Time for some reason in the ADHD debate

I reply to Mr Whitely’s Commentary in this Journal (Whitely, 2013), although this discussion runs the risk of repetition. Mr Whitely and others in the debate appear to agree that attention deficit hyperactivity disorder (ADHD) exists, causes disability and benefits from intervention, although Mr Whitely opposes the use of medication.

I would like to focus on the evidence presented by Mr Whitely, as I am concerned that much of what he presents is not from peer-reviewed journals and therefore not scientifically substantiated. For example, two references describing academic conflicts of interest are from newspaper websites. Furthermore, his interpretation of the Western Australian Raine ADHD Study (Department of Health, 2010), that medication increases the rate of below average academic performance by 10.5 times, is misleading. This study had 131/1785 children whose parents had described them as having ADHD, 80% of whom had received medication at some stage. A logistic regression with data available for 64 of the ADHD subgroup found that those who were medicated had an odds ratio of 10.47 of being described as ‘below average’ academically in a one-off teacher rating, but the 95% confidence interval was 1.12–97.49, an extremely wide range where the bottom value was close to one, scarcely conclusive proof, particularly as there were no operationalised measures for either the ADHD diagnosis or the academic performance, as the study itself acknowledges. Similarly, when reviewing the Oregon Health & Science University Drug Class Review on Pharmacologic Treatments for ADHD (McDonagh et al., 2011), there was evidence for growth inhibition while on medication, some suggestions that atomoxetine had an increased risk of suicide compared to placebo, and little evidence on sudden death. Monitoring is necessary to minimise these side effects, but they are less severe than many of the other drugs used in psychiatry. The Oregon review also concluded that stimulant use in childhood was not associated with a later increased risk of substance abuse.

In summary, Mr Whitely does not provide convincing evidence that ADHD medications are dangerous or ineffective, but as with all medications given to children, careful prescribing and monitoring of side effects is essential. I therefore repeat my plea for access to the updated Australian ADHD Guidelines.

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