Abstract
I congratulate the Editorial Committee for publishing seven papers on child ADHD in a symposium format [1]. Six of the seven highlighted most of the current clinical and research issues, but the first (‘An ethical perspective’) was disappointing. It began with the now historically stale discussion as to whether ADHD exists or not – this is a debate for the academic philosophers, not for the clinicians who treat it every day. It was long on the rhetoric of misdiagnosis, which was based mostly on a supposed quote from the USA National Institute of Health (NIH) consensus statement that ADHD remains of ‘unproven’ status. In fact, this opinion came not from the NIH statement but from Dr Jensen's commentary on the NIH statement as pointed out by Rapoport et al. [2] (in the same journal issue by coincidence).
Terms such as misdiagnosis and over-diagnosis are loosely used and need more accurate justification than that provided by this paper. For instance, the data showing marked variations in dexamphetamine prescribing throughout Australia may, as suggested, reflect different diagnostic practices in child ADHD but there may be other explanations. For instance, the data includes adult ADHD patients as well – their increase has been rapid over the last few years and probably non-uniform due to differing state regulations.
As to the tabulated increases in dexamphetamine prescribing throughout Australia, the fact is that prevalence rates of prescribing remain below the reported rates of ADHD in national surveys (as reported in the other symposium papers). That is, many ADHD sufferers are not on medication.
A further ethical point is made at length about the dangers of over-diagnosis. I think it would be ethically more responsible to balance this with an equally fulsome discussion about the ethical dangers of under-diagnosis.
One last point about the symposium in general. Adult ADHD was hardly mentioned but it would have been justified for two reasons. First, this is now a large part of clinical practice for many psychiatrists throughout Australasia, and second, this journal published the first ever randomized, controlled trial of dexamphetamine versus placebo in an adult ADHD population [3].