The ADHD debate: To bury national guidelines or to praise them?

Mr Whitely expands on his Viewpoint (Whitely, 2012) on attention deficit hyperactivity disorder (ADHD) management, especially related to issues associated with stimulant medication prescribing in Western Australia. His views could best be considered as coming from a community perspective rather than having a clinical or research underpinning. Hence, it is not surprising to see a broader range of references: newspaper articles and his own website. And also a broader range of declaration of interests: Scientology financial support.

I await with interest further community-sourced Viewpoint articles on topics other than ADHD, and I am sure there will be no shortage of interested parties keen to access the ANZJP readership. Now to his concerns in this edition.

His original arguments about the overprescribing of stimulants and their safety were adequately reviewed – and rebutted where necessary (Levy, 2012, 2013; Paterson, 2013; Starling, 2013). I thought that matter had come to an end and am disappointed to see that Mr Whitely has once again submitted strong anti-ADHD views which have little evidential backing. For example, he again argues that there was a ‘massive decline’ of stimulant prescribing between 2002 and 2010, referring to a level of 50% which seems to have been produced by doing his own adjusting ‘for confounding factors’, the nature of which are not made clear.

He then goes on to try to link this supposed ‘massive decline’ to ‘encouraged early retirements’ of prominent prescribers without any evidence that such a thing actually occurred. This is a similar tabloid tone to his original article where he talked about ‘illegal … reckless prescribers … resulted in children being hospitalised’. I would contend that these sorts of accusations are out of place in a scientific journal such as the ANZJP unless there is very good evidence for them, and even then publication of malpractice accusations needs to be carefully thought through.

Mr Whitely writes further about the link between ADHD prescribing and drug abuse, repeating his arguments from his original article. Repetition does not make them right and I see no reason to change my original clarifying comments. Similarly, continued promotion of the Raine ADHD Study as a source of ADHD knowledge is misplaced given its methodological limitations, as previously stated.

What is new in this second article from Mr Whitely is a discussion about the National Health and Medical Research Council (NHMRC) Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder (NHMRC, 2009). The NHMRC commissioned the Royal Australasian College of Physicians (RACP) to update the 1997 NHMRC ADHD guidelines. It is totally unacceptable for Mr Whitely to suggest that the members of the RACP involved in the development of the Draft Guidelines had ‘hidden commercial ties’ when in fact all potential conflict of interest statements were clearly recorded in Appendix B.

The Draft Guidelines were eventually ready for release in 2009 but were not finally approved by the council of the NHMRC. This was as a result of three authors who were heavily referenced in the Draft Guidelines being sanctioned by their employers (Harvard Medical School and Massachusetts General Hospital) for failing to report their industry-sponsored activities which violated their organisations’ conflict of interest policies (NHMRC, 2012b). This was the limit of information revealed about any wrongdoings, and it is out of place for Mr Whitely to speculate on any other wrongdoings on the basis of a newspaper article when there are better references available.

Because the NHMRC were unable to determine the extent to which the conflicts of interest may have impacted on the integrity of the three authors’ research, they decided not to give the Draft Guidelines final approval and they were consigned to prolonged draft status. This was despite there never being any suggestion that the research by the authors concerned was in any way impaired by their failure of disclosure, and no other national guidelines have been withdrawn as a result of the sanctions.

To resolve this impasse, the NHMRC took action: ‘acknowledging the absence of approved guidelines, and noting ongoing clinician and community concern about the use of stimulants as a treatment for children and adolescents with ADHD symptoms, NHMRC developed the Clinical Practice Points (CPPs) on the diagnosis, assessment and management of ADHD in children and adolescents’ (NHMRC, 2012a).

These were released in September 2012 and were a very useful general document but had two major flaws by comparison to the Draft Guidelines: the CPPs did not refer to adult ADHD management and lacked detail. Mr Whitely suggested that the Draft Guidelines Committee was a ‘consensus of like-minded ADHD medication advocates’ who produced recommendations for the use of medication. I am sure even he would agree that the same could not be said about the CPPs Expert Working Group (EWG) who were well recognised as having a broad spectrum of views on ADHD. Even with these differing views, the CPPs EWG was able to unanimously agree on several points: ADHD exists throughout the lifespan; medication is considered useful and safe (even under the age of 7 if all else has failed); and research supports its use for up to 3 years and plausibly longer.

Curiously, the CPPs quoted references which in turn contained further references to the sanctioned authors as above, but this time the NHMRC was not put off from giving its seal of approval. This appears inconsistent and suggests the NHMRC are being overly cautious in not allowing the Draft Guidelines to proceed to fully accepted status.

It would be a great service to the standardisation of ADHD treatment across Australasia if the Draft Guidelines could be accepted, either as they are, or with some tidying up of the references and an update to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. If a revision was thought useful, then it may be time for the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to invest some time and money into this revision (I think the RACP have done their bit). Even if the NHMRC did not want to take part in this process, new updated ADHD guidelines would be a very useful additional resource on the RANZCP website – the current child and adolescent ADHD guideline (RANZCP, 2009) is well past its review date and the new adult ADHD guidelines (RANZCP, 2012) simply refer the reader to the UK (NICE, 2008) and Canadian guidelines (CADDRA, 2011). While awaiting a revision of the Draft Guidelines, the RANZCP could do worse than to follow the example of the RACP (Paediatrics and Child Health Division) who has seen fit to include the current Draft Guidelines on their website.

See Commentary by Whitely, 2013, 47(10): 956–958.