Rise and Fall of ADHD in WA

The ADHD story in Perth Western Australia, the world's most isolated capital city, contains the key disturbing elements of the global ADHD story.  Played out at the top by the pharmaceutical companies and the American Psychiatric Association and, lower down, in tens of thousands of schools and doctors' surgeries across the globe and in towns and cities like Perth.  Internationally millions of parents have been deceived into 'medicating' their children with amphetamines in order to prevent imagined disastrous educational and life outcomes.  However, Perth's story offers hope that with common sense and leadership children can have a future where difference is regarded as a strength, not a disorder, and children with problems have their real needs met.

Until recently Perth had the highest prescription rate of ADHD amphetamines in Australia.  Until August 2005 dexamphetamine was the only drug for ADHD subsidised through the Pharmaceutical Benefits Scheme (PBS). From 1993 until 2003, according to PBS data, WA was consistently the highest prescribing state (or territory) of dexamphetamine.  In 2003 the number of prescriptions dispensed for dexamphetamine in WA was around three and a half times higher per 1000 population than the Australian average and were comparable to the highest prescribing rates in the world.[1]  In 1989 in Western Australia 880 people were prescribed stimulant medication.  By the year 2000 this had increased to 20,648 with the WA Government Health Department estiating 85-90% (17,551 to 18,583) were children. This represented 4.2% to 4.5% of all West Australian children aged between 4-17 years were on ADHD stimulants.[2]  This estimate was based on the age distribution in New South Wales.  It may have been an overestimate as in Western Australia has in later years had a 10 to 15% higher proportion of adults in the ADHD cohort than New South Wales.

Concerns about West Australian ADHD prescribing rates first emerged in the mid 1990's. In 1995 the Court Liberal WA State Government set up a Technical Working Party "to report to government on the incidence of ADHD in Western Australia and to seek expert opinion on the appropriate diagnosis and treatment for the condition." [3]  The Working Party's report highlighted that in 1994 the rates of prescription per child in WA were about two and a half times the national average and there was a 43 - fold growth in the prescription of dexamphetamine to five to 14-year-olds in Western Australia between 1989 and 1994. It also highlighted rates of prescription per child in WA were about two and a half times the national average.  Furthermore, the report identified that prescription patterns varied greatly across the Perth metropolitan area.

Block Authorisation

The report identified concerns with the diagnositic practices of some unnamed Perth paediatricians stating, "The parent is frequently the sole source of information and often educational and behavioural information is not sought. When information is sought from the school, the questions asked are frequently inappropriate. Behavioural observations are rarely obtained." [4]  Furthermore, the report identified that prescription patterns varied greatly across the Perth metropolitan area. It concluded that it is "the view of the working party that the differential rate of prescriptions may be more reflective of the prescribing patterns of paediatricians servicing the various areas than it is of social or other factors associated with ADHD in those areas." [5]  To address the inconsisitency in prescribing practices the report recommended, "that the stimulant committee of the Department of Health be authorised to carry out random audits into the use of block authorisations, and that paediatricians and psychiatrists found to be failing to abide by approriate criteria have their block authorisation capacity removed." [6]

Under Block Authorisation "a practitioner was able to apply to the (West Australian) Department of Health and be granted blanket approval to treat any number of patients with stimulant medication, without further notifying of changes to individual patient details or dosage," provided the dose was within the manufacturers prescribing guidelines.[7]  Block Authorisation granted an exemption from normal accountability requirements to frequently prescribing clinicians considered to be "familiar with the prescribing guidelines." [8]  In effect Block Authorisation meant that frequent prescribers were the least accountable.  In contrast, a clinician who prescribed infrequently as a last resort was accountable for every individual script. Presumably the rationale for the policy of "block authorisation" was the assumption that those who prescribe frequently were familiar with, and therefore competent in, the prescription of dexamphetamine and methylphenidate.

Some isolated and ineffective efforts to rein in the ADHD prescribing rates took place between 1997 and 2000. In 1996 when the concerns about prescribing rates first lead to suggestions to curtail bloc authorisation the rate of prescription of stimulant medication in Western Australia was less than 1 per cent (1.6 per cent of boys and 0.15 per cent of girls). [9]  Four years later in September 2000, "Over 3.7 per cent of Western Australian children under 18 years are (were) on stimulant medication with most of these young people being treated for ADHD". [10]  Despite the fact that concerns had been raised raised before inaction saw rates quadruple in 4 years.

Abolition of Block Authorisation 

In February 2001 the Western Australian State Election resulted in the replacement of the Court Liberal Government with the Gallop Labor Government.  Martin Whitely was elected as the Labor Member for Roleystone and he raised the issue of block authorisation in his inaugural speech stating; "The problem of block authorisation continues. I believe making doctors accountable on a case-by-case basis for the prescription of stimulant medication is essential to dealing with the problem of over prescription." [11] The change of government, Martin's election and the appointment as W.A. Health Minister the Honourable Bob Kucera, a former policemen who had seen the problems of ADHD prescription amphetamine diversion, provided the opportunity for the direction of policy to be reversed.

In 2002 the report "Attentional Problems in Children and Young People" was published by the Western Australian Mental Health Division. An earlier draft of the report emphasised developing a tiered approach with teachers and child-care workers spotting potential ADHD children and referring them up the chain for diagnosis by specialist clinicians.  The draft report was, with my input, significantly altered by Kucera's ministerial office.  The final draft abandoned the tiered spotters' approach, recommended the abolition of bloc authorisation and the establishment of multidisciplinary clinics to diagnose and treat children with behavioural and learning problems, often characterised as ADHD.

Minister Kucera announced the decision to end block authorisation in December 2002 and the practice was stopped in August 2003 so that every authorised prescriber was equally accountable for every individual prescription. After Block Authorisation was abolished every practitioner was compelled to "apply to the (West Australian) Department of Health and obtain a unique Stimulant Prescriber Number (SPN) to initiate stimulant treatment in any patient. The practitioner must provide individual patient details, including age, gender and dose required, thus enabling the collection of data for future analysis of stimulant use in WA." [12]

Prior to the abolition of block authorisation and the introduction of the new stimulants monitoring system information about ADHD prescribing rates was limited to total script numbers provided through the PBS. It was difficult to know the numbers of children and adults who were on ADHD medications or the doses they received. As previously stated the West Australian Department of Health estimated there were 20648 people on ADHD stimulants in WA in 2000.[13]   Based on available information from NSW it was estimated between (85%) 17551 and (90%) 18583 were children (0-17).   By 2005 the number of children on ADHD stimulants had fallen dramatically to 8057, a fall of approximately 55% .[14]  Even if the initial estimates of children as a proportion of the ADHD cohort was an overestimate and the proportion of the ADHD cohort in 2000 was only 70% (14597) this represents a fall in child ADHD drugging rates of over 44%.  Subsequent to the initial fall, child prescribing rates have continued to decline with the number of children prescribed stimulants in 2008 totalling 5666.[15]

There was a vigorous public debate about the validity of ADHD as a diagnosis and the safety and effectiveness of ADHD drugs that may have impacted on prescription rates.  However, it is clear that the main reason for the massive downturn in child drugging rates was the decision to abolish  block authorisation and increase the scrutiny of individual clinician's prescribing practices. 

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[1] In 2003, WA dispensed 86,980 prescriptions for dexamphetamine (WA pop = 1,969, 046) compared to 61,390 in NSW (pop = 6,716,277) which was 44.2 prescriptions per 1000 pop in WA compared to NSW at 9.1/1000 and the Australian average 12.5/1000. Department of Parliamentary Services, Medication for Attention Deficit/Hyperactivity Disorder (ADHD): an Analysis by Federal Electorate (2001-03), Current Issues Brief 16 November 2004, No. 8 2004-2005, Parliament of Australia: p7

[2] Office of Mental Health, Attentional Problems in Children: Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder(ADHD) and Associated Disorders, November 2002, Government of Western Australia: p21  Note: the 85-90% estimate may have been an overestimate of the proportion of ADHD patients who are children as it was based on the age distribution in New South Wales. Western Australia has in later years had a higher proportion of adults in the ADHD cohort than New South Wales.

[3] The Report of the Technical Working Party on Attention Deficit Disorder to the Cabinet Sub-Committee (1997); Parliament House Western Australia: p2

[4] Parliament House Western Australia op cit p8

[5] Parliament House Western Australia op cit p6

[6] Parliament House Western Australia op cit p20

[7] Western Australia Legislative Assembly, Attention Deficit Hyperactivity Disorder in Western Australia, Education and Health Standing Committee, Report No. 8 (2004): p27

[8] The Report of the Technical Working Party on Attention Deficit Disorder to the Cabinet Sub-Committee (1997); Parliament House Western Australia: p20

[9] Draft Report Attentional Problems in Children and Young People, Western Australian Mental Health Division.

[10] Department of Mental Health, 'Attentional Problems in Children and Young People: Diagnosis and Management of ADHD and Associated Disorders, Draft Report, August 2001, Mental Health Division of the Western Australian Department of Health, Western Australia.

[11] Western Australian Legislative Assembly Hansard, Martin Whitely MLA, Inaugural speech, Thursday, 3 May 2001, p152b-179a

[12] Western Australia Legislative Assembly, Attention Deficit Hyperactivity Disorder in Western Australia, Education and Health Standing Committee, Report No. 8 (2004): p27

[13] Office of Mental Health, Attentional Problems in Children: Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder(ADHD) and Associated Disorders, November 2002, Government of Western Australia: p21

[14] Department of Health, Western Australian Stimulant Regulatory Scheme 2005 Annual Report, Pharmaceutical Services Branch, Environmental Health Directorate, Department of Health, Western Australia (2006): pIII

[15] Department of Health, Western Australian Stimulant Regulatory Scheme 2008 Annual Report, Pharmaceutical Services Branch, Health Protection Group, Department of Health, Western Australia (2009): pv