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New ADHD guidelines: a prescription for more than just Ritalin

New guidelines for ADHD emphasise comprehensive assessments before a diagnosis is made. Flickr/Woodlywonderworks

The National Health and Medical Research Council (NHMRC) is seeking feedback on new clinical guidelines for the diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents. The Draft Clinical Practice Points document recommends clinicians try to garner a more in-depth understanding of a child’s behaviour and interactions before diagnosing ADHD. It also cautions against prescribing medication as a first-line treatment and outlines parents’ responsibilities for treating their child’s ADHD.

The former ADHD draft guidelines were abandoned earlier this year after Harvard Medical’s School Professor Joseph Biederman, whose research formed the basis of the document, was sanctioned for failing to declare conflicts of interest.

Child and adolescent psychiatrist and Monash University adjunct senior lecturer George Halasz, explains how the draft guidelines signal a significant shift in the diagnosis and treatment of ADHD:

The pharmacological treatment of ADHD is a very controversial issue with at least a 20-year history. The first point of controversy was working out whether ADHD was an illness, a disease or a collection of symptoms. And we know it’s just a collection of symptoms. The second point of controversy has been how to treat the symptoms. In terms of pharmaceuticals, there are two main approaches:

First is the psychopharmacological approach – if you have the collection of symptoms, then you should treat them with methylphenidate (Ritalin) or a related class of drugs.

The other point of view is that while psychopharmacology has a place in treatment, it should never be used as a first-line option, and even then, it may not necessarily be the best treatment.

The difficulty is that there’s dramatic symptomatic change of the core symptoms of ADHD with medication. And this has falsely led many people to conclude that it’s the treatment of choice.

What is the role of the NHMRC’s Draft Clinical Practice Points document?

The document arose from the controversy surrounding its predecessor, the Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder. That document had been around since 2009 and was awaiting approval.

But the research on which the guidelines were based faced allegations of conflict of interest earlier this year. Harvard Medical School Professor Joseph Biederman – who is one of the main publishers in the area of childhood ADHD – was sanctioned for conflict of interest and this led people to wonder whether there was any impact on the integrity of his research.

The NHMRC has subsequently developed the Draft Clinical Practice Points, which has no mention of Professor Biederman’s work, and is now seeking public feedback on the document.

Do the two documents differ in their advice about the prescribing of Ritalin?

The two documents represent a profound and almost fundamental shift in outlook, including recommendations for medication.

The current Clinical Practice Points draft is a very important shift in the direction of recognising that children’s behaviour should be understood in a much wider context than just the symptoms of ADHD. The current document lists over half a dozen other conditions that really should be excluded before a formal diagnosis of ADHD is made.

ADHD Center

What do the current guidelines say about parental responsibility to treat their child’s ADHD symptoms?

It’s important to get to the wording of this Draft Clinical Practice Points correct – it says, “As with any medical intervention, the inability of parents to implement strategies may raise child protection concerns.”

Some people may interpret this as saying that if a parent doesn’t medicate their child with a drug for ADHD, then they should be reported to child protection authorities. That is misleading. As with any medical intervention – take childhood diabetes or asthma, which are fairly serious conditions – any parent who would not follow recommendations towards assuring the child’s health is possibly at risk for being reported for negligence.

And the wording in this document isn’t directed to medication for ADHD – it’s about implementing strategies.

In saying that, I’m also very mindful of the context of the ADHD in America, where schools have insisted on parents medicating their children for ADHD. In some states, they’ve even had to go to the length of introducing legislation that prohibits the teaching profession from discussing these issues with parents.

So I’m mindful that things can go to extremes but the Clinical Practice Points document doesn’t specify that level of intervention.

There are quite varied opinions among clinicians about how ADHD should be managed. How should parents of children with ADHD navigate such a system?

Parents should download this new document – it is really very enlightening. It explains the importance for specialists to take a full story of the child’s condition – from birth onwards – to understand the child in the family context, in the school context, and any other major stressors that are going on in the child’s life.

Some children have had diagnoses and recommendation for treatment with pills within an hour – I don’t regard that as an adequate assessment to make the diagnosis.

Parents whose children were started on medication after a single consultation of less than an hour owe it to themselves and their children to revisit their doctor and say they’d like to go through the process in a more thorough way.

What’s your assessment on the new document?

I welcome the change in emphasis in the Clinical Practice Points Draft. It’s a dramatic shift from where we’ve been over the past 20 years. It brings together very respected opinions and focuses on how a child should be assessed as a best-practice standard. It may not always be possible to do this, but it’s a major shift and a very positive step towards the way children should be assessed for this complicated disorder.

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