In this episode we are discussing ADHD with Jolané Kotzé a speech therapist from Cape Town South Africa.
Link to Audio Episode
Oliver :: Jolane, Welcome to the show. We are really glad to have you on board. Thanks very much for doing this. So today, we’re going to be talking about ADHD from a speech therapist’s point of view. So firstly, yeah, thank you very much for coming on board and maybe just to kick it off, tell us a little bit about yourself and why you are so intrigued with ADHD.
Jolane :: Okay, so I’ve been a speech therapist for a little while now. And, I like both being a speech therapist and working in academics. I’m also a part time lecturer and supervisor for students. And I think my interest in ADHD has grown over the years, because I have a sister with ADHD, and quite a lot of friends. And that ADHD population makes up quite a big portion of the patients that I see either with the students or at my own practice.
Oliver :: Okay, that’s interesting. So tell me, is it a lot more prevalent now?
Because it seems to be popping up everywhere? I mean, my wife was at a conference recently that expanded over a few days and it’s not just one country, it seems to me like multiple countries. But in your experience with ADHA. Is it something that’s kind of gotten worse over time? Or is it just that we become more aware as a community and people?
Jolane :: I think it’s so difficult, I think as medicine progresses, and we have a better understanding of our own physiology as humans, a lot of new diagnoses pop up. And sometimes there’s a tendency to over diagnose, because we know that this diagnosis encompasses these symptoms.
But I think it is more prevalent, not always correctly diagnosed, because sometimes you just have something that you don’t understand yet. And it seems to be easier to grab onto something that we have some knowledge of, and something that we are able to treat at the moment, instead of trying to grab the dog at something you don’t understand. So definitely more prevalent and I think that’s a good and a bad thing. The more prevalent it becomes, the more uninformed opinions there are of it. But the good thing is, the more prevalent it becomes, the more parents and people with ADHD actually connect with one another and understand themselves and their children a lot better.
Shaz :: So I actually really liked that you said that, that sometimes things get lumped into a blanket diagnosis. And just thinking back to me when I was little, you’d heard of ADD or ADHD and generally it was the kid that was bouncing off the walls and then they were known as the Ritalin babies. Are you finding now that there’s a lot more awareness around ADD or ADHD that there is more structured treatments now than just throwing Ritalin at the problem.
Jolane :: I think I think you are right in a sense that usually it would have been the children that were bouncing off the walls. But now we have more insight into ADHD and we know that ADHD isn’t just equal to hyperactivity, there are other symptoms and parts of it that actually also form part of the diagnosis. You can even have a child that’s inattentive in their own little world that would have previously been seen as ADD, that is also classified as ADHD. So there is definitely a better understanding of it. I like that you say just throw Ritalin at the problem, because I think that is the misconception that most people have about it but in the end, ADHD is really only successfully treated when we combine approaches when we combine a medical approach like medication, for example, with some other behavioral approaches like speech therapy, occupational therapy, and that’s the only way that we are able to successfully treat this child that we see.
Oliver :: So once before, we actually had an OT on that was talking about it from a sensory point of view, you know, how they could almost like use the sensory approach, you know, with the, with the patients, and I think, you know, for mistakes from a speech point of view, obviously, that probably makes it a bit easier as well. But have you seen clients or patients where they are not no medicine? Do you see a major difference between, being on medicine or not, in your practice.
Jolane :: I think the thing we have to understand about ADHD is that it is a neurodevelopmental disorder so there is some sort or some part of the neurological system that functions differently to someone without ADHD. So the thing is that often in therapy, it’s either just medication or either just therapy.
I have truly found that in therapy,if we work with a child that isn’t treated holistically and completely, that you almost work against the child’s neurological system, and you try to do something that the child’s neurological system isn’t ready for. So often, the medication just helps to get the child to that point where they are able to learn, they’re able to take in and make sense of the stimuli that surrounds them all the time. So I found that it’s almost like trying to teach them to ride a bike, but you never actually give them the bike, you just give them the recipe the whole time. So it works sort of against each other, it really has to work in unison and in combination with one another.
Shaz :: I really like that you gave that example. I mean, anybody who’s watched the Big Bang Theory knows that Sheldon learned to swim by, you know, he did all the lessons by swimming on the floor. It does make sense, the medication is almost a tool but the guidance is what comes from the other therapies. So the medication helps you to reach the point where you can accept that guidance and you need the two to work together otherwise, you’re either going to go into one direction or the other, but you’re never actually going to solve the problem.
Another thing that you said is it’s neurodevelopmental so the term we keep hearing is neuro typical or neuro diverse. Would a person with ADHD be considered as neuro typical or neuro diverse?
Jolane :: I think I’m one of the therapists that really don’t like those terms. Because if I just think about myself, my own neurological system functions differently than the person next to me. And it’s not that I’m neurotypical or neuro diverse, or whatever the term may be. So I just like to say that they have this special power that they have this special package in their neurological system that just regulates and processes emotions, attention, and external stimuli differently than someone else who doesn’t have ADHD.
So it doesn’t make them not normal or not typical, they just function in a different way to someone without ADHD. Then again, I also function in a different way. Sometimes I think I have a little bit of OCD, which is different from my husband. For example, we clean the house in different ways. So I think, yeah, I tend to steer away from those terms. If that answers your question?
Oliver :: Answers it brilliantly.
So Shaz decided she’s going to bring her A Game and ask all of the difficult questions. We did hear that and I must admit, the first time I heard even neurotypical, I couldn’t get my mind around the whole term of neurotypical because some parents in the classes I used to call because when our daughter was going to school, they would say no no these kids are normal and these kids are neurodiverse. So, it was always weird for me, but then you went on the other extreme, and you said, the kids with ADHD now have a superpower that’s even more intriguing for me in a base in the whole comic and superhero. realm that Shaz and I like.
So do you think then that it’s not a bad thing, it’s probably a good thing that they do have ADHD. But on the flip side, they do need to, you know, like Superman, he does need to kind of control his superpower or else he destroys everyone?
Jolane :: Exactly
Oliver :: That’s interesting. Okay, so now I’m kind of seeing how your special interest is in ADHD. But that sounds very cool. I don’t think I’ve heard it like that before, because I did ask someone, but this was more on the autistic side, you know, when I said, “ You know, when I think of Rainman, then, I always think, you know, that’s probably the worst example”. But with ADHD, which, you know, what seems to be it’s just like a slight edge and that kind of works based on what I’ve seen as well, because lots of the really good entrepreneurs and business leaders, all profess to have some level of ADHD, and that’s what keeps him motivated and going, which is actually really cool.
Jolane :: My own sister, who has ADHD, she is academically she performed so well, she is doing her master’s degree in biochemistry, now she’s been accepted for her PhD. So they sometimes just have this magical superpower of being able to process so many different things at the same time. I often say they’re almost like a sponge, they just want to keep on learning, sometimes you just have to provide them with the tools to do that.
Shaz :: I love that, that is the phrase you used. Sometimes a person with ADHD is like a sponge and depending on where their area of interest is, they just want to soak up everything that they can about that area of interest. So with that in mind, is there a specific treatment plan that you kind of follow with patients with ADHD? Or is it something that is more determined by the individual? I’m using the phrases because so often we hear of these cookie cutter therapies, where they say, okay, so you’re depressed, you need to do this or you have ADHD so you need to do that. With ADHD and them having so many different areas that maybe the child or the person has strengths and weaknesses in how do you formulate a treatment plan for this person then?
Jolane :: I think to understand the treatment plan, we have to understand that ADHD is highly comorbid with communication impairments, that’s like one of the top comorbidities that ADHD or people with ADHD have. They struggle a lot with understanding language using language and especially social language use so you will always find a child or a person with ADHD, trying to dominate the conversation trying to talk about a lot of different topics in a short period of time.
Our treatment plan for the language aspects, and there are obviously certain approaches and techniques that are shown by research to work for the specific language issues and areas of difficulty. But overall therapy is always an individualized process.
So whatever this patient comes with their little package, we try to sort them out as their own individual instead of trying to enforce our ideas onto them. But there are obviously certain things in our treatment protocol that remain the same so some that have been shown to work that, for example, regulates attention, like using visual schedules or using breaks in between activities. Something we often tell teachers or parents to do at home as well is what we call task modification so instead of giving a three part instruction, maybe break the instruction up into three individual instructions. Then maybe instead of just using your voice, use another modality like visuals or gestures, and just these tiny little modifications have shown to decrease frustration and increase motivation in children with ADHD. So to your question, treatment is definitely individualized, but we do use some techniques and approaches, on all of the kids that we see, because research has shown that those are the most effective ones to use.
Oliver :: We were reminded in another interview, actually, that speech, it’s not just about talking, it’s also about understanding. So I think what you’re saying right now, is such a key component of it is, can the child actually understand the instructions? And I think what you saying is, like, you know, split it out so that they can actually understand because that’s the communication part. But it’s actually interesting. So do you find with patients with ADHD, do they struggle to talk well, or is it that they are almost too distracted to talk? Or is it more that a person with ADHD feels “well they can’t understand me anyway. So I’m not gonna tell them about it” Is that something that you find?
Jolane :: There is a spectrum of it, so I want to say the severity of ADHD depends, and it influences the amount of risk for language disorders. So the more intense and severe ADHD is, the more likely it is that they will have a language impairment.
So sometimes we get children with ADHD that just like you said, they just have too many things to say and often it happens that they forget what they were saying then they just find something new that’s interesting. Or they feel demotivated to talk because people are always reprimanding them or always telling them to slow down or this is not how we say it. So it really depends on the severity of the ADHD and how severe the language impairment that accompanies the disease is.
Oliver :: With your clients, I want to ask it in two ways.
One is do you find this an optimal time when, when patients should be seeing a speech therapist would be the first part and then the second part would be how long do you think normally a patient would be with you, as its as a speech therapist, because I’m assuming the best approach is when they come in really early, right? Because, that’s when they are probably gonna find that they are struggling with either understanding or speaking.
Jolane :: Yes, research has shown that the earlier we start the better because the older a child gets the more demands there are in the academic system that take up more of the language skills that they possess. So we want to provide them with the necessary skills to meet those demands as soon as we can. With that being said,I think of all of the medical professions, we are the ones who have a long term relationship with our patients.
Speech therapy is not a quick fix, it doesn’t happen quickly. It’s not like physio where you can work on a muscle and stretch a muscle and after two or three sessions, you don’t have to go back speech therapy really is a long term investment. We see patients for months and sometimes years. It depends on the patient’s progress, and how quickly they are able to function independently in their environments as successful communicators. Once they are able to do that we are ready to stay back.
Oliver :: That is interesting, because someone reminded me of that in another episode as well. People would think especially as a parent, bringing their child in for speech therapy, the metric would be the child speaking. But, what she reminded us of was, that it actually takes a while for them to almost get to that moment, and then they start speaking, but as someone looking at it, as a parent and going for speech therapy for like a month, two months, and the child is still not talking, with our amateur view on the world looking at this and saying, Why is he still not talking? And that’s kind of the metric? Do you find many of those issues with parents, or more people looking at patients?
Jolane :: Definitely I think that’s why it’s such an important part of our jobs, to manage parents’ expectations, and to always be open and honest about our goals and the progress that we are making. Speech and language is the most complex, fine motor skill that the brain can possibly possess. There’s no other skill as complex as learning language, and coordinating the movements necessary for speech. So we have to manage parents’ expectations in that sense, and really be open about the steps that are needed in order to achieve certain goals. I think that once we are open about it, and we are open about the process, and we include them in the therapy process, they quickly understand that we are going to be a part of their family for quite a while, and then they love us.
Shaz :: It’s interesting that you say that you are going to be a part of their family for a long time. I have a friend who is 37 and has a slight stutter. Every now and then when things get a bit more stressful he’ll actually say “Okay I need to go back and see my speech therapist”. Is this because somewhere along the line he needs to learn a new coping mechanism otherwise the stutter returns? Seeing a speech therapist could actually become almost a life long relationship, as you grow up certain things might change and you need to go back for a top up or go back to to learn or get new tools to now deal with a new environment or new stressors.
Jolane :: Yes, you are correct. I think we go through this thing where we do stop therapy with patients like maybe early primary school, because we feel that they are able to cope with the demands of the system. But as soon as they hit high school, for example, and to just think about the complex language tasks that are in the curriculum in grade eight and upwards. I mean, think about having to write an essay, the type of language skills that you need in order to actually complete that task. So once they sort of hit high school, we tend to start seeing them again, a little bit more.
I think what parents also realize is, as speech therapists we have an extremely close relationship with our patients and their parents and their family members. And we also celebrate all of their successes. We cry when they are sad or when they have hit a wall. So everything that they are going through we are feeling it’s not always great to bring your work home that way. But that is the job of a speech therapist. You can’t be a speech therapist and not be involved. Once you have that relationship with a family, they are so much more open to coming back to you whenever they need you and realizing firstly when they need your help again.
Oliver :: I do have another question, how do accents actually form, is it just because of the people that you are around?
Jolane :: Yes, so the thing is that learning language works in such a way that the child learns what they hear and they learn from the language models in the immediate environment so that’s definitely how an accent is formed it’s because the child is so immersed in an environment where that’s the type of speech intonation and patterns and speech and yeah, the speech sounds and dialects that they hear. I think there are speech therapists that want to fix it, I’m not one of them. I completely feel that dialect is something really spatial and trying to change a dialect when the environment is still going to remain speaking the same dialect it’s really working against yourself so it’s an interesting question and we have loads of dialects that we still have to I want to say research and just come up with the right assessments and treatments for those specific dialect so hopefully in the future we will be able to do more inclusive speech therapy where we understand something like dialects a lot more than we do at the moment.
Oliver :: I suppose my only comment would be what would you fix it to? Like the UK because the UK is supposed to be English but I mean to understand most of the people in the UK or in England it is pretty difficult for most people that speak English and I mean we have Australia and New Zealand, even American I mean it’s crazy how that would be. I mean, for me, we went to Mauritius for our honeymoon and then I went, twice on business trips, and Mauritius is predominantly Indian, but hearing the Indian people speak French in my mind, it’s just like it doesn’t work. So it’s like something is wrong here,it feels like you are watching the wrong movie.
Is there anything else around ADHD and how you work as a speech therapist that you think we probably missed or we probably should have asked you?
Jolane :: I think something that we have to be open and honest about is the harsh reality of ADHD is that there is no cure for it. It is something that, although we don’t necessarily understand it fully yet, we are on our way there. It is something that persists from childhood until adulthood, research actually shows that it persists in plus minus 50 to 80% of cases. So I think we always have to be open and honest about the fact that this is something that a parent or person themselves with ADHD is going to struggle with for their whole lives. And as soon as we are able to, we have to diagnose it and treat it as, best we can, in order to really manage the presentation that it has throughout a person’s life. I think that’s the only point that I wanted to also just explain a little bit more.
Oliver :: Again, it’s interesting that you mentioned that. So it seems like people don’t really get over ADHD. They are helped to cope with it better, and maybe fit in a bit better, but it always shows in some way or the other. But what you said already, which I really like, is that it’s a superpower. And they should embrace it, know when to take the cape out and when not to take the cape out and make sure that everything is kind of safe around them. Shaz anything on your site before we close it up?
Shaz :: Just on that line it’s a superpower and it’s always there. I think one of the most powerful lines from one of the Avengers movies is when Captain America asks Bruce Banner, “what is your secret? How do you keep the Hulk under control?” and Bruce turns around, and says, “My secret is I’m always angry.” When you think about it, somebody with ADHD will always have ADHD. The fact of the matter is, that is the superpower. That is what sets you apart from somebody else, and gives you maybe an advantage in another area.
I think we’re moving more into an age now where you’re not looking at things like ADHD, or sensory integration or any of the taboo subjects from 20 or 30 years ago, as taboo anymore, you’re starting to be starting to see them more and more as these are actually strengths. And they’re being treated as I’m not trying to cure this because I can’t cure this, but rather I’m trying to teach you how to handle this, because you know, “with great power comes great responsibility” and all of that.
Jolane :: Yes, I agree and I think on that note, just the fact that you know that it is your superpower, you now know that there are other people who share your superpower and that in its own is a superpower having the ability to actually talk to someone else and experience what you’re experiencing with someone else. So I think the more we become aware of it, the more we are open about what we are experiencing and if we are old enough to actually say, “Hey, I have ADHD”. That will engage much more conversation around it and it will just connect people more and make people more understanding of it so that we don’t think about it as you said previously, the Ritalin children, we think about it as someone really interesting that knows a lot about a lot of stuff that we can learn from instead of looking at it in such a negative light.
Oliver :: So the one question I think we probably didn’t ask is, if someone is thinking of coming through for therapy, how would they work with you? For parents thinking of bringing their child in for speech therapy, they probably have a diagnosis of ADHD already from the pediatrician, if not the psychiatrist or someone else. What, what can they expect and how would you work with them?
Jolane :: I always talk about the process that’s involved because it’s obviously a big financial burden if you don’t have medical aid, so you have to really understand what you’re letting yourself in for. We would first start with an assessment where we use multiple types of measures to assess whether it’s formal tests that have been developed by researchers or informal measures where we use developmental norms. Then out of that assessment, we are able to determine the areas of difficulty which shapes our treatment plan and from our treatment plan, we then use our specific approaches that are shown to work for these areas of difficulty. Therapy can then be once a week, it can be twice a week, and it can be for a few months or a few years, and we can do it either in a group or individually. And then from there on, we just try to do our best and try to do as much as we can, with the help of parents, that’s the important part is, we see a child for 30 minutes a week, most of the time. So we want to always try to encourage parents to become therapists at home. So it’s also a big responsibility on the parents’ part to become part of the process and not just send the child to speech therapy and hope it’s going to get better.
Oliver :: I’m really glad you mentioned that and that is kind of what has come up with lots of the therapists that do work with children is that they are almost the guide, or the mentors, meaning they give us the skills and the knowledge. But it’s actually the practice or the continuous exercise of doing the stuff that’s the actual, healing part or the improvement part. I’m glad you mentioned that, because that kind of collaborates the story with most of the practitioners that we’ve had on that work with children.
This has been amazing thank you. I mean, again, it sheds some light on some superhuman qualities that most humans have, especially the little ones as they grow up. So I’m glad to have you on board. And Shaz thanks on your site as well. I mean, you asked really amazing questions, which is pretty cool. Yeah, so hope to have you on board, again, maybe in a multidisciplinary type approach. Because I think speech therapists definitely work really well with that, maybe an OT and physiotherapist, maybe a psychiatrist, which would be amazing. What do you think?
Jolane :: I think that would be great, I mean that is our job on a daily basis. We have friends in a lot of disciplines that we chat to every day because that’s really the only way to treat a patient is by making sure that you work in a team and that everyone in the team is on board and share the same goals. So that’s ultimately our goal in therapy. So thank you for having me. Thank you for being open to having me again.