Politics vs practice: Commentary on the ADHD debate

Historical perspective

As an ex-West Australian, and having lived through various cycles of anti-attention-deficit hyperactivity disorder (ADHD) publicity, it could be useful to take a historical perspective. In the early 1970s, most stimulant prescribing in Sydney was carried out by a small number of child psychiatrists and paediatric neurologists. However, with the training and interest of increasing numbers of behavioural paediatricians, and the migration from overseas of paediatricians experienced in the use of methylphenidate and dexamphetamine for attention-disordered children, stimulant prescribing became more widespread across New South Wales, and across age groups. At times, stimulants were prescribed for adolescents who were found to develop ‘attention problems’ prior to the Higher School Certificate. Some of these adolescents were observed to show over-focused ‘zombie-like’ behaviour, causing great concern among school counsellors. This gave rise to the establishment of the NSW Health Department Stimulant Committee, who aimed to develop NSW guidelines for stimulant use. Having been instrumental in their development, I should point out that there were vigorous arguments about appropriate age and dose levels; generally taking a conservative position myself. This was sometimes in the face of colleagues’ enthusiasm and some evidence from overseas of ‘linear dose responses’ (Douglas, 1995). In general, the ‘Stimulant Committee’ provided a useful educational as well as monitoring function in relation to stimulant use in NSW (Salmelainen, 2002).

At the same time, similar developments were occurring in other states, with the patterns varying according to the practice of professional leaders in each state. Thus, Western Australia was considered enthusiastic while Victoria was generally negative and South Australia downright negative (Hinshaw et al., 2011; Levy et al., 2010). Unfortunately, no one was able to explain why some children appeared to derive considerable benefits from stimulant medications, while other children of similar age and apparent problems developed side effects such as headache and rigidity at very similar dose levels (Levy, 2012a).

Levy (2012b) has postulated that because dopamine metabolism in the prefrontal cortex (PFC) is by catechol-O-methyltransferase (COMT) (as distinct from the dopamine transporter (DAT) subcortically), response to stimulant medication will depend on the relative dopamine metabolising efficiency of COMT genes. At room temperature, the COMT met enzyme is less efficient in metabolising dopamine at the PFC than is the COMT val enzyme. It is hypothesised that children who are COMT met/met will show dopaminergic side effects at lower stimulant doses than children who are COMT val/val, and this may result in the occurrence of the above rigidity symptoms in those children who metabolise dopamine more slowly in the PFC (see Levy, 2009). This hypothesis is testable and perhaps more useful than repetitive political debate.

With the increase in diagnosis and treatment of ADHD in the 1980s and 1990s, the National Health and Medical Research Council (NHMRC) established a committee, who produced the original Australian ADHD Guidelines (NHMRC, 1997). These went into professional use and were generally accepted as an appropriate guide to clinical practice. An exception was in Western Australia, where an ex-high school teacher cum politician, who had observed the ‘zombie’ effect on some adolescents, campaigned stridently against stimulant use (initially allowing use in some children, but more recently hardening his position to declare that ADHD does not exist) (Whitely, 2012).

NHMRC Guidelines

Come the 2000s, and the advent of slow-release stimulant medications, the NHMRC decided it was time to revise the original guidelines and rather than appoint a committee, the project was put out to tender (Efron, 2005). This was awarded to the Royal Australasian College of Physicians Paediatrics and Child Health Division. An unfortunate political result of this development was an increasingly strident political campaign by both the Victorian media and the Western Australian politician, outlined in Whitely’s web posting on 4 December 2010 entitled ‘One year on from the release of the corrupted National ADHD Guidelines’ (Whitely, 2010).

The NHMRC committee, as a result of extensive time and work produced, in my view, excellent and comprehensive guidelines, and an extremely extensive critically reviewed bibliography (the Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder; NHMRC, 2009). Coincidentally, at around this time, Dr Joseph Biederman, a long-time ADHD researcher, was censured by his employers in Massachusetts, USA for a perceived conflict of interest, in not declaring pharma support.

Suddenly, in far away Australia the roars of Guideline criticism became almost deafening. Under political pressure the NHMRC website (March, 2012) stated ‘The Draft Guidelines will soon be removed from the NHMRC website’. The reason given was an ‘identified conflict of interest’. The NHMRC post continued, ‘Unfortunately, this announcement [from Harvard] did not reveal the extent to which the conflicts impacted on the integrity of the research cited in the Draft Guidelines. NHMRC was unable to approve the Guidelines as it cannot be guaranteed that the evidence underpinning them is free from bias’ (NHMRC, 2012).

Ethical questions

These events raise a number of questions:

Conclusion

I believe the role of child psychopharmacology to be currently under political assault, and subject to alarmist, adversarial, and selective attack, which threatens to take us back to where it was in the early 1970s, despite a huge literature, public support and steady advances. The ‘WA controversy’ is part of a larger questioning of child psychopharmacology, which should of course be open to question, but not closed down.