Attention deficit and hyperactivity disorder (ADHD) affects between 5% and 7% of schoolgoing children, but because doctors can only prescribe treatment for a month at a time, many kids in South Africa, especially those who can’t afford monthly doctor’s visits, don’t access medication regularly.
Methylphenidate, which is a central nervous system stimulant that can significantly reduce symptoms in about 70% of users with the condition and which the World Health Organisation recommends for the treatment of ADHD, helps people with ADHD to concentrate better, and to be less impulsive and overactive.
Studies have shown that when methylphenidate — the gold standard for ADHD treatment — is used correctly, children’s school marks improve and they are better equipped to develop social skills. In other words, effective ADHD treatment doesn’t just help youngsters with ADHD to sit still and focus in class, but supports them to learn and socialise — outcomes which form the foundation of a healthy and productive adulthood.
Methylphenidate is, however, classified as a schedule 6 drug in South Africa, placing it in the same regulatory category as medicines with a high potential for abuse. Pharmacies are therefore only allowed to dispense the medicine to people with doctor’s prescriptions, and by law, physicians can only prescribe 30 days’ worth of methylphenidate treatment at a time.
This means patients need to visit their doctor each month for a new prescription, so in the private sector they’d need to pay for a doctor’s visit each month, on top of paying for the medication, and in the public sector patients would need to take a day each month to queue at their local clinic — and they’d have to make sure it’s a day on which a doctor, as opposed to only nurses, are available at their health facility.
This scheduling creates huge administrative and financial difficulties for patients and caregivers when they try to get treatment, especially for those navigating ADHD’s severe symptoms: executive dysfunction, forgetfulness and inattention.
As a psychiatrist working in both the public and private health-care sector, I’ve seen the toll that untreated ADHD takes on children, adults and families — from fractured educational journeys to unemployment, depression, addiction and even suicide.
These are not theoretical risks but daily realities for many South Africans. And yet one of the biggest obstacles that locks people out of treatment — our own health-care policies — remains unchanged.
It’s time we changed that script.
A 2024 qualitative study with 23 South African stakeholders, including health-care professionals, pharmacists, regulators, patients and caregivers, revealed they did not see the current scheduling as an effective way to prevent misuse and illegal use. Instead, participants said, classifying methylphenidate as a schedule 6 drug “negatively impacts on treatment adherence”.
The South African Health Products Regulatory Authority (Sahpra) must urgently review the scheduling of methylphenidate to consider making it a schedule 5 drug, which will allow doctors to provide six-monthly scripts. Schedule 5 medicines have a low to moderate potential for abuse or dependence.
Here are four reasons methylphenidate should be a schedule 5 medication.
This raises an uncomfortable truth: those determined to misuse the drug will find ways to do so
1. More people with ADHD will get treated
ADHD is not rare — a review of 53 research studies shows it affects 7.6% of children aged between three and 12 and 5.6% of teens between 12 and 18.
In 65% of cases, children’s ADHD persists, at least partially, into adulthood.
While we rightly invest in treating chronic conditions such as diabetes and hypertension, we continue to overlook the profound, lifelong impact of untreated ADHD. Studies have confirmed that people with ADHD have a higher chance to develop other psychiatric disorders such as anxiety or depression, they’re far more likely to suffer from substance use disorders, to have accidental injuries, to underachieve in school, to be unemployed, to become gamblers, to fall pregnant as teenagers, to die by suicide and to die early.
These factors contribute to the burden of disease and consequent stress on the health system — but most importantly, they reduce the quality of life of people with ADHD and their families.
Medication can change this, yet access is limited. In many poorer communities virtually no children who need treatment are receiving it.
Though stigma and the cost of methylphenidate (on average, in today’s terms, between R700 and R1,000 for a month’s treatment in the private sector) play a role in making treatment harder to get, having it classified as a schedule 6 drug plays a big part in making the medication inaccessible — and it affects people in rural areas, the unemployed and those without medical aid the most, which further widens the treatment gap between the public and the private health-care sectors.
2. Current scheduling does not prevent abuse
Opponents of rescheduling often cite concerns about misuse — especially among tertiary students using methylphenidate for academic enhancement. Though these concerns are valid, evidence suggests that the current schedule 6 classification does little to prevent nonmedical use.
In fact, studies show that 28.1% of medical students have used methylphenidate without a prescription. This raises an uncomfortable truth: those determined to misuse the drug will find ways to do so, regardless of scheduling.
One South African study showed that of the 11.3% of students who reported having used methylphenidate in the past year, only 27.3% had been diagnosed with ADHD; despite this, two-thirds obtained their medication through doctors’ prescriptions, just under a third got it from friends and 6.1% bought it illegally.
Meanwhile, genuine patients — particularly children and teenagers — are penalised by overly restrictive policies that reduce access to the very tools designed to help them succeed.
We must ask: is the current scheduling preventing abuse, or is it merely restricting access for those who need it most? If the answer is the latter, then we have an ethical obligation to change course.
Rescheduling does not mean deregulation. It means creating a more nuanced, risk-based framework — one that acknowledges both the need for control and the realities of living with a chronic disorder.
In the case of ADHD, we must choose inclusion over exclusion, access over fear, and healing over harm
3. More people will take their medicine correctly
How well someone adheres to their medication determines, to a large extent, how well the medicine works for them.
But studies show that between 13% and 64% of people with ADHD who often use methylphenidate don’t use their medication as prescribed.
For people with ADHD — with symptoms that impair their ability to organise, plan and follow through — the monthly schedule 6 script requirement can become a self-defeating cycle. The very condition we are trying to treat creates challenges in adhering to its treatment.
Unsurprisingly, participants in the 2024 stakeholder study mentioned earlier viewed the current scheduling as counterproductive, and “expressed their support for the convenience of six-monthly scripts for obtaining treatment”. Stakeholders argued that overall adherence would improve by reducing administrative challenges such as the need to take time off work and arrange monthly doctor’s visits.
Moreover, research shows that people with ADHD who use their medication correctly are also more likely to adhere to medication for other conditions, such as diabetes or HIV infection, that they may have. Improving adherence to ADHD medication therefore does not only improve the quality of patients’ lives but lessens the burden on our health system overall.
4. The state is doing the same thing for antidepressants and anti-anxiety meds
ADHD medication is not the only psychiatric medicine that needs rescheduling. South Africa’s HIV plan for 2023-2028 recommends that certain antidepressants and anti-anxiety medications be descheduled from schedule 5 drugs — which only doctors can prescribe — to schedule 4, so that specially trained nurses can prescribe them.
Research has shown that there’s a high chance for someone with HIV to develop depression or anxiety; these conditions are associated with people with HIV taking their medicine less regularly.
But South Africa’s government health system — which most HIV-positive people in the country use to get their treatment — doesn’t have nearly enough doctors to staff clinics full-time. Instead, nurses run such clinics, with doctors only doing shifts once or twice a week.
Getting nurses to diagnose mental health conditions and prescribe treatment will mean that patients won’t have to return for doctor’s appointments to get treated.
Policy is never value neutral. It reflects what we, as a society, choose to prioritise. In the case of ADHD, we must choose inclusion over exclusion, access over fear, and healing over harm. Rescheduling methylphenidate is not about giving up control; it’s about restoring agency to patients, families and clinicians alike.
* Sahpra CEO Boitumelo Semete-Makokotlela responds: “Sahpra is open to the rescheduling of scheduled substances. For this to happen, either the manufacturer of a medicine or anyone in the scientific community who has data for us to consider has to submit a request for rescheduling, along with the required scientific and clinical data. We’ll have our names and scheduling committee, as well as our clinical committee, review the submissions. We would also consider additional data, outside of what would have been provided, and then make a decision. This process takes about 120 days.”
* Prof Renata Schoeman is a Cape Town-based psychiatrist, the co-author of South Africa’s ADHD management guidelines and chair of the South African Society of Psychiatrists’ special interest group for ADHD. She serves on the ministerial advisory committee for mental health and heads up the health-care leadership MBA specialisation stream at Stellenbosch University.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
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