By Martin Whitely MLA

The off colour Australian colloquialism ‘you can’t polish a turd but you can cover it in glitter’ is a fitting analogy for the danger of legitimising ADHD as a diagnosable mental illness by developing treatment guidelines. However, treatment guidelines are being developed and the more conservative the treatment guidelines, the fewer children risk damage with the long-term administration of amphetamines.

That is why I welcome the release by the National Health and Medical Research Council (NHMRC) of the Australian ADHD Clinical Practice Points (CPPs) as a small but significant step in the right direction. (The CPPs available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf )

Eventually ADHD will be regarded as an embarrassing footnote of history and society will collectively wonder how anyone ever thought it would be a good idea to give amphetamines to children. But in the meantime improvements like those in the ADHD CPPs, although modest, will hopefully see fewer children diagnosed and drugged.

That said, the CPPs are far from perfect. The statement that, “…stimulants might be considered for this age group (under 7 years)” leaves the door open for drugging very young children.[1] The manufacturers prescribing information for all stimulants state they should not be used in children under 6 years, since safety and efficacy in this age group have not been established.[2] Any clinician ignoring the manufacturers warning is inviting a future law suit for negligence.

The ADHD CPPs were developed as a stop gap replacement for the corrupted NHMRC 2009 Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder which in turn replaced the deeply flawed 1997 NHMRC ADHD Guidelines that were rescinded in 2005.[3] The ADHD CPPs state the 2009 Draft Guidelines were “not approved by NHMRC” as “…undisclosed sponsorship may have affected the findings of a large number of publications (co-authored by Prof Joseph Biederman and Drs Thomas Spencer and Timothy Wilens) relied on for the Draft Guidelines”.(Page 4)

Undue drug company influence went much deeper than simply relying on corrupted research. While I am not suggesting they were individually corrupt; the majority of members of the guidelines development group had ties to ADHD drug manufacturers and were enthusiastic proponents of ADHD child drugging. (For more detail on the corrupted guidelines development process refer to Open book approach a good start for the new National ADHD Guidelines Committee)

It took six years of determined advocacy to expose the connections and prompt the intervention of Mental Health Minister Mark Butler. In contrast to the indifference and incompetence of previously responsible ministers Nicola Roxon and Tony Abbott, Minister Butler established the relatively conflict of interest free[4] and transparent ADHD CPPs development process.

Although the ADHD CPPS are described as being “based on expert consensus” it would probably have been more accurate if they were described as being “based on expert compromise”. This was an inevitable product of a committee which contained members with diametrically opposed views like ADHD sceptic, Professor Jon Jureidini, and ADHD prescribing enthusiast, Professor Michael Kohn. (see Where is the evidence to support ‘ADHD expert’ Prof Kohn’s claim that amphetamines aid brain development? ) As a result in several places the ADHD CPPs are contradictory.

Despite their limitations Mental Health Minister Mark Butler deserves credit for establishing the ADHD CPPs process. There was significant opportunity for public input with approximately 140 submissions spanning the divergent range of views on ADHD and resulting in significant differences between draft and final guidelines.[5]

One of the more notable improvements from the draft was the removal of the statement that “as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns”.[6] This statement attracted widespread media attention and condemnation.[7]  On 23 November 2011 the NHMRC issued a media release denying that a failure to medicate may result in the intervention of child protection authorities.[8] This statement was welcome however it should never have been included in the draft ADHD CPPs in the first place.

Overall the final September 2012 ADHD CPPs represent a significant improvement on the November 2011 draft ADHD CPPs and a vast improvement on the corrupted 2009 Draft Australian Guidelines. Below I have listed both positive and negative features of the final ADHD CPPs.

Positive features of the final ADHD CPPs include the statements that:

• “The clinician should always be mindful of seeking a more meaningful explanation of the child/adolescent’s behaviour than simply labelling it as ADHD because it meets diagnostic criteria.” (Page 14)
• “ADHD is a description rather than an explanation of a pervasive, persistent, disabling pattern of inattentiveness, overactivity and/or impulsivity. A child/adolescent who meets diagnostic criteria for ADHD may not be always best served by making that diagnosis. For example, their behaviour could be understood as a reaction to specific cognitive difficulties or family/environmental circumstances.” (Page 6)
• Comment- A very good statement, however I would argue that a child is never best served by applying a one size fits all label that fails to explain their unique circumstances.

• “All children and adolescents can display active, impulsive and inattentive behaviour as part of normal development. This does not mean that they have a disorder, and important controversies exist about the use of ADHD as a diagnosis for children and adolescents.” (Page 10)
• “Parents/carers must be given information on the diagnosis and management plan, including any potential adverse effects of treatment in order to fully inform them and to have them make a decision regarding the treatment that is offered to their child.” (Page 16)
• Potential “adverse-effects” of stimulants identified in the ADHD CPPs include sleep disturbance, reduced appetite, abdominal pain, headaches, crying spells, repetitive movements, slowed growth (height and weight), restlessness, dizziness, anxiety, irritability cardiovascular effects such as tachycardia, palpitations and minor increases in blood pressure and psychosis or mania.  In addition the ADHD CPPS say where to report side-effects in Australia (to the TGA) and acknowledge that stimulants are Schedule 8 drugs because they can be addictive and are abused.  (Page 20)
• “Children/adolescents on stimulant medication require 3-6 monthly clinical assessment and review to ensure the management strategies remain appropriate and effective. Monitoring should include assessment of side effects and particularly psychological symptoms and plotting of growth parameters, pubertal development, heart rate and blood pressure.” (Page 8)
• “Not all children and adolescents with ADHD will require, or benefit from, pharmacological management.”  (Page 8)
• Comment- A double edged sword but nonetheless an improvement from previous guidelines that promoted the use of ADHD amphetamines as the first line treatment for all children diagnosed with ADHD.

• “Practical supports for families, such as respite care, parenting education and guidance and counselling, may be helpful or even a sufficient intervention perhaps obviating the need for specific treatment and psychological management of the child.” (Page 17)
• “When stimulant treatment is used it should only be continued if there is demonstrated benefit in the absence of unacceptable side effects. “ (Page 8).
• Comment- Again a double edged sword but an improvement from previous guidelines.

• “There is no one single known cause of ADHD….” (Page 10).
• Comment- Would have been more accurate to say there is no one single known cause of the inattentive and/or impulsive behaviours characterised as ADHD

• “….the effect of medication and behavioural or educational interventions on long-term outcomes such as academic and social and emotional outcomes, has not been established…..“ (Page 11) AND “Considering that there is insufficient evidence on the long-term outcomes and long-term adverse effects following use of stimulants, the continuing benefit from, and need for medication should be regularly assessed.” (Page 21)
• Comment- The limited long term evidence available indicates that children diagnosed with ADHD and never medicated do much better than children diagnosed with ADHD and medicated. Therefore the prudent ‘first do no harm’ step would be to never medicate or time limit the use of stimulants by children to a year. For more information on the long term effects of stimulants see One year on from the Raine Study ADHD Medication Review – Will the analysis of this unique long term data source continue and if so can we trust those doing the analysis?

• “….there are no specific treatments to ‘cure’ ADHD…..” (Page 16)
• “In the absence of another diagnosis, neuroleptics (anti-psychotics) have no role in the treatment of ADHD.” (Page 18)On the negative side the ADHD CPPs include the statements that:

• “The risk of not making a diagnosis is that the child/adolescent may not receive appropriate management and care.” (Page 12)
• Comment-This is one of the most disturbing statements in the CPPs. ADHD is a dumbed down label that does nothing to explain a child’s individual circumstances. It prevents understanding and invites a dangerous one size fits all treatment, stimulants, that mask behaviours without addressing any underlying problems. 

• “Regardless of whether the cause is explicable or not these symptoms impact so adversely on the child or adolescent and their family that the symptoms cannot be left untreated.” (Page 11)
• Comment- These first two statements may panic clinicians and parents in premature treatment with unnecessary and potentially dangerous drugs, i.e. amphetamines. The statements are inconsistent with the precautionary first do no harm principal of medicine. Understanding the cause of any problem is essential to identifying appropriate long term solutions.

• “Use of stimulant medications (methylphenidate and dexamphetamine sulphate) can reduce core ADHD symptoms and improve social skills and peer relations in children and adolescents diagnosed with ADHD in the short term (up to 3 years).” (Page 8)
• Comment- I agree that drugs will alter behaviour immediately and in some cases make boisterous, even annoying and in some cases traumatised children more compliant. However, achieving social control and compliance in that manner is a violation of the rights of the child and frequently covers up underlying serious problems including in some cases the traumatic effects of child abuse and neglect.

• “Both medication and combined medication and behavioural treatment have been shown to be more effective in treating ADHD symptoms than psychosocial or behavioural interventions alone.” (Page 19)
• Comment- Again I agree that drugs will alter behaviour immediately, however achieving compliant behaviour in the short term is not an appropriate way to measure child welfare. The only consideration that should matter is the long-term welfare of the child not the convenience of others. The limited long term evidence available indicates that children diagnosed with ADHD and never medicated do much better than children diagnosed with ADHD and medicated.

• “For young children (under 7 years) psychological, environmental and family interventions should, if possible, be trialed and evaluated before initiating pharmacological treatment. If all these other interventions have not been effective then stimulants might be considered for this age group in consultation with the parents or guardians and including when appropriate teachers or other carers.” (Page 9)
• Comment- This is the most concerning recommendation as it leaves the door open for drugging very young children. The manufacturers prescribing information for all stimulants state stimulants should not be used in children under 6 years, since safety and efficacy in this age group have not been established.[9]

• “It is rare that symptoms of ADHD occur in isolation. In the assessment of a child/adolescent with ADHD the specialist clinician should assess for other psychological, social, emotional and behavioural difficulties that might coexist with ADHD (comorbidities).” (Page 11)
• Comment – Psychological, social and emotional difficulties are often the causes of ADHD type behaviours. In these cases ADHD doesn’t coexist, rather the ADHD type behaviours are caused by psychological, social and emotional difficulties.

• “Children/adolescents with ADHD may have other mental health problems, such as depression, which may be associated with an increased risk of suicidal ideation. Conducting a mental health assessment, where indicated, can detect mental health problems and inform appropriate management.” (Page 15)
• Comment – Inviting multiple diagnoses invites poly-pharmacy in the minds of some medical practitioners. Antidepressants are not approved for use in young people as studies show they increase suicidality by approximately 80%.[10]

• “Assessment of response to treatment and periodic review of progress is facilitated by the use of questionnaires from parents/carers, teachers and if possible the child/adolescent using psychometrically sound, evidence-based checklists such as the Conners’ ADHD/DSM-IV Scales (CADS).” (Page 16)
• Comment- Please let’s all stop pretending the diagnosis of ADHD involves scientific testing. These so-called psychometrically sound, evidence-based checklists are no more than loosely defined behavioural tick-lists and are reminiscent of a Dolly Magazine find your perfect boyfriend tick-box questionnaire.

• “Heredity, genetic, neuro-imaging and neuro-psychological studies provide evidence for a biological basis for inattention and impulsiveness.” (Page 10)
• Comment- This is concerning for two reasons. Firstly it overstates the validity of this evidence. Secondly and most significantly even if a biological basis for ” for inattention and impulsiveness” is established this does not make a disease or disorder any more than other genetic variations like height or skin colour. Refer to The ‘Genetic basis of ADHD’ – much ado about nothing

• “Data from 2000 indicates the prevalence rate of ADHD symptoms among 6–17 year-olds in Australia is around 11%.” (Page 11)Related Media
•  Experts alarmed at new ADHD guidelines | News.com.au Sue Dunlevy, News Limited Network, October 03, 2012
• Comment- This is a massive overestimate of the proportion of children who would qualify for a DSMIV diagnosis as when conducting this research there was no assessment for impairment or requirement for children to display sustained ADHD in multiple settings. Nonetheless the garbage research continues to be quoted by the ADHD industry, the NHMRC and even Commonwealth Ministers.[11]

[1] Page 9 of the ADHD CPPs available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf

[2] Ritalin prescribing information says “Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established” see http://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf   Concerta’s says “safety and efficacy has not been established in children less than six years old or elderly patients greater than 65 years of age” see http://www.concerta.net/sites/default/files/pdf/Prescribing_Info-short.pdf#zoom=56  Dexedrine’s (brand of dexamphetamine) says “Long-term effects of amphetamines in pediatric patients have not been well established. DEXEDRINE is not recommended for use in pediatric patients younger than 6 years of age with Attention Deficit Disorder with Hyperactivity” see http://www.dexedrine.com/docs/dexedrine_PI.pdf

[3] National Health and Medical Research Council, Attention Deficit Hyperactivity Disorder (ADHD), Canberra, 1997. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ch36.pdf

[4] Conflict of Interest details available at http://www.nhmrc.gov.au/guidelines/adhd-conflicts-interest

[5] For details of the effect of the submissions on the final ADHD CPPs see appendix D page 16 available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_appendices_120903_0.pdf

[6] 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 p15. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d

[7] 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

[8] 8. see http://www.nhmrc.gov.au/media/releases/2011/reassuring-parents-new-draft-adhd-clinical-practice-points-do-not-mandate-medica

[9] Ritalin prescribing information says “Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established” see http://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf   Concerta’s says “safety and efficacy has not been established in children less than six years old or elderly patients greater than 65 years of age” see http://www.concerta.net/sites/default/files/pdf/Prescribing_Info-short.pdf#zoom=56  Dexedrine’s (brand of dexamphetamine) says “Long-term effects of amphetamines in pediatric patients have not been well established. DEXEDRINE is not recommended for use in pediatric patients younger than 6 years of age with Attention Deficit Disorder with Hyperactivity” see http://www.dexedrine.com/docs/dexedrine_PI.pdf

[10] See http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm096273.htm

[11] Draft ADHD Guidelines Released, Joint Media Release, 30 November 2009.  The Hon Nicola Roxon MP, Minister for Health and Ageing, National Health and Medical Research Council, and Royal Australasian College of Physicians.]

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