Treating ADHD – Best Practice or Easy Options?

A recent document about ADHD released by the National Health and Medical Research Council is causing ripples of concern.

The Draft Clinical Practice Points (CPPs) on Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents was recently released for public comment.

The purpose of this paper is to allegedly provide best practice on the diagnosis, assessment and management of ADHD.

To complement existing guidelines, policies and procedures for the identification and treatment of this widespread condition.

It sounds good in theory.

There is one statement buried on page 15 of the Clinical Practice Points that initially raises the alarm bells:

“ As with any medical intervention, the inability of parents to implement strategies may raise child protection concerns”.

These “strategies” are predominantly pharmaceutical medications (In Australia alone approximately 60,000 children received medication in 2010).

The implied threat therefore is that a parent’s refusal to allow their child to be drugged with amphetamines or similar medication may see the intervention of child protection agencies.

As incredulous as this sounds, there is a US precedent.

Mercifully, a number of American states have since legislated to prevent child protection authorities and schools from medicating children with drugs against the wishes of their parents.

Will Australia have to do the same?

It is worth noting at this point that the ADHD Expert Working Group comprises those with extensive pharmaceutical company ties. There is therefore a distinct bias toward the promotion of pharmaceutical treatments.

Unfortunately, there is no level of consideration towards the systematic, long term evidence of the safety and efficacy of ADHD medications.

In fact, this draft paper is quick to dismiss the value of Complementary Therapies recommending a higher standard of long term evidence as to their benefits.

It does not however impose this same caveat towards long term use of ADHD medication.

 

Emed Comment

The diagnosis of ADHD remains largely subjective. The CPP acknowledges there is no known cause so ADHD remains a description rather than an explanation.

Consequently, the child’s label is based on the opinion of parents, teachers and doctors.

A recent research finding may lead the way to identifying a possible cause for ADHD.

Researchers from the Center for Applied Genomics at The Children’s Hospital of Philadelphia have reported in the journal Nature Genetics that four gene variants (all members of the glutamate receptor gene family) appear to be involved in vital brain signalling pathways in a sub-set of children with ADHD.

Glutamate is an amino acid used to make all of the proteins in our body. It acts as a neurotransmitter ie transmits signals between brain neurons.

Dr Josephine Elia, an expert in ADHD has endorsed this research by stating “This.. allow[s] new therapies to be developed that are tailored to treating underlying causes of ADHD. This is another step toward individualizing treatment to a child’s genetic profile”.

Currently, the easier treatment option is to medicate and the reasons for doing so can be tenuous at best.

While there is only limited evidence about the long term safety and efficacy of medication, what is available strongly suggests significant long term harm with no sustained benefit.

Of added concern here is that the CPPs state a pre-school child under the age of 6 can be diagnosed with ADHD and therefore medically treated. A diagnosis of ADHD is especially subjective amongst pre-school children as this behaviour can in fact be entirely normal for that age range.

The CPP has also made some sweeping statements that a diagnosis of ADHD increases the risk of subsequent mental health, relationship, occupational, legal and substance abuse problems in adult life. Wow! This certainly paints a very bleak picture.

It does not always follow that dysfunctional behaviours cause dysfunctional behaviours.

In fact it would be great to see a recommendation within the CPP that clinicians have the responsibility to identify where family dysfunction may actually be contributing to a child’s impulsive behaviour and to offer strategies for support.

So the CPPs need some further revision. Let us hope for the sake of the thousands of children labelled with this disorder that a thorough and balanced review of all aspects surrounding the condition occurs.

It is an opportunity to question and potentially rein in the large pharmaceutical prescribing rates.

To discuss treatment options and the best nutritional approach for your child, talk to a qualified Emed Consultant

Further Reading