New Australian ADHD Clinical Practice Points – After 6 years of frustrated advocacy at last a small victory over Big Pharma.
By Martin Whitely MLA www.speedupsitstill.com
Related Media – Experts alarmed at new ADHD guidlelines | News.com.au Sue Dunlevy, News Limited Network, October 03, 2012
The unpleasant Australian colloquialism ‘you can’t polish a t___ but you can cover it in glitter’ is a fitting although off-colour analogy for the danger of legitimising ADHD as a diagnosable mental illness by developing treatment guidelines. Nonetheless for now at least, ADHD is the most frequently diagnosed childhood psychiatric disorder and drugging children with amphetamines, the most common treatment. Therefore treatment guidelines matter.
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 (ADHD CPPS) as a small but significant step in the right direction. (The ADHD 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.
Having said that, the ADHD 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Attention Deficit Hyperactivity Disorder which in turn replaced the deeply flawed 1997 NHMRC ADHD Guidelines that were rescinded in 2005.3 The ADHD CPPS state the 2009 Draft Guidelines were “not approved by NHMRC” as “…undisclosed sponsorship may have affected the findings of a large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 on 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 free4 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 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 statemet was welcome however itshould 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.
- page 9 of the ADHD CPPs available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf ↩
- 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 ↩
- National Health and Medical Research Council, Attention Deficit Hyperactivity Disorder (ADHD), Canberra, 1997. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ch36.pdf ↩
- Conflict of Interest details available at http://www.nhmrc.gov.au/guidelines/adhd-conflicts-interest ↩
- 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 ↩
- 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 ↩
- 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 ↩
- see http://www.nhmrc.gov.au/media/releases/2011/reassuring-parents-new-draft-adhd-clinical-practice-points-do-not-mandate-medica ↩