Commentary on Levy (2012) Politics vs practice: Withdrawal of the Draft NHMRC ADHD Guidelines

Professor Levy’s exploration of the politics of the withdrawal of the Draft NHMRC Guidelines provides much food for thought. Her viewpoint is that attention deficit hyperactivity disorder (ADHD) is a mental illness with an excellent evidence base for treatment, but social and political forces in Australia have successfully campaigned to remove draft guidelines, without any apparent plan for rewriting or resubmission (Levy, 2012).

ADHD is worth treating because children with moderate-to-severe ADHD not only have significant behavioural difficulties but also an increased risk of poor educational and family functioning and reduced quality of life, particularly on parent report (Danckaerts et al., 2010). They also have higher rates of behavioural disorders, smoking and alcohol and drug abuse in adult life (Wilens et al., 2011).

At face value, ADHD drug treatments have the best evidence base of any pharmacotherapy in childhood. There are not only many short-term randomized controlled trials, particularly of the stimulants methylphenidate and dexamphetamine, but enough data for meta-analysis, not just for stimulants (Faraone and Buitelaar, 2010) but also for a more recent treatment, atomoxetine (Cheng et al., 2007). The data for longer-term treatment is less clear. A National Institute of Mental Health-sponsored study (Jensen et al., 2007) showed significant improvement in ADHD symptoms and functional performance in children treated with either medication or combined medication and behaviour management at 14- and 24-month follow-up; however, at 36 months all groups, including controls, had improved significantly. Much of the variance in outcome appeared due to individual and psychosocial variables such as sex, intelligence and psychosocial disadvantage rather than treatment.

Pharmacotherapy for ADHD in Australia and New Zealand is appropriately highly regulated because stimulants are potential drugs of addiction. Prescription is restricted to certain specialties (generally paediatricians and child psychiatrists, with other recognized prescribers in some states), with strict prescribing criteria and guidelines (NSW Ministry of Health, 2012). New Zealand has national guidelines, although they would benefit from updating (New Zealand Ministry of Health, 2001). Comprehensive international guidelines include those from the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom (NICE, 2008).

Why has the concept of ADHD and its treatment become such a contentious issue? Controversy about reliance on pharmaceutical industry-sponsored drug trials is not just an ADHD issue. In her article, Professor Levy suggests one reason for opposition to prescribing – the severe side effects of stimulants in some children – but there are several other possible reasons. One is general concern about prescribing psychotropic drugs for children at all, with a similar controversy about selective serotonin reuptake inhibitors for depression (Hetrick et al., 2010). There could also be concerns about over diagnosis, as the identification of mild ADHD can be extremely subjective. Many normal children need high levels of physical activity – social changes such as apartment living and less time for free play have made this more difficult. Also, not all children with hyperactivity have ADHD. Children with adjustment disorders, attachment disorders, depressed mothers or chronic trauma may also present with hyperactivity (Freitag et al., 2012). ADHD has a high level of comorbidity with other behaviour disorders and developmental disorders, but parents, teachers and doctors may be tempted to focus mainly on the ADHD as it can seem simpler to give a child medication than manage their behaviour, whether at school or home. At times it may even be less threatening for children themselves to see their behaviour as a disease and out of their control (Singh, 2011).

In summary, ADHD is a complex disorder best explained by a multifactorial model of neurodevelopmental and environmental risk factors with high levels of comorbidity and overlap both with other disorders and with normal functioning. There is good evidence for at least short-term effectiveness of some drug treatments, but multimodal treatment is optimal, especially for the comorbid conditions. It is crucial that treatment practices follow appropriate guidelines and regulations, which is why the withdrawal of the Draft NHMRC Guidelines was so disappointing.

See Commentary by Levy, 2013, 47(1): 89-91.