PDF of full thesis available at Martin Whitely PhD Thesis Copy – ADHD and Regulatory Capture in Australia PDF

Abstract

Like many first world nations, Australia has demonstrated an increasingly pharmaceuticalized response to Attention Deficit Hyperactivity Disorder (ADHD).  Per capita rates of prescriptions of ADHD medications grew 277 percent between 1995 and 2010. However, there have been large and inconsistent intertemporal variations between state jurisdictions (shifting over time in relative terms).  Most notably, in Western Australia (WA) in 2002 the child Pharmaceutical Benefits Scheme (PBS) per capita prescribing rate was 142 percent above the national average.  However, after 2003, while in other states prescribing rates grew, they fell by 50 percent in WA, and by 2011 they were 11 percent below the national average.

There has been significant academic, public and media interest not only about the growing and inconsistent prescribing rates, but also about concerns that conflicts of interests and ‘regulatory capture’ may have affected significant policy development and regulatory processes in relation to ADHD. Regulatory capture occurs if an entity that is supposed to advance the public interest instead acts to benefit commercial or industry interests in ways that are contrary to the public interest.

The thesis draws heavily on the work of British sociologist John Abraham, who contends that regulatory capture is the most significant explanation of the process of pharmaceuticalization for many health conditions, including ADHD. Here key ADHD policy development processes are analysed to evaluate the extent of regulatory capture in Australian national and state jurisdictions. These include the development of national treatment guidelines and state-specific reviews of WA and New South Wales (NSW) prescribing practices. 

For the purposes of this thesis, the term ‘regulatory capture’ is taken to have a broad scope, encompassing capture of any or all of the actors, both government and non-government, which have the declared intention of protecting and enhancing the public good. Examples of non-government actors include professional organisations, researchers, and patient advocacy groups.

The history of ADHD policy and regulation nationally from 1992 to 2012, in WA from 1993 to 2011 and in NSW from 2007 to 2011 is that regulatory capture occurred in the majority of policy development and regulatory processes. These ‘captured’ processes have been associated with subsequent ADHD child pharmaceuticalization. Conversely the only ADHD-critic dominated process identified occurred in WA in 2002 and was associated with subsequent ADHD child de-pharmaceuticalization. The findings of this thesis are consistent with Abraham’s assertion that regulatory capture is a significant driver of pharmaceuticalization.

Hypothesis (page7)

The central hypothesis of this research is: The occurrence or absence of regulatory capture of the development and implementation of ADHD policy has contributed significantly to variations in Australian national and state ADHD medication child prescribing rates between 1992 and 2012.

Summary of ADHD prescribing statistics 1992-2011 (page 97)

Australian ADHD prescribing rates grew very rapidly between 1992 and 2011, with WA per capita rates growing much faster than the other states.  By 2000, WA child prescribing rates were at least double the national average and adult prescribing rates were over four times the national rate.  However, beginning in 2003, WA prescribing rates for children began to fall and by 2010 were approximately half of what they were in 2002.

Child prescribing rates, however, rose in all other states so that by 2011 WA rates were (approximately 11 percent) below the national average.  In contrast NSW child prescribing rates, which were significantly below WA rates in 2000, have grown rapidly and are now significantly higher than WA rates.  Other states have also demonstrated a pattern of increasing prescribing rates although South Australian and Victorian child prescribing rates both remain lower than WA rates.

WA’s adult ADHD prescribing experience has been significantly different from that for WA child prescribing.  While there was a modest fall in the mid-2000s the rates have remained consistently much higher than all other Australian states. 

Conclusion (page 241)

The purpose of this thesis was to examine the relationship between regulatory capture of ADHD policy and regulatory processes and child ADHD prescribing rates in Australia nationally and within state jurisdictions.  The history of ADHD policy and regulation nationally from 1992 to 2012, in Western Australia from 1993 to 2011 and in New South Wales from 2007 to 2011 indicates regulatory capture and corresponding pharmaceuticalization is highly probable, but not inevitable.  With the exception of Western Australia post 2001 and the balanced national ADHD Clinical Practice Point process in 2011-2012, all the other State and Commonwealth Government processes examined have been captured by ADHD proponents in the policy development and/or implementation phase.  Even WA’s balanced 1997 Technical Working Party process was captured in the implementation phase when the Stimulants Committee set up as a result of the Working Party recommendations was captured by ADHD proponents. 

All of these captured processes have been associated with subsequent ADHD child pharmaceuticalization, i.e. rapidly increasing per capita child prescribing rates. Conversely the only ADHD critic dominated process was associated with subsequent ADHD child de-pharmaceuticalization, i.e. rapidly falling per capita child prescribing rates.  In summary the evidence in relation to Government policy and regulation indicates that in relation to ADHD in Australia for the period 1993 to 2011, regulatory capture leading to pharmaceuticalization was normal but not inevitable. 

Australian regulatory capture has been reinforced by ‘imported regulatory capture’.  Specifically there has been a pattern of selective attention to international research and practices favourable to the perspective of ADHD proponents.  Most notably despite significant and substantiated concerns about improper pharmaceutical company influence upon the American Psychiatric Association (APA), Australian agencies, both government and non- government, have endorsed and promoted the use of the ADHD DSM-IV diagnostic criteria.  Alternative diagnostic criteria in the International Clarification of Diseases 10 (ICD-10) produced by the World Health Organisation (WHO), has been consistently ignored by Australian regulatory agencies and stakeholders, despite Australia being a member of the WHO.  The use of DSM-IV criteria are associated with increased prescribing rates as compared to jurisdictions relying on ICD-10.  It is therefore likely that regulatory capture of the American Psychiatric Association has contributed significantly to Australia’s increasingly pharmaceuticalized response to ADHD. 

Caution needs to be displayed in generalising the findings of this thesis.  It relates specifically to ADHD in Australia and it is impossible to quantify the relative importance of the many factors that may influence prescribing rates.  However, the positive relationship between regulatory capture and pharmaceuticalization demonstrated in this thesis is consistent with Abraham’s contention that ‘regulatory capture’ is the most significant driver of pharmaceuticalization in general and ADHD pharmaceuticalization in particular.  Further research is warranted on the relationship between ‘regulatory capture’ and pharmaceuticalization for ADHD and other controversial medical/psychiatric conditions in Australia and other jurisdictions.

A review of the medical records of 937,943 Canadian children showed that children born in December, the last month of their school year intake, were much more likely to be diagnosed and medicated for ADHD than their classmates born in January.

The eleven year study of children aged six to twelve in the Canadian province of British Columbiaian, titled Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children1, confirms the ADHD late birthdate effect found in two recent smaller US studies described in my previous blog post.

The late birthday effect in the massive new Canadian study was very significant. Boys who were born in December were 30% more likely to have a diagnosis and 41% more likely to have a prescription for ADHD than their peers born in January.

The effect was even stronger for girls.  Girls born in December were 70% more likely to have a diagnosis and 77% more likely, to have a prescription for ADHD than their peers born in January.

British Columbia children exhibited the general worldwide trend that ADHD diagnosis and prescribing rates for boys are approximately three times greater than for girls.2  This is consistent with the traditional wisdom that girls grow up faster than boys.

Drugging boys to make them behave more like girls in class demonstrates just how empty modern educational ‘philosophies of inclusion’ are.  But many girls are also chemically punished for their childishness when compared to their older classmates.

Obviously younger children are more likely to be immature with the youngest kindergarten children having 20% less life experience than their oldest classmates. However, it should not be lost that children develop at different rates.

If a child is less mature than other children their own age, or even younger, they are not diseased, they are different.  Classing relative immaturity as a disease to be treated with amphetamines, is a barbaric abuse of a child’s right to grow at their own pace.

If, as the ADHD Industry frequently claims, ADHD is a neurobiological disease, a child’s birth date should have no bearing on their chances of being diagnosed and ‘medicated’.  Yet the ADHD Industry will respond as it always does and ignore or spin yet another inconvenient truth revealed in this study.

 

 Related Media:

Martin Whitely interviewed by Greg Carey, Radio 4BC, Brisbane 20 March 2012. http://www.4bc.com.au/blogs/4bc-blog/adhd-misdiagnosis/20120320-1vh3e.html

Sue Dunlevy, Immature Children prone to ADHD Tag, The Australian, 20 March 2012 http://www.theaustralian.com.au/news/health-science/immature-children-prone-to-adhd-tag/story-e6frg8y6-1226304525855

For more related information see Pseudoscience supporting ADHD and How is ADHD Diagnosed?

  1. Richard L. Morrow MA (et al), ‘Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children’ CMAJ, March 5, 2012, http://www.cmaj.ca/content/early/2012/03/05/cmaj.111619.full.pdf+html
  2. Boyles, S. ‘Study confirms ADHD is more common in boys’, WebMD Health News, 15 September 2004 <http://www.webmd.com/add-adhd/news/20040915/study-confirms-adhd-is-more-common-in-boys> (accessed 10 March 2011)

On Friday 24 July 2006 the Royal Australasian College of Physicians (RACP) issued a press release calling for “legal defences in Australia for the use of corporal punishment (to) be amended … (so) that all forms of corporal punishment are unlawful” (see Child health experts call for change on how we discipline our children).  Predictably the call attracted extensive media coverage and generated impassioned polarised talkback radio.

The RACP’s release stated “research is increasingly showing that physical punishment may be harmful and children who receive physical punishment are at increased risk for a range of adverse outcomes both in childhood and as adults…These include mental health problems such as depression, anxiety, aggressive or antisocial behaviour, substance use problems and abuse of their own children or spouse…While many children will not experience negative outcomes as a result of moderate or reasonable physical punishment, why put your child’s future health and emotional wellbeing at risk?”

I don’t intend to enter the contentious ‘smacking debate’, except to say that there is a significant difference between a light smack on your child’s backside designed to bring their attention to their poor behaviour and inflicting significant pain with a belt or other ‘weapon’.  I am however struck by the contrast between the RACP’s anti-smacking stance and its promotion of the use of amphetamines to alter the behaviour of children, even pre-schoolers. The RACP took the lead role in producing and is continuing to promote discredited draft national ADHD treatment guidelines that relied on discredited and commercially corrupted research to promote the first line use of stimulants to treat ADHD.

The guidelines have never been endorsed by the National Health and Medical Research Council (NHMRC) who paid the RACP $135,000 to develop them.  The reason they were not endorsed according to the NHMRC is that “in July 2011 Harvard Medical School and Massachusetts General Hospital sanctioned Professor Biederman and Drs. Spencer and Wilens (whose work is heavily cited throughout the Draft Guidelines) for failing to report their industry sponsored activities and subsequently violating their organisations’ conflict of interest policies.” (http://www.nhmrc.gov.au/guidelines/publications/ch54 accessed 26 July 2013)  Biederman, Spencer and Wilens received millions in undisclosed drug company payments (see World leading ADHD ‘expert’ Harvard Professor Joseph Biederman sanctioned over hidden drug company money ).

However, these were not the only conflict of interest issues to dog the RACP ADHD guidelines process.  Most of the members of the RACP committee who developed the guidelines had commercial ties to ADHD drug manufacturers that were only disclosed through ‘Freedom of Information’ processes and the RACP itself has received sponsorship from the same companies. (see One year on from the release of the corrupted National ADHD Guidelines ).

Nonetheless the RACP website continues to promote the discredited guidelines stating “the RACP has conducted a thorough and careful process to develop the updated draft Guidelines and believes that these Guidelines will assist in improving the assessment, treatment and care of people with ADHD in Australia.” (http://www.racp.edu.au/index.cfm?objectid=393DD54A-04C5-85AC-B35FE82BA4849595 accessed 26 July 2013)

Regardless of the merits of their anti-smacking stance, the RACP would have more credibility when expressing concern about parenting and child welfare if they got their own house in order.

Sign the online petition to Boycott the DSM5 at http://dsm5response.com/

By Martin Whitely

DSM-5, the newest edition of the American Psychiatric Association’s ‘Bible of Psychiatry’ will be officially released in May 2013 and is already available for presale.  However, this edition of the DSM may not prove as profitable for the American Psychiatric Association (APA) as there is a growing international chorus of voices, many from within mainstream psychiatry, calling for a boycott of the DSM5.

Continue reading “Boycott DSM5 – it is dangerous and scientically unsound” »

by Professor Allen J. Frances, M.D. Chairperson of the American Psychiatric Association DSM-4 Task Force

This blog was originally Published on December 2, 2012 in DSM5 in Distress at http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association (APA) has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound.  My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.  Just ignore the ten changes that make no sense.

Brief background.  DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal- to produce a paradigm shift in psychiatry.  Excessive ambition combined with disorganized execution led inevitably to many ill-conceived and risky proposals. 

These were vigorously opposed.  More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits.  Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM 5 has neither been able to self-correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis.  Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably ‘psychosis risk’, mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, ‘hebephilia’, cumbersome personality ratings, and sharply lowered thresholds for many existing disorders).  But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below.

The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good.  Yesterday’s APA approval makes it likely that DSM 5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

The motives of the people working on DSM 5 have often been questioned.  They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine.  But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies.  Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

The APA’s deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation.  There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller.  When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control.  The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA’s projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation. 

This is no way to prepare or to approve a diagnostic system.  Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM 5′s ten most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM 5 decisions.

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

 8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot.  Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets. 

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life.  Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment.  This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM’s teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be.  Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and ‘behavioral addictions’ will soon be mislabeled as psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill. 

Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession.  But we have to know our limits and stay within them.

DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm!  That is why this is such a sad moment.

 

Martin Whitely’s comment:  Professor Frances’ comments can’t be dismissed as the architect of the old edition protecting his work from revision. As the overall leader of the DSM-4 development process he has accepted his share of responsibility for the problems DSM-4 helped create.1  However, rather than learn the lessons of inappropriate medicalisation of behavior and over-prescription from DSM-4, the American Psychiatric Association is about to deliver much worse in DSM-5.  Surely now is the time for the Australian psychiatric profession to end its slavish devotion to the broken American model that sees more than one in five US adults on at least one mental health drug.2

 

In August 2003 in response to concerns about the high number of children prescribed dexamphetamine for ADHD in Western Australia (WA), the state government tightened prescribing controls and introduced the Stimulants Regulatory Scheme. The introduction of the scheme with annual reporting was followed by a large and sustained fall in child patient numbers but a significant increase in the number of WA adults prescribed ADHD stimulants.

The 2011 Annual Report (the eighth annual report) was released on 17 October 2012 and is available at http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

Highlights of the WA Stimulants Regulatory Scheme 2011 Annual Report

Child Prescribing Rates- WA Stimulants Regulatory Scheme 2011 Annual Report contains both good and bad news. The good news is that the 2011 report confirms there has been a massive decline in per-capita prescribing rates for children since the Stimulant Regulatory Scheme was introduced in mid-2003. However, the bad news is that there was a spike in the number of new cases diagnosed in 2011.

Between 2004 (the first year for which figures are available) and 2010 per-capita ADHD child prescribing rates fell from 2.25 % to 1.3%.1 Federal Government figures2 indicate the number of children on ADHD medications in WA peaked in 2002 at 2.6%, indicating a 50% fall from the peak. However, in 2011 the rate rose marginally (to 1.34%) for the first time since the system was introduced. This was due to a significant increase in the number of first time child patients from a low of 883 in 2007, to 1628 in 2011.3 Most of these (824 or 51%) were aged 9 or less.

The bottom line is that although Perth is the world’s only ADHD child drugging hotspot to have seen a massive decline in child prescribing rates, there are signs that this hard won progress is in danger of being undone. To prevent history repeating there needs to be a crackdown on reckless prescribing now.

Adult Prescribing Rates- Adult ADHD per-capita prescribing rates continue to grow. They are generally not carryover patients from childhood, as 80% are diagnosed first as adults.4 The vast majority of adults get prescribed dexamphetamine (81.3% as opposed to 22.3% for children)5 and the majority are first diagnosed between 18 and 29.6 During 2011, 137 patients had their authority to receive psychostimulants withdrawn because they had abused prescription drugs.7 All of the facts support the contention that this is the tip of the iceberg and that many of Perth’s twenty to thirty somethings are doctor shopping for dexamphetamine. (For more info see Perth’s Dexamphetamine Hangover

Perth’s New Rogue Prescriber- One clinician (a psychiatrist) was responsible for prescribing to 1473 patients (1346 adults and 127 children) in 2011.8 The obvious question is how long is this doctor spending with each patient before prescribing them amphetamines? They can’t be doing much more than meeting each patient for a brief consultation and issuing a script!

There is a precedent for this type of prescribing. When the stimulants monitoring system was first introduced it revealed that a single paediatrician prescribed to 2077 children in 17 months from August 2003 to December 2004.9 This paediatrician was ‘encouraged’ to retire from prescribing and his subsequent retirement was immediately followed by a significant decrease in child prescribing rates.

History appears to be repeating itself although the major difference is this psychiatrist is prescribing primarily dexamphetamine to adults and there is every reason to be concerned that much of this taxpayer subsidised amphetamine is being abused.  At the very least there needs to be a prescribing audit of this practitioner and ideally they need to be encouraged to find an alternate vocation.

Geography- Geraldton with the highest child and second highest adult prescribing rates is the ADHD capital of WA.10 Geraldton has long had very high ADHD prescribing rates and concerns have long been raised about prescription drug abuse in the Mid-West Port Town. In 2010 a Geraldton mother of seven with a history of abusing a variety of prescription drugs, including dexamphetamine, died from an overdose of prescription methadone. (Refer to  Prescription drug abuse – A large and growing problem with a very simple solution

The Oceanic Health District (Perth’s City and wealthy western suburbs) has the highest adult rate but an average child prescribing rate. The considerable anecdotal evidence of high rates of diversion of amphetamines in Perth’s Western suburbs is supported by these high adult prescribing rates.

Conclusion- Western Australia’s scheme provides detailed publicly available (although de-identified) information. This information has been vital in highlighting anomalies, especially the prescribing records of rogue prescribers. It is a system worth replicating in other jurisdictions.

 

Related Media

Cathy O’Leary, The West Australian, More kids prescribed ADHD drugs, October 17, 2012 page 4. http://au.news.yahoo.com/thewest/a/-/breaking/15137786/rise-in-new-adhd-drug-use/

 

  1. Note: The stimulants regulatory scheme only reports child ADHD prescribing rate for stimulants (1.25% in 2010). Strattera (the brand name for atomoxetine hydrochloride) is a rarely prescribed non-stimulant ADHD medication. When Commonwealth Department of Health and Ageing data on Strattera Pharmaceutical Benefits Scheme prescriptions is included the rate in 2010 is 1.3% of 4 to 17 year olds. WA Stimulants Regulatory Scheme 2011 Annual Report http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf and Department of Health and Ageing Pharmaceutical Benefits Scheme figures prescribing of ADHD medications provided to Martin Whitely on request.
  2. Department of Health and Ageing Pharmaceutical Benefits Scheme figures prescribing of ADHD medications provided to Martin Whitely on request.
  3. WA Stimulants Regulatory Scheme 2011 Annual Report Page 63 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf
  4. WA Stimulants Regulatory Scheme 2011 Annual Report Page 41 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf
  5. WA Stimulants Regulatory Scheme 2011 Annual Report Pages 28 and 43. http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf
  6. WA Stimulants Regulatory Scheme 2011 Annual Report Pages 41. http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf
  7. WA Stimulants Regulatory Scheme 2011 Annual Report Page 19 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf
  8. WA Stimulants Regulatory Scheme 2011 Annual Report Pages 21 and 37 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf
  9. Stimulant Prescribing and Usage Patterns for the Treatment of ADHD in Western Australia  1 August 2003 – 31 December 2004 Western Australian Department of Health page 17  http://www.public.health.wa.gov.au/cproot/3609/2/03-04_Report.pdf
  10. WA Stimulants Regulatory Scheme 2011 Annual Report Pages 27 and 42 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

Colbert Report - Meducation

 

Stephen Colbert’s ‘Meducation’ plan for America’s third rate public schools – Don’t laugh too hard it is already happening (apologies for video quality – high quality video no longer available)

On October 10 2012 American comedian Stephen Colbert coined the term “meducation” to describe the growing practice of drugging with ADHD amphetamines, American children with mediocre school grades, who do not have a diagnosis of ADHD.

The catalyst for the mock right wing political commentator’s endorsement of ADHD drugs as smart pills was a front page article in the New York Times in which peadiatrician Dr Michael Anderson advocated their widespreade use to compensate for America’s third rate public education system. Doctor Anderson said “we’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.” Unlike Colbert, Dr Anderson is not a comedian but unfortunately for some of the children of Ganton Georgia he is their doctor.

In his comedic monologue Colbert argues the child drugging program should be extended beyond amphetamines. “Folks, I believe this is a great fiscally responsible answer, but we can do more.  I mean, we might be cutting arts programs, but one tab of acid, and your kid will be seeing colors you can’t find in a Crayola box.” Colbert’s mock rant concludes with a serious warning; “Now, of course, eventually it may turn out that drugging poor students creates more problems than it solves.  In which case, we’ll have to stop trying to change our children, and think about changing ourselves.”

Despite Dr Anderson’s claims and Colbert’s mock endorsement, ADHD amphetamines are anything but ‘smart drugs’. Unique long term (8 year) Australian research shows that children diagnosed ADHD and ‘ever medicated’ with amphetamines were a staggering 950% more likely to be rated by their teacher as “performing below age-level” than children diagnosed with ADHD and ‘never medicated’. (see far below) And as pointed out by Colbert the USA, the home of ADHD child drugging, lags most comparable developed nations (and a few second world nations) in terms of academic achievement.

The message is pretty clear – if you want to dumb down - speed up!

(A full transcript of Colbert’s ‘Meducation’ rant is available at http://www.dailykos.com/story/2012/10/11/1143009/-Stephen-Colbert-on-medicating-children-to-improve-their-grades )


Excerpt  from ‘Attention Disorder or Not, Pills to Help in School’

by Alan Schwarz New York Times, page 1, October 9, 2012

full text available at http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=1&_r=1&emc=eta1

When (American paediatrician) Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall (a mixture of four amphetamine salts1)…

Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools. “I don’t have a whole lot of choice…We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”…

Dr. Anderson’s instinct, he said, is that of a “social justice thinker” who is “evening the scales a little bit.” He said that the children he sees with academic problems are essentially “mismatched with their environment” — square pegs chafing the round holes of public education…

About 9.5 percent of Americans ages 4 to 17 were judged to have it (ADHD) in 2007, or about 5.4 million children, according to the Centers for Disease Control and Prevention2

According to guidelines published last year by the American Academy of Pediatrics, physicians should use one of several behavior rating scales, some of which feature dozens of categories, to make sure that a child not only fits criteria for A.D.H.D., but also has no related condition like dyslexia or oppositional defiant disorder, in which intense anger is directed toward authority figures. However, a 2010 study in the Journal of Attention Disorders suggested that at least 20 percent of doctors said they did not follow this protocol when making their A.D.H.D. diagnoses, with many of them following personal instinct…

Dr. Anderson said (ADHD diagnostic criteria)…were codified only to “make something completely subjective look objective.”…

“This is my whole angst about the thing,” Dr. Anderson said. “We put a label on something that isn’t binary — you have it or you don’t. We won’t just say that there is a student who has problems in school, problems at home, and probably, according to the doctor with agreement of the parents, will try medical treatment.”

He added, “We might not know the long-term effects, but we do know the short-term costs of school failure, which are real. I am looking to the individual person and where they are right now. I am the doctor for the patient, not for society.”

Martin Whitely’s Comment – I am torn between loathing Doctor Anderson for his blatant disregard for the long term welfare of the children he is supposed to be helping; and respecting him for his honest assessment of the unscientific nature of an ADHD diagnosis and the American public education system. However, his justification for using Adderall on children with mediocre or worse grades is built on a very flawed premise; that is the belief that amphetamines are an academic performance enhancer.


 Australian study shows ‘Smart Pills’ a Dumb Claim

Published in February 2010 the Raine Study ADHD Medication Review provided the world’s first independent data on the long-term effects (eight years) of psychostimulant medication. (full opy available at http://www.health.wa.gov.au/publications/documents/MICADHD_Raine_ADHD_Study_report_022010.pdf)

The two most significant findings of the Raine Study ADHD Medication Review were:

1.   School failure: ‘In children with ADHD, ever receiving stimulant medication was found to increase the odds of being identified as performing below age-level by a classroom teacher by a factor of 10.5 times.”3

2.   Long-term cardiovascular damage: ‘The most noteworthy finding in the study was the association between stimulant medication and diastolic blood pressure. Compared to not receiving medication, the consistent use of stimulant medication was associated with a significantly higher diastolic blood pressure (of over 10mmHg)…These findings indicate there may be a lasting longer term effect of stimulant medication on diastolic blood pressure above and beyond the immediate short-term side effects.’4

In addition the report indicated that there was a marginally negative outcome for both ADHD symptoms (inattention and hyperactivity) and depression with the long-term use of stimulant medication.5

The finding was that past stimulant use increased the probability of an ADHD child falling behind at school by a massive 950 per cent completely undermines the hypothetical basis of medicating for ADHD. As stated in the Raine Medication Review report, the basis of the belief that amphetamines have long-term benefits is short-term studies, which ‘indicate that immediate management of ADHD symptoms allows children to function more effectively within a classroom. It is hypothesised that this makes children more available for learning and allows children to learn skills and concepts which are necessary to function well within a classroom in the future.’6 The analysis of the Raine Study data was the first time this hypothesis had been tested.

The finding that amphetamine use may permanently raise diastolic blood pressure is also of great significance. It had been previously recognised that while stimulants were in the patient’s system, heart rate and blood pressure were elevated, leading to the associated risks of heart attacks and strokes. But it was assumed that when the short-term stimulant effects wore off the cardiovascular system returned to normal.

An advantage of using data from the Raine Study is that it reduces the risk of design bias as the original designers of the study had no idea the data would eventually be used to study ADHD.  In addition the body that commissioned the ADHD review, the Western Australian Ministerial Implementation Committee on ADHD (MICADHD), was an extremely diverse group. Opinions as to the safety and efficacy of stimulant medications within MICADHD were highly divergent.  This lack of consensus, was a strength of the study, as it limited the potential for ‘publication bias’ where there is a collective decision to bury results that are not in keeping with the consensus position of participants.

The suggestion that the Raine Study would be a possible source of long-term data on stimulant medication was first made by MICADHD members with a long history of prescribing and advocating the use of stimulants. They were obviously expecting very different results. I expected the results to show no long-term educational benefits or some adverse educational outcome from stimulants, but even I was surprised by the strength of the negative outcome. Initially, the medication proponents on MICADHD tried to claim that the outcomes for the medicated children were most probably worse than those for un-medicated children, because the medicated children had more severe ADHD. However, as a member of the MICADHD committee I insisted on a comparison of the groups at age five, which was prior to any of the children having been medicated. This analysis established that there were no statistically significant differences in developmental, behavioural and health measures before the children were medicated.

As with all studies there are limitations with the ADHD medication review. While the sample size (131) was small, ‘it was larger than those in many short-term studies that supported the use of stimulants as a safe and effective treatment for children with ADHD’.7 Although the evidence now available from the Review does not prove that amphetamines cause failure at school and permanent cardiovascular damage, it is significant because there is so little other long term research to guide clinical practice.

The lack of enthusiasm for the findings of the research demonstrated by some of its authors diminished its impact when it was first published in February 2010. If not for the robustness of MICADHD Committee processes and the integrity of its chairperson, Professor Lou Landau, it challenging findings may have never been published. Follow up findings for the children at age 17 and 20 are expected to be published within the next twelve months.

To read more about the methodology and findings of the Raine Study ADHD Medication Review see One year on from the Raine Study ADHD Medication Review – Will the analysis of this unique long term data source continue and if so can we trust those doing the analysis?

 

  1. See http://www.rxlist.com/adderall-drug.htm 
  2. See http://www.cdc.gov/ncbddd/adhd/data.html
  3. Government of Western Australia, Department of Health, Raine ADHD Study: Long-term outcomes associated with stimulant medication in the treatment of ADHD in children, Department of Health, Perth, 2010. , p. 6. http://www.health.wa.gov.au/publications/documents/MICADHD_Raine_ADHD_Study_report_022010.pdf 
  4. Government of Western Australia, Department of Health, Raine ADHD Study: Long-term outcomes associated with stimulant medication in the treatment of ADHD in children, Department of Health, Perth, 2010. , p. 52. http://www.health.wa.gov.au/publications/documents/MICADHD_Raine_ADHD_Study_report_022010.pdf 
  5. Government of Western Australia, Department of Health, Raine ADHD Study: Long-term outcomes associated with stimulant medication in the treatment of ADHD in children, Department of Health, Perth, 2010. , p. 5 http://www.health.wa.gov.au/publications/documents/MICADHD_Raine_ADHD_Study_report_022010.pdf 
  6. The short term studies referred to in the Raine Study are Howard B. Abikoff, et al., ‘Methylphenidate effects on Functional Outcomes in the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS)’, Journal of Child and Adolescent Psychopharmacology, 17(5), 2007, pp. 581–92; C. L. Carlson & M. R. Bunner, ‘Effects of Methylphenidate on the Academic Performance of Children with Attention-Deficit Hyperactivity Disorder and Learning Disabilities’, School Psychology Review, 22(2), 1993, pp. 184–98; Irene M. Loe & Heidi M. Feldman, ‘Academic and educational outcomes
    of children with ADHD’, Journal of Pediatric Psychology, 32(6), 2007, pp. 643–54. Government of Western Australia, Department of Health, Raine ADHD Study: Long-term outcomes associated with stimulant medication in the treatment of ADHD in children, Department of Health, Perth, 2010. , p. 30 http://www.health.wa.gov.au/publications/documents/MICADHD_Raine_ADHD_Study_report_022010.pdf 
  7. Government of Western Australia, Department of Health, Study raises questions about long-term effect of ADHD medication, Media Release, 17 February 2010. http://www.health.wa.gov.au/press/view_press.cfm?id=884 

« Older entries