a hostile world. Almost impossible! Learning, in fact then involves not only learning in the strict sense of academic learning, but also learning to behave, learning to socialise, learning to comply.

This genetically inherited pattern can be recognised from a very early age, if seen by somebody who understands the condition. The biggest problem at the moment is too little is generally known about a condition that very definitely exists and can be recognised, provided that the investigator has the knowledge. Equally, it can be very successfully treated by a team using two main areas of involvement, namely medication and management.

On the one hand we would see that to understand, accept and know how to help the condition would be labeled management. The other is medical treatment that can be used most successfully, to rectify the cerebral dysfunction. Management on its own will have some value, but where the medication is correctly used the combination is devastatingly successful. Where medication is not used, when it is urgently needed, then the outcome for the child, his parents, family and the teacher is devastatingly disastrous. There is nothing so soul destroying as a child who appears to have talent but won't learn, a child who is given opportunities to behave and he doesn't conform, who is capable of achieving, but ultimately drops out. This is a tragedy that needs to be recognised at its earliest, treated intensely and correctly, with most gratifying results.

Once it is understood that this is a neurological dysfunction due to a chemical deficiency in the brain, and that the chemicals can be replaced artificially even though it is a temporary crutch, if correctly applied, the child is given the opportunity of functioning at almost the normal level. With this new found capability, if there is no back log, then the child will progress well. Obviously, the medication will not make up for the backlog and remedial therapy is sometimes needed as well.

There is a specific way to establish whether a child does qualify for medication. This is called a therapeutic trial. The trial is to establish whether the child responds to the medication. The team consisting of parents, teachers and doctor, who evaluate the effect of medication to ascertain initially if it has value. Subsequently to establish the ideal dose, and ultimately, to stop the medication when sufficient maturity has taken place. There are a number of medications which can be used and I will name a few and then concentrate on one specific one. Seranase, Tofranil, Nootropil, Vasopresin, Rispidal, Corgard and Ritalin, have been used for children with learning disabilities, concentration problems and behavior problems. Ritalin needs to be given closer attention. It is the one that works best, fastest, safest most effective and has been on the market for almost 50 years. Despite a tremendous amount of research into the effectiveness and safety of Ritalin, what comes across so often is lay press comment on dangers relating to Ritalin that medical science has never experienced. One wonders where this misinformation comes from!!

If one talks about the problems of discipline then many a hyperactive child with a very talented right brain and an immature left brain certainly qualifies as a disciplinary problem. These children are hasty, restless and do without thinking. They are often aggressive and temperamental. The fact that they can be told one thing today, they can forget about what they were told and seconds later do the same thing again, makes them difficult to discipline. As parents try and force their discipline on a child who cannot cope with it, the child becomes resentful, antagonistic and rebellious. We then have an explosive situation where the parent is frantic, the child is desperate and the usual form of discipline has no place. If such a child is correctly diagnosed and the parents are correctly informed as to how to handle the situation, and if medication is given in the correct dose, the child is dramatically better. This is only while the medication is actually working, and the child reverts to the usual behavior once the medication wears off. If for most of the day, under the influence of medication, the child is reasonable and responsible and responsive, he can now be taught in the usual way, and he starts to achieve. Ultimately the difficult behavior off medication becomes less of a problem. As the child matures and at the same time through training and experience the parents and teacher become more able to cope, and to teach this child who is so different from others, success is achieved.

This success does not happen overnight. Neither is it smooth sailing in one direction. These children can go through phases when things are fine. When things are not going so well, the doctor, parents, teachers and the child need to review the situation to see what adjustments need to be made to ensure success once again. As the child grows, his education and disciplinary needs and medical dosages need to be modified to suit him at all times. The fact that these needs are not constant makes repeated monitoring, re-evaluation vital to the ultimate success. It is vital to ensure the child actually takes his medication exactly as prescribed.

The age at which a child can commence with treatment will depend on how early it is diagnosed. It can begin before they enter Nursery School, at Nursery School, right through Primary School, high school, University and even in the adult.

No age is too young or too old if treatment is necessary, however, prescribed medication is never a cure, but for some a vital and safe means of achieving a turning point in a program.

February 2006.

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