New Draft ADHD Clinical Practice Points out for Public Comment – Please Contribute

The Draft Australian ADHD Clinical Practice Points are out for public comment until 28 November 2011. (available at http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d) Please make the effort to prepare a submission. Common-sense voices concerned about the welfare of children, and not the profit and convenience of adults, need to be heard right now. It is certain the ADHD industry will be very organised and use this opportunity to try and expand their already lucrative markets. They cannot be allowed to dominate this very important process.  My detailed submission follows. Feel free to borrow at will.

Lobbying began over four years ago to have the development of guidelines and clinical practice points on Attention Deficit Hyperactivity Disorder (ADHD) put in the control of a multidisciplinary group without ties to the pharmaceutical industry. Now that a relatively conflict of interest free* Expert Working Group has released its draft Clinical Practice Points on ADHD in Children and Adolescents (Clinical Practice Points or CPPs) it is heartbreaking to see the minimal impact of the process to date.

I had hoped the Expert Working Group would provide decisive leadership on the issue. I had hoped the Expert Working Group would reject the American Psychiatric Associations DSMIV position that being disorganised, disliking homework, fidgeting, playing too loudly and losing toys and pencils are valid diagnostic criteria for a childhood psychiatric disorder. I had hoped the Expert Working Group would say that administering amphetamines and amphetamine like drugs is bad for children in the long run and must not happen. However, so far their work is very disappointing.

The next step in the process, considering public submissions, is crucial. It is a rare opportunity to fight-back and rein in Australia’s large and growing ADHD child prescribing rates. For the sake of Australian kids please be part of the process.

* For details of conflicts of interest see  http://speedupsitstill.com/mental-health-minister-mark-butler-scores-8-10-open-book-approach-australian-national-adhd-guidelines-committee

Related Media- Sue Dunleavy, The Australian medicate ADHD kids or else parents told 21/11/2011 http://www.theaustralian.com.au/national-affairs/medicate-adhd-kids-or-else-parents-told/story-fn59niix-1226200652633 Update; On 23 November 2011 the NHMRC issued a media release denying that a failure to medicate may result in the intervention of child proection authorities ( http://www.nhmrc.gov.au/media/releases/2011/reassuring-parents-new-draft-adhd-clinical-practice-points-do-not-mandate-medica ). This is welcome, however, the statement ‘as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns’ should never have been included in the CPPs.

Draft ADHD Clinical Practice Points – Built on Rotten Foundations

Submission by Martin Whitely MLA – Member for Bassendean Legislative Assembly of WA

Executive Summary and Recommendations

In fairness to the Expert Working Group given that their purpose ‘is to consider the Draft NHMRC ADHD Guidelines (2009) and develop clinical practice points to assist clinicians’ it was almost inevitable that their draft Clinical Practice Points (CPPs) would be significantly flawed.[2. The draft Clinical Practice Points are “developed to complement, not replace, existing guidelines” including the “Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder (2009)” that “are available on the NHMRC web site but are waiting to be finalised.” National Health and Medical Research Council, Public Consultation on the Draft Clinical Practice Points on the Diagnosis, Assessment and Management of Attention Deficit Hyperactivity Disorder in Children and Adolescents, Australian Government, November 2011, p. 20.  Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d  ] the Draft NHMRC ADHD Guidelines are a rotten foundation on which to build the Clinical Practice Points. The Draft Guidelines were prepared by a committee with extensive pharmaceutical company ties who relied primarily on group consensus and secondly on corrupted research. Furthermore the Guidelines Development Committee ignored compelling conflicting evidence and recommended the indiscriminate diagnosis of ADHD and use of pharmaceutical interventions.

Whilst there are modest improvements, the fundamental flaws of the Draft Australian Guidelines are apparent in the draft Clinical Practice Points. As a result, despite the efforts of the Expert Working Group, the draft Clinical Practice Points are riddled with inconsistencies and must be substantially rewritten. In addition the Draft NHMRC ADHD Guidelines must be rejected in total and removed from the NHMRC website.

However, not all of the flaws in the draft Clinical Practice Points are inherited from the Draft Guidelines. One of the most alarming statements in the Clinical Practice Points is original and states that ‘as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns’.[3. Clinical Practice Points p15. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d  ] The dominant medical interventions for ADHD are stimulants. The implied threat is that a parent’s refusal to allow their child to be drugged with amphetamines or similar drugs may see the intervention of child protection agencies. As absurd as this sounds there is a US precedent. A number of American states have legislated to prevent child protection authorities and schools enforcing the ‘medication’ of children with psychotropic drugs against the wishes of their parents.[4. Kate Zernike and Melody Petersen, ‘Schools’ Backing of Behavior Drugs Comes Under Fire’,  New York Times, 19 August 2001.  Available http://www.nytimes.com/2001/08/19/us/schools-backing-of-behavior-drugs-comes-under-fire.html?pagewanted=all&src=pm (accessed 17 November 2011)]

The core problem with the CPPs is that the Expert Working Group has failed to deal decisively with the fundamental issue; What is ADHD and is it a valid diagnosis? They are having an each way bet. Clearly they are concerned that a clinician diagnosing a child with ADHD can’t identify what is causing the problem behaviours and therefore has no idea what treatment will match the cause. Yet ultimately they validate the diagnosis of ADHD in children.

The Expert Working Group has recognised but placed insufficient weight on the absence of systematic, long term, evidence as to the safety and efficacy of ADHD medications.  Similarly the Expert Working Group has fallen into the traps of;

  • dismissing anything that is not a one size fits all treatment even though they acknowledge ADHD behaviours have multiple potential causes and
  • requiring a higher standard of long term evidence from low risk treatments than that required from invasive inherently high risk treatments.

As it was with the Draft Guidelines significant evidence of long term harms arising from the use of stimulants has also been overlooked in the CPPs. There are also a number of statements in the CPPs that are either simply wrong, or present unproven hypothesis as fact.

The Expert Working Group has acknowledged that ICD10 is an alternative diagnostic framework. However, by validating the existence of discrete ADHD subtypes the Expert Working Group have explicitly validated the DSM and American psychiatric practice as the dominant clinical model for Australia. This is a significant issue as the application of the more conservative World Health Organisation criteria would see far fewer children diagnosed and ’medicated’. Furthermore locking Australia into DSMIV makes it even more likely we will continue to follow the APA on its next step towards the already discredited DSM5.

While the language of the CPPs is an improvement from the Draft Guidelines they allow too much discretion based on clinical preference and prejudice. The aim of the CPPs should be to achieve more consistent clinical practice.  Unfortunately the current practice of diagnosing and prescribing for ADHD is so subjective that a diagnosis of ADHD tells us more about the adults (parents, teachers, doctors) in a child’s life, than it does about the child.

Consistency can only be achieved through clear boundaries, including the prohibition of diagnosing pre-schoolers and the use of ADHD medications for longer than 12 months. Consistency can also only be achieved if the clinicians authorised to diagnose and prescribe are trained appropriately in paediatric mental health.  Finally clinicians need to display sufficient integrity and professionalism in their practice to resist easy options.

These CPPs are extremely important. In Australia in 2010 approximately 60,000 children received medication, primarily amphetamines and near amphetamines, to manage inattentive and hyperactive behaviours like fidgeting and playing too loudly.[5. Department of Human Services, Medicare Australia, ‘Pharmaceutical Benefit Scheme Child Prescribing (0-18) Patient Numbers for ADHD Drugs in 2010’, Australian Government, 2011. Provided on request to Martin Whitely.] These children, all children, deserve better.

After reviewing the CPPs I recommend the following specific changes. Detailed argument fo each of the recommendations follows:

Recommendation 1- The Expert Working Group should recommend that the discredited Draft NHMRC ADHD Guidelines are rejected in total and removed from the NHMRC website.

Recommendation 2 – The CPPs should state that ADHD is not a useful diagnosis and that the term Unexplained Attention and Hyperactive Behaviour Difficulties is a far more accurate description of both the child’s behaviour and the clinicians understanding of its causes. Specifically the term Attention Deficit Hyperactivity Disorder should be abandoned and replaced with Unexplained Attention and Hyperactive Behaviour Difficulties for dysfunctionally inattentive and/or hyperactive/impulsive children when there is no identified cause of their problem behaviours.

Recommendation 3 – The Clinical Practice Points should be rewritten to state some alternative treatments (behavioural optometry, biofeedback, physical activity, etc.) may benefit a subset of children currently diagnosed ADHD, however there is at present insufficient evidence to evaluate their relative effectiveness.

Recommendation 4 – The Clinical Practice Points should state that although there is evidence that pharmaceutical interventions may help moderate ADHD symptoms in the short term, there is limited evidence in regard to their long term safety and efficacy. Furthermore the limited long term evidence available suggests significant long term harms and no sustained benefits. Therefore ADHD medications should only be used when extreme inattentive and hyperactive/impulsive behaviours represent a significant risk to the immediate welfare of the child (extreme hyperkinetic disorder) and their use must be restricted to short term interventions (never longer than 12 months).

Recommendation 5 – The Clinical Practice Points should be rewritten to explicitly reject the American Psychiatric Associations DSM process and state that the ICD-10 diagnostic criteria are to be met in full before a child is diagnosed with Unexplained Attention and Hyperactive Behaviour Difficulties (refer Recommendation 1)

Recommendation 6- The statement that ‘as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns’ must be removed from the Clinical Practice Points.

Recommendation 7- The statement that children meeting DSM IV diagnostic criteria for ADHD are described as typically having brain development that is inconsistent with age matched peers, for example, slower rates of cortical thinning is unsubstantiated speculation and must be removed from the Clinical Practice Points.

Recommendation 8- The statement that ‘ADHD also increases the risk of a range of adverse outcomes including educational, social, emotional and behavioural problems during childhood, and subsequent mental health, relationship, occupational, legal, and substance abuse problems in adult life’ is equivalent to saying dysfuntional behaviours cause dysfunctional behaviours and should be removed from the Clinical Practice Points.

Recommendation 9- The proposition that ‘developing an effective plan also involves educating the child/adolescent and his or her family and carers about the disorder and its impact on various domains of the child’s life’ has the potential to create self fulfilling prophecies of failure for many Australian children and should be removed from the Clinical Practice Points.

Recommendation 10- The CPPs should retain the question ‘Can pre-school children (under 6 years) be diagnosed with ADHD?’ but change the response to ‘NO. A diagnosis of ADHD is especially subjective amongst pre-school children as ADHD type behaviours are entirely normal behaviours for young children’.

Recommendation 11- The CPPs should include the statement that in line with manufacturers recommmendations, medications, including amphetamines and near amphetamines, should not be prescribed for ADHD under any circumstances for children younger than six years of age.

Recommendation 12 – The CPPs should include the statement Clinicians have a responsibility to identify where family dysfunction may be contributing to a child’s inattentive or hyperactive/impulsive behaviour and where appropriate to suggest supportive strategies.

Recommendation 13 – As ADHD type behaviours have many potential causes and there is nothing unique or explanatory about the label ADHD the CPPs should remove any reference to ADHD being a comorbid disorder.

Recommendation 14 – Remove the innaccurate and misleading statement ‘the rate of sudden death in patients taking methylphenidate or atomoxetine is below background rates’ from the CPPs.

Recommendation 15: The CPPs should state that ‘in order to give children at least as much protection from insufficiently trained diagnosticians and prescribers as adults, only child psychiatrists or paediatricians who have been assessed as having achieved specific mental health competencies should be able to diagnose and prescribe medications for the treatment of childhood mental health disorders including ADHD’.

Detailed Discussion

Relationship of Clinical Practice Points to Draft Guidelines

The terms of reference for the Expert Working Group that developed the draft Clinical Practice Points state that their purpose ‘is to consider the Draft NHMRC ADHD Guidelines (2009) and develop clinical practice points to assist clinicians’. The Draft NHMRC ADHD Guidelines are a rotten foundation on which to build the Clinical Practice Points. The Draft Guidelines were prepared by a committee with extensive pharmaceutical company ties who relied primarily on group consensus and secondly on corrupted research. Furthermore the Guidelines Development Committee ignored compelling conflicting evidence and recommended the indiscriminate diagnosis of ADHD and use of pharmaceutical interventions.

Whilst there are modest improvements the fundamental flaws of the Draft Australian Guidelines are apparent in the draft Clinical Practice Points. As a result despite the efforts of the Expert Working Group the draft Clinical Practice Points are riddled with inconsistencies and must be substantially rewritten.

 

The Future of the Draft NHMRC ADHD Guidelines (2009)

Final approval of the Draft NHMRC ADHD Guidelines was suspended in November 2009 because of the then uncompleted investigation into undisclosed drug company payments to three prominent US researchers, Harvard Professors Biederman, Spencer and Wilens, whose work is referenced 82, 46 and 32 times respectively in the draft Australian Guidelines. The NHMRC later issued a press release stating that ‘If the US investigation remains unresolved by mid-2010, NHMRC will move to redevelop the draft guidelines’. [6. NHMRC, ‘Draft Australian Guidelines on ADHD – NHMRC consideration deferred pending outcome of USA investigation’, NHMRC Noticeboard, 2009. Available  http://www.nhmrc.gov.au/media/noticeboard/notice09/091130-adhd.htm (accessed 5 January 2010).] Despite this the mid 2010 deadline passed without action and the draft guidelines are still available on the NHMRC website.

The CPPs incorrectly state ‘given the lack of resolution of the Biederman allegations, it was not possible to finalise these Draft Guidelines at the time of developing these CPPs.’ [7. Clinical Practice Points p15. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] The investigation into Biederman, Wilens and Spencer was completed in July 2011 and the Boston Globe [8. Liz Kowalcyzk, ‘Harvard doctors punished over pay’, Boston Globe, 2 July 2011.  Available http://articles.boston.com/2011-07-02/lifestyle/29731040_1_harvard-medical-school-physicians-harvard-doctors  (accessed 13 October 2011).] reported Bierderman, Spencer and Wilens were sanctioned by Harvard for failing to disclose millions of dollars in pharmaceutical company payments. [9. On June 8 2008 the New York Times first exposed how Dr Biederman was paid US$1.6 million in consulting fees from drug makers between 2000 and 2007 but did not disclose this income to his employer Harvard University.  Gardiner Harris and Benedict Carey, ‘Researchers Fail to Reveal Full Drug Pay’ New York Times, 8 June 2008.   Dr. Biederman has received research funds from 15 pharmaceutical companies and serves as a paid speaker or adviser to at least seven drug companies, cited in ‘The Evolving Face of ADHD: From Adolescence to Adulthood—Clinical Implications’.  Available at www.adhdhome.com (accessed 2 May 2008)]

The Boston Globe article states:In a letter to co-workers yesterday, Biederman and Drs. Thomas Spencer and Timothy Wilens said the hospital and medical school “have determined that we violated certain requirements” of the institutions’ policies. They did not specify the nature of the violations. But in 2008, Senator Charles Grassley, an Iowa Republican, accused the three doctors of accepting millions of dollars in consulting fees from drug makers from 2000 to 2007, and of failing for years to report much of the income to university officials. Officials at Harvard and Massachusetts General released the letter to the Globe, but would not answer questions about the probe.

Whilst the reliance on Biederman’s research is a significant issue there are many other flaws within the Guidelines process and outcomes. Despite the emphasis placed on Biederman research by the NHMRC it was not the only ‘conflict of interest’ controversy around the Draft National ADHD Guidelines. The Guidelines committee was initially chaired by Dr Daryl Efron until his ADHD pharmaceutical company ties were exposed by the Daily Telegraph in April 2007.[10. Janet Fife-Yeomans, ‘ADHD guru quits over Ritalin link’, The Daily Telegraph, 5 May 2007.  Available http://www.dailytelegraph.com.au/news/sydney-nsw/adhd-guru-quits-over-ritalin-link/story-e6freuzi-1111113472188  (accessed 4 October 2009).]

Dr Efron had been on the advisory boards of Novartis (Ritalin) and Eli Lilly (Strattera). Media exposure of Dr Efron’s pharmaceutical company ties prompted then Health Minister Tony Abbott’s intervention and Efron’s resignation as chair, but not from the committee. Freedom of Information processes also revealed that at least 70%, but probably 80%, ‘of the original (guidelines committee) group members, including doctors, have declared receiving grants and air fares, hotels and overseas trips from companies making drugs to treat the disorder. [11. Janet Fife-Yeomans, ‘Guidelines panel linked to drug firms’, The Advertiser, 17 November 2008.  Available http://www.news.com.au/adelaidenow/story/0,22606,24660999-5006301,00.html (accessed 4 October 2009).]

Perhaps the most disturbing element of the draft guidelines is the number of pro-drugging recommendations where there was reference group consensus, despite a complete lack of (even poor quality) supporting evidence. Over two thirds of the 208 recommendations had no supporting evidence and were justified as ‘best practice based on clinical experience and expert opinion’.[12. National Health and Medical Research Council, Draft: Australian Guidelines on Attention Deficit Hypertactivity Disorder (ADHD), Royal Australasian College of Physicians,  June 2009.  Available http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ch54_draft_guidelines.pdf (accessed 16 November 2011)] ‘Group Think’ amongst a clique, most of whom have commercial and professional ties to ADHD drug manufacturers, should not be driving our national response to ADHD.

Please find enclosed as part of my submission my book, Speed Up and Sit Still – The Controversies of ADHD diagnosis and treatment (2010 University of Western Australia Publishing). Pages 105 to 118 provide further detail of the flawed process content of the Draft NHMRC ADHD Guidelines or alternatively view http://speedupsitstill.com/gillard-government-continues-turn-blind-eye-drug-company-money

Recommendation 1- The Expert Working Group should recommend that the discredited Draft NHMRC ADHD Guidelines are rejected in total and removed from the NHMRC website.

 

Contradictions in Regard to the Fundamental Question; What is ADHD?

The Clinical Practice Points state that ADHD ‘is a description rather than an explanation’ of a ‘disabling pattern’ of ‘inattentiveness, overactivity and/or impulsiveness’.[13. Clinical Practice Points p4. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] They also state that the ‘clinician should always be mindful of seeking a more meaningful explanation of the child’s behaviour than simply labelling it as ADHD because it meets diagnostic criteria.’ [14. Clinical Practice Points p10. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] However, elsewhere they treat ADHD as if it is an explanation of last resort, in that when no explanation of a child’s behaviour is established, ADHD is regarded as the cause.

For example the question at 1.4 ‘Could hyperactive, inattentive and impulsive behaviours be explained by something other than ADHD?’ implies ADHD is in and of itself a possible explanation of impulsive and/or inattentive behaviours. In other words ADHD is caused by ADHD.[15. Psychologist and Professor Emeritus at California State University, David Keirsey, criticises the circularity of the argument stating, ‘It’s preposterous to say that the symptoms of attention deficit cause the deficit of attention.’ David Keirsey, ‘The Great A.D.D. Hoax’ at Keirsey.com, n.d., http://www.keirsey.com/add_hoax.aspx  (accessed 20 March 2008).]

The Expert Working Group has failed to deal decisively with the fundamental issue; What is ADHD and is it a valid diagnosis? They are having an each way bet. Clearly they are concerned that a clinician diagnosing a child with ADHD can’t identify what is causing the problem behaviours and therefore has no idea what treatment will match the cause. Yet ultimately they validate the diagnosis of ADHD in children.

Typical of this ‘half pregnant’ approach is the statement in the Clinical Practice Points that ‘a child who meets diagnostic criteria for ADHD may not be best served by making that diagnosis; their behaviour might be better understood as a reaction to more specific cognitive difficulties or family/environmental circumstances.’[16. Clinical Practice Points p4. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ]

They must go further and ask if ADHD is a meaningless diagnosis how is a child is ever best served by being diagnosed ADHD?

If clinicians don’t know what is going on they should just say so. If they absolutely must have a label, that label should accurately reflect the child’s behaviour and the clinicians understanding of the cause of the behaviour. Unexplained Attention and Hyperactive Behaviour Difficulties is a far more accurate and honest description.

Recommendation 2 – The CPPs should state that ADHD is not a useful diagnosis and that the term Unexplained Attention and Hyperactive Behaviour Difficulties is a far more accurate description of both the child’s behaviour and the clinicians understanding of its causes. Specifically the term Attention Deficit Hyperactivity Disorder should be abandoned and replaced with Unexplained Attention and Hyperactive Behaviour Difficulties for dysfunctionally inattentive and/or hyperactive/impulsive children when there is no identified cause of their problem behaviours. 

 

Short Term Focus of Draft Practice Point’s

The CPPs state ‘while (drug) interventions can reduce the core symptoms of ADHD in the short term, the effect of medication and behavioural or educational interventions on long term outcomes such as academic and social and emotional outcomes, is inconclusive and requires further study.’[17. Clinical Practice Points p9. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] The fact that the long term effects are not known shouldn’t simply require further study, it requires that potentially harmful interventions are not utilised until the long term effects are fully understood.

ADHD drug manufacturers exploit this long term evidence vacuum. They sponsor literally thousands of short term studies but virtually never engage in long term research. They argue it would be unethical to experiment long term on children with potentially harmful pharmacological interventions but happily profit from the sustained long term ‘treatment’ of children with unproven drugs.

In short-term research trials their products invariably appear more effective than non-drug treatments for two reasons. First, drugs alter behaviour much faster than non-drug treatments, and trials most often measure improvements by short-term symptom management (often for no longer than a few weeks). Second, while the behaviour-altering effects of stimulants are almost universal, other forms of treatment are not. Family counselling, for example, will be of little or no benefit if the underlying cause of behavioural problems is exposure to environmental toxins.

The dismissal in the CPPs of numerous alternative treatments due to there being ‘insufficient evidence to support the management of ADHD in children and adolescents using’[18. Clinical Practice Points p16. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] drug free approaches reflects the abovementioned biases. Some of these treatments may be of no benefit under any circumstances. However others, if used on a sustained basis where the treatment matches the cause, may benefit a subset of children diagnosed ADHD.

In addition it is hard to see how many of the dismissed treatments represent a health risk in the way that the sustained use of dexamphetamine, Ritalin or Strattera does. A risk/benefit, rather than a short-term symptom management based evaluation of potential treatments would likely have produced different recommendations.

The Expert Working Group has fallen into the traps of;

  • dismissing anything that is not a one size fits all treatment even though they acknowledge ADHD behaviours have multiple potential causes and
  • requiring a higher standard of long term evidence from low risk treatments than that required from invasive inherently high risk treatments.

Recommendation 3 – The Clinical Practice Points should be rewritten to state some alternative treatments (behavioural optometry, biofeedback, physical activity, etc.) may benefit a subset of children currently diagnosed ADHD, however there is at present insufficient evidence to evaluate their relative effectiveness.

 

Significant Long Term Evidence Ignored

The CPPs ignore significant evidence as to the efficacy of stimulants. They state ‘for children and adolescents diagnosed with ADHD, stimulant medications (methylphenidate) can reduce core ADHD symptoms and improve social skills and peer relations in the short term (up to 14 months) … The benefit of medication in the longer term compared to behavioural management or no treatment is not established’.[19. Clinical Practice Points p13. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ]

The MTA Study

The evidence of short term improvement of up to 14 months comes from the Multimodal Treatment Study for Attention Deficit Hyperactivity Disorder (aka the MTA Study). While there were several methodological flaws, notably a lack of a placebo and blind raters, the MTA Study did follow a significant number of children over a number of years.[20. Peter Breggin, ‘A Critical Analysis of The NIMH Multimodal Treatment Study for Attention-Deficit/Hyperactivity Disorder: a critical analysis.  Available at http://breggin.com/index.php?option=com_content&task=view&id=107   (accessed 17 November 2011).   Note:  The MTA Study was ‘the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the (U.S.) National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care.’ K. C. Wells, W. E. Pelham, et al., ‘Psychosocial treatment strategies in the MTA study: rationale, methods, and critical issues in design and implementation’, (abstract), Journal of Abnormal Child Psychology, Vol. 28, No. 6, 2000. Available http://www.ncbi.nlm.nih.gov/pubmed/11104313 (accessed 7 February 2008).] In 1999 after conducting the first fourteen months of the study the authors concluded that ‘carefully crafted medication management was superior to the behavioural treatment and to routine clinical care that included medication’.[21. The study was sponsored by the National Institute of Mental Health (NIMH) and conducted at six separate US sites. At each site, the study compared four treatment conditions: medication management alone, combined medication management and behavioural therapy, behavioural therapy, and community care. The average age of the children was eight and 80 per cent were boys. For more information, see The MTA Cooperative Group, ‘A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder’, Archives of General Psychiatry, 56, 1999, p. 1073.] It was described as ‘one of the first studies to demonstrate benefits of multimodal and pharmacological interventions lasting longer than a year and became one of the most frequently quoted sources supporting the use of stimulants for ADHD.[22. Merle G. Paule, Andrew S. Rowland, Sherry A. Ferguson, et al., ‘Attention deficit/hyperactivity disorder: characteristics, interventions, and models’ in Neurotoxicology and Teratology, Vol. 22, No. 5, 2000, p. 631. Available http://cat.inist.fr/?aModele=afficheN&cpsidt=1030283  (accessed 13 February 2009).]

However, in 2007, after an analysis of the three-year follow-up to the MTA Study, one of the scientists who ran the study, Professor William Pelham, concluded: ‘I think we exaggerated the beneficial impact of medication in the first study. We had thought that children medicated longer would have better out-comes. That didn’t happen to be the case…In the short run [medication] will help the child behave better, in the long run it won’t. And that information should be made very clear to parents.’[23. Allegra Stratton, ‘Questions raised about drugs as treatment for ADHD sufferers’, The Guardian, November 12th, 2007. Available at http://www.thefooddoctor.com (accessed 26 March 2008).]

The three-year data also showed that children using behavioural therapy alone had ‘a slightly lower rate of substance abuse’ and that ‘the (medicated) children had a substantial decrease in their rate of growth, so they weren’t growing as much as other kids in terms of both their height and their weight’.[24. Brooke Molina, Kate Flory, Stephen P. Hinshaw et al., ‘Delinquent Behavior and Emerging Substance Use in the MTA at 36 Months: Prevalence, Course, and Treatment Effects’, Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 46 No. 8, August 2007: pp. 1028–1040; Stratton, ‘Questions raised about drugs as treatment for ADHD sufferers’.]

The fact that the fourteen-month data supported the use of stimulants and the three-year data did not, is entirely in keeping with the commonsense proposition that while nothing affects behaviour as fast as behaviour-altering medications, amphetamines and amphetamine like drugs simply mask symptoms and do nothing in the long term to address the cause of problem behaviours.

Oregon ADHD Drug Effectiveness Review

When asked for proof of medications effectiveness, ‘ADHD experts’ will often respond that there are thousands of scientific papers that support their claims. When asked, however, which one of these scientific papers has robust methodology, they cannot identify a single long-term research paper that withstands scrutiny.

Compelling evidence for the poor quality of this research was demonstrated in 2005 through the Oregon Health and Science University ADHD Drug Effectiveness Review Project. The review was commissioned by fifteen US states in order to determine which drugs were the safest and most cost effective.[25. Marian S. McDonagh, Kim Petersen, et al., Drug Class Review on Pharmacologic Treatments for ADHD: Final Report Update 2, Portland, Oregon Health & Science University (2007). Available http://www.ohsu.edu/ohsuedu/research/policycenter/customcf/derp/product/ADHD_Final%20Report%20Update%202_Evidence%20Tables.pdf  (accessed 13 February 2009).] The 731-page review analysed 2287 studies, ‘virtually every investigation ever done on ADHD drugs anywhere in the world’.[26. Alexander Otto, ‘Are ADHD drugs safe? Report finds little proof’, The News Tribune, 13 September 2005. Available http://www.playattention.com/are-adhd-drugs-safe-report-finds-little-proof/  (accessed 12 May 2007).]

 Of the studies analysed, ‘The group rejected 2,107 investigations as being unreliable, and reviewed the remaining 180 to find superior drugs’.[27. Alexander Otto, ‘Are ADHD drugs safe? Report finds little proof’, The News Tribune, 13 September 2005. Available http://www.playattention.com/are-adhd-drugs-safe-report-finds-little-proof/ (accessed 12 May 2007).] Instead of being able to make objective comparisons of the safety and effectiveness of the different drugs, the review was ‘severely limited’ by a lack of studies measuring ‘functional or long-term outcomes’.[28. Alexander Otto, ‘Are ADHD drugs safe? Report finds little proof’, The News Tribune, 13 September 2005. Available http://www.playattention.com/are-adhd-drugs-safe-report-finds-little-proof/ (accessed 12 May 2007).]

The review concluded that ‘evidence on the effectiveness of pharmacotherapy for ADHD in young children is seriously lacking’[29. Oregon Health & Science University, Drug Class Review on Pharmacologic Treatments for ADHD, Portland, Oregon, 2007, p. 24.] and that there was ‘no evidence on long-term safety of drugs used to treat ADHD in adolescents’.[30. Oregon Health & Science University, Drug Class Review on Pharmacologic Treatments for ADHD, Portland, Oregon, 2007, p. 20.] The review also found that ‘good quality evidence on the use of drugs to affect outcomes relating to global academic performance, consequences of risky behaviours, social achievements, etc. is lacking’.[31. Oregon Health & Science University, Drug Class Review on Pharmacologic Treatments for ADHD, Portland, Oregon, 2007, p. 16.] It was also critical of the lack of research into the possibility that some ADHD drugs could stunt growth[32. Oregon Health & Science University, Drug Class Review on Pharmacologic Treatments for ADHD, Portland, Oregon, 2007, p. 19.] and found that the evidence that ADHD drugs help adults was ‘not compelling’.[33. Oregon Health & Science University, Drug Class Review on Pharmacologic Treatments for ADHD, Portland, Oregon, 2007, p. 21.] Overall, the report ascertained that the body of evidence was of ‘poor quality’.

Good science is not about quantity of research, it is about quality. None of the thousands of papers cited by ADHD proponents prove that ADHD is a biochemical imbalance or that amphetamines are safe and effective. Despite the ‘paucity of evidence on the long term effects of psycho-stimulants on children’[34. Finding 13, Western Australia Legislative Assembly, Attention Deficit Hyperactivity Disorder in Western Australia, Education and Health Standing Committee, Report No. 8, 2004, p. 42.], parents are commonly reassured that stimulants have been used to control ADHD-like behaviour since the 1930s.[35. As early as the 1930s, low doses of stimulant drugs were used to try to modify the behaviour of children with these diagnoses.’ Earl Mindell and Virginia Hopkins, Alternatives: Hundreds of safe, natural, prescription-free remedies to restore and maintain your health, McGraw Hill, New York, 2009.] This begs the obvious question: why haven’t the pharmaceutical companies set up a systematic review of the long-term effects of their products? Instead time after time they have repeated fundamentally the same experiment and confirmed that nothing alters behaviour faster than behaviour altering drugs.

Raine Study Long Term Data

Data that showed significant evidence of long-term harm from the use of stimulants for children diagnosed with ADHD came from the Western Australian Ministerial Implementation Committee on ADHD (MICADHD, of which I was a member) Raine Study Review. The Review studied the data provided by the Raine Study, a long-term, large-scale, generalised study into children’s health and wellbeing conducted at Perth’s King Edward Memorial Hospital.[36. The Raine Study started in 1989, when 2900 pregnant women were recruited into a comprehensive health and wellbeing research study at King Edward Memorial Hospital to examine ultrasound imaging. The mothers were assessed during pregnancy and after the children were born, and at one year, then two, three and five years of age. Information on their height, weight, eating, walking, talking, eating, behaviour, any medical conditions or illness etc. was collected. Further follow ups of the cohort have been conducted at eight, ten, fourteen, and seventeen years of age. At each follow-up information is collected from the parents and the child. The current follow up is being done at twenty years of age. By age fourteen ‘of the 1785 adolescents (remaining) in the sample, 131 (7.3 per cent) had received a diagnosis of ADHD’. At age five none of the 131 had taken ADHD stimulants. By age fourteen, twenty-nine had never taken stimulants, forty-one had been on prescription stimulants in the past but were not taking them, and sixty-one were on ADHD stimulants. This gave three groups for comparison, the ‘never medicated’, ‘previously medicated’ and the ‘currently medicated’ groups. In addition analysis of the effect of the duration of stimulant treatment was undertaken. Available http://www.rainestudy.org.au/ (accessed 7 May 2010).

The statistically significant differences that existed at age fourteen occurred between age five and fourteen, after some of the children were medicated. To the extent that (non-statistically significant differences) existed at age five these were ‘controlled for by using the “propensity for medication” score, the symptom severity before commencement of medication treatment, and a number of sociodemographic measures’.]

Published in February 2010 it provided unique independent data on the long-term effects (nine years) of psychostimulant medication.[37. 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.]

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

1.    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). This effect did not appear to be solely attributable to any short-term effects of stimulant medication, as when comparing groups who were currently receiving medication, it was found that those who had consistently received medication at all time points had a significantly higher mean diastolic blood pressure than those who had not consistently received medication in the past (difference of 7mmHg). 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.’[38. 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.]

2.    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.’[39. 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.]

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.[40. 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]

The finding that amphetamine use may permanently raise diastolic blood pressure is 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.

The most startling finding was that past stimulant use increased the probability of an ADHD child falling behind at school by a massive 950 per cent. This finding completely undermines the hypothetical basis of medicating for ADHD. As stated in the MICADHD report, the basis of the belief that amphetamines have long-term benefits are 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.’[41. 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.  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.] The analysis of the Raine Study data was the first time this hypothesis had been tested.

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. Initially, the ADHD 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 to his credit the Committee Chair, Doctor Lou Landau, 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.[42. Martin Whitely, ‘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?’, Speed Up & Sit Still: The Story of ADHD in Australia, 20 February 2011.  Available at http://speedupsitstill.com/raine-study-review-one-year-on (accessed 15 November 2011).] 

As with all studies there are limitations with the MICADHD study. 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’.[43. Government of Western Australia, Department of Health, ‘Study raises questions about long-term effect of ADHD medication’, Media Release, 17 February 2010.]

Although the evidence now available from the Review does not prove that amphetamines cause failure at school and permanent cardiovascular damage, it is compelling and demands a precautionary approach.

The CPPs states that, ‘the benefit of medication in the longer term, compared to behavioural management or no treatment is not established’.[44. Clinical Practice Points p13. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] This is true. However, the Raine Study, the three year results of the MTA and the Oregon ADHD Drug Effectiveness Review, suggest that there are significant risks including educational failure in allowing the continued long term administration of amphetamines and near amphetamines to ADHD diagnosed children.

Recommendation 4 – The Clinical Practice Points should state that although there is evidence that pharmaceutical interventions may help moderate ADHD symptoms in the short term, there is limited evidence in regard to their long term safety and efficacy. Furthermore the limited long term evidence available suggests significant long term harms and no sustained benefits. Therefore ADHD medications should only be used when extreme inattentive and hyperactive/impulsive behaviours represent a significant risk to the immediate welfare of the child (extreme hyperkinetic disorder) and their use must be restricted to short term interventions (never longer than 12 months).

 

Diagnostic Criteria DSMIV and ICD10

The CPPs state that the ‘DSM-IV or ICD10 criteria must be met for a diagnosis of ADHD to occur’. However, they also state that ‘not all children diagnosed with ADHD will function abnormally in all three domains (hyperactivity,/impulsivity and inattention’ andsome children are predominantly hyperactive and impulsive, while others are mainly inattentive’.[46. Clinical Practice Points p7. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] Unlike DSMIV, ICD-10 requires a child to be both hyperactive/impulsive and inattentive. This implies the primacy of the American Psychiatric Association’s (APA) DSMIV over the World Health Organisation’s (WHO) ICD-10.

The eighteen diagnostic criteria for hyperkinetic disorder outlined in ICD-10 are virtually identical to those for ADHD in DSM-IV however, for a diagnosis of hyperkinetic disorder, an individual is required to display at least six of nine of the inattentive and three of five of the hyperactive and one of four of the impulsive behaviours. For a DSM-IV diagnosis of ADHD, six of nine of the inattentive or six of nine of the hyperactive/impulsive are sufficient.

While many of the criticisms of subjectivity of assessment of behaviours are common to both the DSM-IV and ICD-10, in practice far fewer children are diagnosed using ICD-10. Despite the fact that Australia is a member of the WHO and obviously not the APA, DSM-IV is the predominant criteria used in Australia. As a consequence, the rate of psycho-stimulant use per head in the US and Western Australia (using DSM-IV) between 1994 and 2000 was approximately ten times the UK rate (predominantly using ICD-10).[47. ‘The use of different diagnostic tools may explain the variation in ADHD prevalence rates between Australia (DSM-IV) and the United Kingdom (ICD-10).’ Western Australia Legislative Assembly, Attention Deficit Hyperactivity Disorder in Western Australia, Education and Health Standing Committee, Report No. 8, 2004, p. 14; Constantine G. Berbatis, V. Bruce Sunderland et al., ‘Licit psychostimulant consumption in Australia, 1984-2000: international and jurisdictional comparison’, Medical Journal of Australia, 177; 10, 2002, p. 540; ‘The DSM-IV allows for multiple diagnosis with co-morbid conditions such as conduct disorder, while ICD-10 does not…As a result, prevalence studies from other countries using the ICD-10 (e.g. UK) indicate much lower ADHD rates than those from Australia and the USA.’ Parliament of South Australia, Inquiry into Attention Deficit Hyperactivity Disorder: Sixteenth Report of the Social Development Committee, Legislative Council, 2002, p. 12.] This is not only true for ADHD. DSM-IV generally contains looser, less rigorous diagnostic criteria than ICD-10. A 2005 study compared diagnosis rates for a range of childhood psychiatric disorders using the diagnostic criteria in DSM-IV and the equivalent disorder in ICD-10. For the majority of disorders, including ADHD, rates of diagnosis were higher using DSM-IV.[48. Merete Juul Sorenson, Ole Mors and Per Hove Thomsen, ‘DSM-IV or ICD-10-DCR diagnoses in child and adolescent psychiatry: does it matter?, European Journal of Child and Adolescent Psychiatry, 14; 6 (Sept 2005): p. 339.]

The USA is the home of ADHD child drugging with at least 2.7 million children currently taking ADHD ‘medications’.[49. ‘In total, (in 2007) 4.8% of all children aged 4–17 years (2.7 million) were taking medication for ADHD’. Note; since 2007 prescription rates have continued to grow. SN Visser, MS; RH Bitsko, PhD; ML Danielson, MSPH; R Perou, PhD; SJ Blumberg, PhD Increasing Prevalence of Parent-reported Attention-deficit/Hyperactivity Disorder Among Children — United States, 2003 and 2007, Morbidity & Mortality Weekly Report, Centers for Disease Control and Prevention, (2010): 59(44):1439-1443. Available at http://www.medscape.com/viewarticle/732545 (accessed 18 January 2011).] As American psychologist Dr Leonard Sax points out, given that many of the supposed benefits of medication for ADHD children relate to education, ‘you would expect American children to be racing ahead in their school work’; but as it is, ‘France, Germany, and Japan continue to maintain their traditional lead over the United States in tests of math and reading ability’.[50. Leonard Sax, ‘Ritalin: Better Living Through Chemistry?’  Available at http://www.vanguardnews.com/2000/001101ridlan.htm (accessed 15 November 2011).  Dr Sax quotes these statistics from Jodie Morse, ‘Summertime and School Isn’t Easy’, Time, 31 July 2000, p. 20.  French students scored 23 points above the international average; Japanese students, 94 points above. German students on average were 5 points below the international average; American students, 39 points below.] Similarly, if ADHD drugs worked, measures of social functioning like juvenile crime rates would be lower in countries with high prescribing rates like the US. Clearly America’s ‘medicated’ children are not doing so well.

Australia should hardly be using America as the model for enhancing the welfare of children. However, the reliance of Australian psychiatric practice on imported American (APA) diagnostic criteria, over which the Australian medical profession has no control, leaves Australian consumers, particularly children, vulnerable to the same forces that make America the home of indiscriminate psychiatric drugging.

That is not to say that the ICD10 should be our final destination or that many of the same corrupting commercial influences don’t have an effect on the World Health Organisation’s ICD development processes. But it is an easily obtainable improvement and at least Australia is a member of the WHO with some capacity to influence its processes.

DSMIV is bad enough DSM5 is worse

The APA has published its draft changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5), due for final release in May 2013.  Along with other worrying changes the APA seems determined to further loosen its already absurdly broad diagnostic criteria for ADHD. The most obvious of the changes is the inclusion of four extra ways of exhibiting ADHD.

The four additional criteria are;

1- Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

2- Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

3- Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

4- Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).[51. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

To anyone with a modicum of common sense or empathy the absurdity of these extra diagnostic criteria is self-evident. Although in fairness they are no more ridiculous than the current DSMIV criteria which include disliking homework and chores, losing toys, not listening, fidgeting, butting in, talking excessively or being easily distracted or forgetful.

For a diagnosis of the primarily hyperactive subtype, instead of children having to display 6 of 9 (67%) impulsive/hyperactive diagnostic criteria, 6 of 13 (47%) would be sufficient. For anyone 17 or older the ADHD bar will be lowered even further. It will be sufficient to meet as little as 4 (down from 6) of either the 9 inattentive or 4 of the expanded 13 impulsive/hyperactive criteria.[52. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

These changes continue the long term trend of lowering the bar for a diagnosis of ADHD.  DSMIII required six of nine inattentive behaviours and six of nine impulsive/hyperactive behaviours.  The bar was lowered significantly in DSM-IV when reduced to six of nine inattentive or six of nine hyperactive/impulsive behaviours.[53. For a full description of the history of how ADHD has evolved see Martin Whitely, Speed Up & Sit Still: The Controversies of ADHD Diagnosis and Treatment, Perth, UWA Publishing (2010): p.16]

DSM5 lowers it even further.  Effectively an adult was required to display at least 12 of 18 (67%) behaviours in DSMIII, however for DSM-5 it proposed that as few as 4 of 22 (17%) will qualify for a diagnosis.

Other subtle but nonetheless significant changes include:

1- The relaxation of the DSMIV expectation that teachers independently provide evidence.[54. DSMIV states:  ‘The clinician should therefore gather information from multiple sources (e.g. parents, teachers) and inquire about the individual’s behavior in a variety of situations within each setting. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition, Text Revision, Washington DC, American Psychiatric Association (2000): p.87.  The wording proposed for DSM5 is: ‘In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers. When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child’s behavior and performance at school.’ American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 (accessed 15 November 2011).]

2- Replacing hyperactive actions in the wording of criteria to feelings or perceptions of ‘restlessness’.[55. One of the hyperactive/impulsive diagnostic criteria in DSMIV states: ‘often leaves seat in classroom or in other situations in which remaining seated is expected.’ American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition, Text Revision, Washington DC, American Psychiatric Association (2000): p.92. The wording proposed to replace this in DSM5 is: often restless during activities when others are seated (may leave his or her place in the classroom, office or other workplace, or in other situations that require remaining seated). American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

3- The medicalisation, of the normal phenomena that ADHD behaviours are ‘typically more marked during times when the person is studying or working’ than ‘during vacation’.[56. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

4- The inclusion of adult relevant examples in most of the diagnostic criteria which had previously been primarily orientated to children in a school setting.[57. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

5- The change in the requirement that signs of the behaviour should be displayed before age seven to age twelve.[58. American Psychiatric Association, DSM-5 Development, Proposed Revision, Attention Deficit/Hyperactivity Disorder.  Available  http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

The history of ADHD is a classic example of how to create and then expand a previously non-existent market. It was initially sold as a boy’s disorder requiring both hyperactivity and inattention. Then passive ADD (without the H for Hyperactivity) was marketed as a gender equity issue with the argument that ‘quiet girls’ were believed to be missing out as their ‘disability’ was ‘under-recognised’.[59. For more detail on the history of the expansion of ADHD symptoms and behaviours, see Martin Whitely, Speed Up & Sit Still: The Controversies of ADHD Diagnosis and Treatment,  UWA Publishing, Perth (2010): pp.14-21 ] The changes proposed for DSM5 will protect and enhance the child market and create continuity of the pharmaceutical company’s customer base into adulthood and likely replicate the massive explosion in psychotropic drug prescribing rates that occurred when DSMIV replaced DSMIII in 1994.[60. In 1991 in Australia, less than 10,000 prescriptions were dispensed for dexamphetamine sulphate.  In 1998, nearly 250,000 prescriptions were dispensed for the same drug, an increase of 2400 per cent.  Paul Mackey and Andrew Kopras, Medication for Attention Deficit Hyperactivity Disorder (ADHD): An Analysis by Federal Electorate, Parliament of Australia, Canberra (2001): p.4]

With the benefit of hindsight, Dr Allen Frances, who was the chief of psychiatry at the Duke University Medical Centre and led the effort to update DSM-IV, regretted broadening the diagnostic criteria and warned of problems with the drafting of the next edition, DSM5, due for final release in 2013. Frances believes:

‘We learned some very, very, painful lessons in doing DSM IV…we thought we were being really careful about everything we did and we wanted to discourage changes. But inadvertently, I think we helped to trigger three false epidemics. One for Autistic Disorder…another for the childhood diagnosis of Bi-Polar Disorder and the third for the wild over-diagnosis of Attention Deficit Disorder.’[61. Dr Allen Frances, ‘Psychiatrists Propose Revisions to Diagnosis Manual’, PBS Newshour, 10 February 2010. Available http://www.pbs.org/newshour/bb/health/jan-june10/mentalillness_02-10.html (accessed 26 February 2010). ]

Dr Frances along with British Psychological Association and a number of Divisions of the American Psychological Association are leading an international backlash against the proposed DSM5. Furthermore Dr Frances has publicly endorsed my criticism of DSMIV ADHD diagnostic criteria and my critique of the changes proposed for ADHD in DSM5.[62. Allen Frances MD, ‘DSM 5 will further inflate the ADD bubble’, Psychology Today, 1 August 2011.  Available http://www.psychologytoday.com/blog/dsm5-in-distress/201108/dsm-5-will-further-inflate-the-add-bubble (accessed 15 November 2011)] In August 2011 Dr Frances blogged;

‘We are already in the midst of a false epidemic of ADD… In part this came from changes in DSM IV, but most of the inflation was caused by a marketing blitz to practitioners that accompanied new on-patent drugs amplified by new regulations that also allowed direct to consumer advertising to parents and teachers. In a sensible world, DSM5 would now offer much tighter criteria for ADD and much clearer advice on the steps needed in its differential diagnosis. This would push back, however feebly, against the skilled and well financed drug company sell. DSM 5 should work hard to improve its text, not play carelessly with the ADD criteria in a way that may unleash a whole set of dreadful unintended consequences – unneeded medication, stigma, lowered expectations, misallocation of resources, and contribution to the illegal secondary market peddling stimulants for recreation or performance enhancement.’[63. Allen Frances MD, ‘DSM 5 will further inflate the ADD bubble’, Psychology Today, 1 August 2011.  Available http://www.psychologytoday.com/blog/dsm5-in-distress/201108/dsm-5-will-further-inflate-the-add-bubble (accessed 15 November 2011)]

Given that significant forces within the psychiatric establishment and the DSM itself are openly scathing of its future, it seems absurd that Australia continues to utilise DSM rather than the more conservative ICD-10.

Recommendation 5 – The Clinical Practice Points should be rewritten to explicitly reject the American Psychiatric Associations DSM process and state that the ICD-10 diagnostic criteria are to be met in full before a child is diagnosed with Unexplained Attention and Hyperactive Behaviour Difficulties (refer Recommendation 1)

 

Child Protection and Enforced Child Drugging

One of the most alarming statements in the CPPs is that ‘as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns’.[64. Clinical Practice Points p15. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] The only possible medical interventions are ADHD drugs and the implied threat that a parent’s refusal to allow their child to be ‘medicated’ (i.e. drugged) with amphetamines, may see their children put in care. As absurd as this sounds many American states have found it necessary to legislate to prevent schools and child protection agencies from telling parents they must put their children on drugs to treat disorders like ADHD.[65. Kate Zernike and Melody Petersen, ‘Schools’ Backing of Behavior Drugs Comes Under Fire’, New York Times, 19 August 2001.]

Recommendation 6- The statement that ‘as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns’ must be removed from the Clinical Practice Points.

 

Broken Brains and ADHD drugs – The chicken or the egg?

The Clinical Practice Points state that ‘children meeting DSM IV diagnostic criteria for ADHD are described as typically having brain development that is inconsistent with age matched peers, for example, slower rates of cortical thinning’.[66. Clinical Practice Points p7. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] This implies (are described rather than have) neurological differences. That is, faulty brains may be the cause of ADHD. The study referenced as supporting the hypothesised brain differences (slower rates of cortical thinning) compared ‘Nineteen (ADHD) patients not treated with psycho-stimulants between brain scans’ with ‘24 (ADHD) patients who were treated with psycho-stimulants.’[67. Shaw P, Sharp WS, Morrison M, Eckstrand K, Greenstein DK, Clasen LS, et al. ‘Psychostimulant treatment and the developing cortex in attention deficit hyperactivity disorder’, Am J Psychiatry. 2009; 166(1):58-63.] The tiny sample size was not the only significant limitation to this study and it is hardly compelling evidence.

Most of the research undertaken by proponents of ADHD is designed to show that ADHD medication works or that children diagnosed with ADHD are different from other children. Many past claims of new research purporting to prove this difference have been shown to be false. Many of the studies that claim to show differences compared brains that had never been medicated to brains that had been exposed to psycho-stimulants.

Psycho-stimulants ‘routinely cause gross malfunctions in the brain of the child’ and ‘can cause shrinkage (atrophy) or other permanent physical abnormalities’.[68. Peter R. Breggin, M.D., Talking Back to Ritalin: What Doctors Aren’t Telling You about Stimulants for Children, Common Courage Press, Monroe, 1998, p. 358.]

Most of the supposed breakthroughs relate to brain-imaging using PET scanners or MRI technology. None of the claims, however, have been sustained and all mainstream medical authorities recognise that the technologies have no role in the diagnosis of ADHD. Even the more optimistic of assessments recognise brain-imaging technologies as having no diagnostic value, merely unfulfilled potential.[69. ‘Despite significant advances in the state of the art, the potential clinical applications of neuroimaging research to the psychiatric care of children has yet to be realized.’ Gahan J. Pandina, ‘Review of Neuroimaging Studies of Child Adolescent Psychiatric Disorders from the past 10 years (Statistical Data Included)’, Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 39 No. 7, July 2000, pp. 815–28.]

Recommendation 7- The statement that children meeting DSM IV diagnostic criteria for ADHD are described as typically having brain development that is inconsistent with age matched peers, for example, slower rates of cortical thinning is unsubstantiated speculation and must be removed from the Clinical Practice Points.

 

Confusion of Cause and Effect

The CPP’s state ‘ADHD also increases the risk of a range of adverse outcomes including educational, social, emotional and behavioural problems during childhood, and subsequent mental health, relationship, occupational, legal, and substance abuse problems in adult life.’[70. Clinical Practice Points p9. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] This statement is typical of many by ADHD proponents that attributes severe dysfunction even criminality and drug abuse to undiagnosed, and therefore un-medicated, ADHD.[71. An example is the following verbal evidence given on behalf of LADS to the 2004 Western Australian parliamentary inquiry into ADHD: “The research shows that people with ADHD are six times more likely to develop a substance abuse problem. However, if they are treated with stimulant medication, the risk is reduced to the same as someone without ADHD…Some excellent work has been done by Dr Tony Mastrioni on the New South Wales prison system. He estimates that 30 per cent of the prison population in NSW has ADHD, either diagnosed or undiagnosed.”  Department of Health, Government of Western Australia, Inquiry into Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder in Western Australia, Legislative Assembly, Transcript of evidence taken on 27 October 2003, p. 2 (Michelle Toner).]

The effect of this association with extreme dysfunctional behaviour is to create a sense of crisis that extreme consequences will result from ADHD going untreated which really means un-medicated. Criminal and drug-taking behaviour are in themselves dysfunctional and most often impulsive acts. How many drug addicts aren’t forgetful, distracted or disorganised?

It is self-evident that many criminals and drug addicts tend to demonstrate ADHD behaviours and certainly live dysfunctional lives, therefore qualifying for a diagnosis of adult ADHD. Yet to argue that ADHD, when left un-medicated, causes criminal behaviour or drug abuse is to confuse cause and effect. It involves identifying dysfunction in what is already identified as a dysfunctional population. This is the equivalent of being able to bet on a horse after the race has finished.

Recommendation 8- The statement that ‘ADHD also increases the risk of a range of adverse outcomes including educational, social, emotional and behavioural problems during childhood, and subsequent mental health, relationship, occupational, legal, and substance abuse problems in adult life’ is equivalent to saying dysfuntional behaviours cause dysfunctional behaviours and should be removed from the Clinical Practice Points.

Lowering Expectations – a Self-fulfilling Prophecy

The CPPs recognise that ADHD is not a meaningful label and yet they recommend ‘educating the child/adolescent and his or her family and carers about the disorder and its impact on various domains of the child’s life.’[72. Clinical Practice Points p11. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] The potential impact on a child’s self-esteem from being labelled ADHD, with the implication that they are disabled with abnormal brain function, is of enormous concern.  Similarly educating a child’s parents on the impact of the disorder in various domains can lower expectations creating a self-fulfilling prophecy of dysfunction.

Recommendation 9- The proposition that ‘developing an effective plan also involves educating the child/adolescent and his or her family and carers about the disorder and its impact on various domains of the child’s life’ has the potential to create self fulfilling prophecies of failure for many Australian children and should be removed from the Clinical Practice Points.

 

Prohibit diagnosing and Prescribing Pre-schoolers

The CPPs pose the question ‘Can pre-school children (under 6 years) be diagnosed with ADHD?’ and respond ‘Yes’. Although the CPPs then state that an ADHD ‘diagnosis may not be reliable until the child moves into more challenging social and academic environments.’[73. Clinical Practice Points p10. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] It is completely unacceptable to apply this unreliable diagnosis to pre-schoolers especially when a likely outcome is that they will be prescribed amphetamines or similarly dangerous drugs.

Recommendation 10- The CPPs should retain the question ‘Can pre-school children (under 6 years) be diagnosed with ADHD?’ but change the response to ‘NO. A diagnosis of ADHD is especially subjective amongst pre-school children as ADHD type behaviours are entirely normal behaviours for young children’.

While the CPPs state ‘best practice indicates that pharmacological treatment in pre-schoolers be deferred until the effect of psychological, environmental and family interventions have been evaluated’,[74. Clinical Practice Points p14. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] prescribing is not precluded. Even the manufacturers of Ritalin acknowledge ‘there is not enough information to recommend its use in children under 6 years old.’[75. Novartis Pharmaceuticals Australia, Consumer Medicine Information: Ritalin 10, August 2010.  Available http://www.nps.org.au/__data/assets/pdf_file/0013/16006/nvcrtlor.pdf (accessed 17 November 2011).]

Recommendation 11- The CPPs should include the statement that in line with manufacturers recommmendations, medications, including amphetamines and near amphetamines, should not be prescribed for ADHD under any circumstances for children younger than six years of age.

 

Age, Gender and ADHD

The CPPS include the question; ‘Does the presentation vary with age and over time?’[76.  Clinical Practice Points p7. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] The response is ‘Yes’. However, there is no specific information as to how this affects the application of the diagnostic criteria. The same imprecise, subjective diagnostic criteria are applied whether their child is two or seventeen.

Furthermore the CPPs include the statement “hyperactive behaviour can lessen or disappear later in life, whereas inattentive behaviour tends to be more constant across development.” [77. Clinical Practice Points p7. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ]

This is an absurd medicalization of normal human maturation. Similarly the statement ‘boys are more likely to meet the diagnostic criteria for hyperactivity-impulsive type and tend to have higher levels of disruptive behavioural disorders than females’[78. Clinical Practice Points p10. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ] demonstrates how ADHD makes a disease of human diversity, in this case masculinity.

 

ADHD and Family Dysfunction

The CPPs include the statement that ‘parents of children with ADHD often face increased levels of stress, low parenting self-efficacy, low self-esteem, marital discord and depression. They may develop maladaptive and counterproductive parenting strategies that serve to maintain their child’s existing behavioural difficulties or even exacerbate them.’[79. Clinical Practice Points p15. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ]

The interaction of the difficult and challenging behaviours in children and family dysfunction is obviously complex with each potentially causing the other.  An ADHD diagnosis simplifies the equation by removing responsibility from the parents and gives them the physical evidence of successful treatment in the form of their drugged compliant child.

This has been the experience of the Perth based Bentley ADHD Team whose submission to the Western Australian 2004 Parliamentary inquiry into ADHD stated, ‘We have observed that once medication has been commenced, it is often difficult to convince the family to consider reducing or ceasing the medication as it has created the ‘perfect child’…a child who has become frozen – in effect quietened and serious in nature, certainly not your typical child.’[80. Egan, Colleen, ‘Drugging Our Young’,  The Sunday Times, 11 July 2004: pp11]

How parents interact with their child influences the child’s behaviour.  Effective parents help children to learn, and to behave in socially acceptable ways.  It is an unpleasant yet obvious realty that no matter how well meaning, ill equipped parents will in some cases cause ADHD type behaviours in their children.  In these cases the parents become not only the cause of the ADHD behaviours but also are the primary source of behavioural information used to diagnose ADHD.

It is a brave clinician who will suggest to parents that the family dynamic may be the problem.  An ADHD diagnosis may help some parents to avoid that unpleasant reality and prevent the clinician from having to ask difficult and confronting questions.

Recommendation 12 – The CPPs should include the statement Clinicians have a responsibility to identify where family dysfunction may be contributing to a child’s inattentive or hyperactive/impulsive behaviour and where appropriate to suggest supportive strategies.

 

Comorbidity

Problems with inattention, impulsivity and hyperactivity occur for a multitude of reasons. Poor diet, problems with sight and hearing, physical, sexual or psychological abuse or trauma, sedentary lifestyle, neurotoxin exposure, underlying medical conditions and even boredom can lead to a child failing to pay attention and/or acting in an impulsive or hyperactive manner. The CPPs state ‘ADHD is commonly associated with other comorbid disorders affecting mood, learning and behaviour. ADHD can also occur in conjunction with cognitive function deficits, such as impaired executive function and emotional regulation.’[81. Clinical Practice Points p8. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ]

American paediatrician Lydia Furnam argues rather than being distinct conditions requiring separate treatment ADHD symptoms are often predictable consequences of the “co-morbid” condition. In 2005 Furnam wrote;

‘Study after study documents a significant rate of co-morbid psychiatric conditions in children diagnosed with ADHD.  These co-existing conditions include problems with parent-child interaction, family violence, and parental psychopathology, as well as childhood anxiety; mood disorders, including mania, bipolar disorder, and depression; learning disabilities; conduct disorder; and oppositional defiant disorder.  Estimates of the rates of these comorbid conditions range from 35% to 60% for oppositional or conduct disorder, from 12% to 60% for learning disabilities, from 18% to 60% for mood disorders, including major depression, and from 25% to 34% for anxiety disorders……….In summary, the prominent and often complete symptom overlap of ADHD with other psychopathology and the difficulties distinguishing ADHD from other pathology can be viewed as supporting the thesis that ADHD is not a distinct neurologic or psychologic disease entity.’[82. Furman, Lydia, MD, “ What is Attention-Deficit Hyperactivity Disorder (ADHD)?” in Child Neurology, 2005; 20(12): pp. 994-1003.]

ADHD is not a unique medical condition, or set of conditions. Rather it is a set of loosely defined symptoms resulting from (not co-morbid to) a diverse range of conditions.  Unless and until unique symptoms or an identifiable, predictive aetiology is established for ADHD, it should not be regarded as a valid science based diagnosis.

Recommendation 13 – As ADHD type behaviours have many potential causes and there is nothing unique or explanatory about the label ADHD the CPPs should remove any reference to ADHD being a comorbid disorder.

 

Long Term Drug Safety

The CPPs state ‘the rate of sudden death in patients taking methylphenidate or atomoxetine is below background rates’ [83. Clinical Practice Points p14. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d  ] and quotes two articles to support this assertion. However, close review of both articles reveal neither article come anywhere near justifying this statement.

The first, by R Hamilton et al uses grossly flawed methodology. It divides the number of deaths of children attributed to adverse reactions to the ADHD drugs by the estimated number of children on ADHD medications.[84. Hamilton R, Gray C, Belanger SA et al, ‘Cardiac risk assessment before the use of stimulant medications in children and youth: A joint position statement by the Canadian Paediatric Society, the Canadian Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry. Canadian Journal of Cardiology. 2009; 25(11):625-30. Available http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765391/  (accessed 16 November 2011).] The reporting system is voluntary and only a fraction of adverse events are reported to health regulators. Furthermore the FDA will not report those deaths it does not consider attributable to the drugs. This massive underestimation was then compared to general population death data for children. Even then the paper only concludes ‘analysis of patient-year data for children on ADHD medications suggests that the rate of sudden death is similar to the general population.’[85. Hamilton R, Gray C, Belanger SA et al, ‘Cardiac risk assessment before the use of stimulant medications in children and youth: A joint position statement by the Canadian Paediatric Society, the Canadian Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry. Canadian Journal of Cardiology. 2009; 25(11):625-30.  Available http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765391/ (accessed 16 November 2011).]

The second by Schellman et al, funded by ADHD drug manufacturer Shire Pharmaceuticals,  concluded ‘although the low incidence of events does not permit us to exclude the existence of moderate or even large relative associations, the absolute risk of cardiovascular events in children and adolescents receiving ADHD medications in this very large cohort was still very low.’[86. Schelleman H, Bilker, Warren B, Strom Brian L et al, ‘Cardiovascular Events and Death in Children Exposed and Unexposed to ADHD Agents’, Pediatrics, 2011; 127(6): pp. 1102-1110.  Available http://pediatrics.aappublications.org/content/127/6/1102.long (accessed 16 November 2011).]  In other words the rates could be above background rates but the overall risk of death is still low.

It is alarming the CPPs could include such a definitive statement that is so wrong.

Recommendation 14 – Remove the innaccurate and misleading statement ‘the rate of sudden death in patients taking methylphenidate or atomoxetine is below background rates’ from the CPPs.

 

The Roles of Specialist Clinicians in Diagnosis and Prescribing

The CPPs state ‘the ability to accurately diagnose ADHD requires clinical training and experience and hence should be made by a specialist clinician’.[87. Clinical Practice Points p8.  Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d ]  This is a good start however needs strengthening to ensure that paediatricians involved in diagnosing and prescribing do have the requisite clinical training.

A 2004 Western Australian parliamentary inquiry into ADHD found that ‘during their training, paediatricians have not been adequately informed about the extent of alternative diagnoses and treatment methods, and are therefore more likely to use drug therapy in the first instance in the management of ADHD’.  Part of the evidence the parliamentary inquiry used to reach this conclusion was the written submission by Dr Susan Prescott UWA Head of School Faculty of Medicine and Dentistry, to the 2004 WA Parliamentary Inquiry which stated that seeing a paediatri­cian, as opposed to a mental health professional (i.e. psychiatrist), had been identified as a ‘risk factor in the use of stimulant medication.’[88. 36th Parliament Education and Health Standing Committee, Attention Deficit Hyperactivity Disorder in Western Australia: Report No. 8, (2004): p23.  Available http://www.parliament.wa.gov.au/web/newwebparl.nsf/iframewebpages/Committees+-+Reports (accessed 15 November 2011).]   The submission stated, ‘by virtue of their training and workload it is also possible that pae­diatricians may be more prone to use drug therapy than the other therapies recommended for the management of ADHD.’[89. 36th Parliament Education and Health Standing Committee, Attention Deficit Hyperactivity Disorder in Western Australia: Report No. 8, Report Finding 4, (2004): p24.  Available http://www.parliament.wa.gov.au/web/newwebparl.nsf/iframewebpages/Committees+-+Reports (accessed 15 November 2011).]

Psychiatrists in most states have exclusive authority to prescribe stimulants for ADHD to adults. (The only exclusion to my knowledge is Queensland where GPs can prescribe) Children, however, are frequently prescribed stimulants for ADHD, by paediatricians and even G.P.’s who are not as well trained as psychiatrists in diagnosing and treating mental health disorders.[90. 36th Parliament Education and Health Standing Committee, Attention Deficit Hyperactivity Disorder in Western Australia: Report No. 8, Report Finding 4, (2004): p24.  Available http://www.parliament.wa.gov.au/web/newwebparl.nsf/iframewebpages/Committees+-+Reports ] The diagnosis of mental health disorders in children should be consistent and at least as thorough for children as it is for adults, as children have neither the authority nor capacity to make informed judgements about their treatment.

Recommendation 15: The CPPs should state that ‘in order to give children at least as much protection from insufficiently trained diagnosticians and prescribers as adults, only child psychiatrists or paediatricians who have been assessed as having achieved specific mental health competencies should be able to diagnose and prescribe medications for the treatment childhood mental health disorders including ADHD’.

 Additional Issue – The Diversion of ADHD Amphetamines

 Perth: A Case History of Amphetamine Abuse

Despite the clear warnings for addiction and abuse, one of the most aggressively marketed claims about ADHD is that its ‘under-recognition’ is a cause of illicit drug abuse. It is argued by the ADHD industry that early identification of ADHD and subsequent medication prevents undiagnosed individuals using illicit drugs to self-medicate.[91. For instance, see Dave Coghill, ‘Attention-deficit hyperactivity disorder: should we believe the mass media or peer-reviewed literature?’, The Psychiatrist, 29, 2005, pp. 288–91; Dr Ken Whiting, Fact Sheet: Attention Deficit/Hyperactivity Disorder 2003 Update, Learning and Attentional Disorders Society of WA, Perth, 2003.] In the 1990s and early 2000s Western Australia, particularly Perth, had Australia’s highest ADHD amphetamine prescription rate. If the above claims about drug abuse were correct, it would be expected that WA rates of drug abuse would have been among the lowest in Australia.

The evidence suggests the opposite. When WA had Australia’s highest dexamphetamine prescription rate, it also had the highest amphetamine abuse rates and relatively high rates of abuse for other illicit drugs.[92. From 1995-2004 Western Australia had the highest rate of illicit drug abuse of any Australian state. The rates of abuse of amphetamines were also the highest in Australia. Source: 2004 National Drug Strategy Household survey, State and Territory Supplement. Australian Institute of Health and Welfare, Canberra, 2005.] In 1999 illicit amphetamine abuse rates among secondary school children were the highest in the nation, over double the national average.  Abuse rates for cannabis, tranquillisers, steroids, cocaine, ecstasy, heroin and LSD/hallucinogenics were all above the national average.[93. 1999 Australian School Students Alcohol and Drugs Survey quoted in Kate Gauntlett, ‘Drugs so easy to find’, The West Australian, 14 June 2003.]

Conversely, when Perth’s prescribing rates for children plummeted so did amphetamine abuse rates. Between 2002 and 2008 there was a 51 per cent reduction (for people aged twelve to seventeen years of age) in rates of abusing amphetamines in the last 12 months.[94. The 2008 Australian Secondary Students’ Alcohol and Drug Survey (ASSAD) data indicated a reduction in ‘last 12 month amphetamine abuse’ by school children 12–17 years old from 10.3 per cent in 2002, 6.5 per cent in 2005, and 5.1 per cent in 2008. P. Griffiths, R. Kalic, & A. Gunnell, Australian School Student Survey 2008: Western Australian Results (excluding tobacco), Brief Communication no. 2, Drug and Alcohol Office, Perth, 2009.] This massive decline occurred at the same time as a huge fall (60 to 70 per cent) in child prescribing rates.[95. Martin Whitely, ‘Rise and Fall of Child ADHD in WA’, Speed Up & Sit Still: The Story of ADHD in Australia.  Available http://speedupsitstill.com/rise-and-fall-of-child-adhd-in-wa (accessed 15 November 2011).]

Far from validating the assertion that medicating for ADHD prevents Illicit drug abuse by self-medicating untreated ADHD sufferers, the West Australian experience makes a mockery of the ADHD industry claims.  WA’s experience provides unequivocal evidence supporting the commonsense proposition that prescribing amphetamines facilitates their abuse.  Although child amphetamine abuse rates have thankfully fallen, Perth still suffers the high rates of amphetamine abuse by adults.  There Is significant evidence this is in part fuelled by the diversion of dexamphetamine abuse problem.[96. Martin Whitely, ‘Perth’s Dexamphetamine Hangover’, Speed Up & Sit Still: The Story of ADHD in Australia, 19 July 2011.  Available  http://speedupsitstill.com/perth%e2%80%99s-dexamphetamine-hangover-3#more-2046 (accessed 15 November 2011).]

Note:  Even though abuse rates began to drop by 2005, a survey of Western Australian secondary school students (the Australian School Students Alcohol and Drug Survey or ASSAD) found that 84 per cent of those who had abused amphetamines in the last year had abused prescription amphetamines.[97. Drug and Alcohol Office WA, ASSAD Drug Report 2005, Mt Lawley, March 2007, pp. 30–32.] The same survey found that 27 per cent of twelve- to seventeen-year-olds who had been prescribed stimulant medication either gave it away or sold it.[98. Drug and Alcohol Office WA, ASSAD Drug Report 2005, Mt Lawley, March 2007, p. 33.]

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  1. bjcirceleb’s avatar

    Some of the comments under the article in The Australian are very interesting. One doctor saying that he has never understood why you felt the need to step in and speak about this issue, you are not a doctor and know nothing at all about the condition!!

    How can they continue to say that this is a proven disease. If they want parents to agree with what they are saying then prove it. If these are proven brain diseases then WHY diagnose them with a pen and paper sitting four feet away from someone. WHY diagnose a disorder in a child without even seeing the child??

    And this continual comparision with diabetes is just getting rediculous. IF a person does not take insulin they die, it is as simple as that. And you would not have time to report a parent to child protection the child would already be dead! The parents would then be charged with a criminal offence. ADHD does not kill anyone, although the medications can do a pretty good job in some cases. And of course they publically admit to not knowing the long term outcomes of the medication use?? How can you FORCE someone to take medication for the rest of there life for something you do not know anything about, that is voted on at a meeting, no one had a vote to decide what diabetes was, and when there is no proof at all that the medications do anything at all. In fact a large percentage of the time the medications do nothing at all and of course after a period of time the body becomes immune to the medication and so they then add on other medications, more often than not antipsychotics. Since when do antipsychotics cure ADHD??

    Reply

  2. Dr Joe’s avatar

    When a child grabbing a toy from a shelf can be considered to have a “disease” we have lost the plot. ADHD is now an industry and it trades on the misdiagnosis and medicating of children who have done nothing other than just be themselves.

    Reply

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