NSW Judge Speaks his Mind on ADHD Drugging

In April 2007 New South Wales (NSW) District Court Judge Paul Conlon, when sentencing a 21 year old man said that in his experience it was ADHD medications that were causing a tide of criminality and drug abuse. "I have huge concerns. The tide of cases is amazing. I am starting to lose count of (the number of) offenders coming before the courts who were diagnosed at a very young age with ADHD for which they were 'medicated'."[1]  Judge Conlon also said he had seen signs that children prescribed psycho-stimulant drugs like Ritalin went on to develop addiction to drugs like methamphetamine.  He also expressed frustration at the failure of the medical profession to effectively self regulate.  "My own research indicates that ADHD is perhaps the most over-diagnosed condition in today's society. I think it's an absolute disgrace and those doctors and psychiatrists really need to look much more closely at the child and consider other methods of treatment other than putting them on these drugs and chemicals. In other words, they need to apply greater professional rigour."[2] 

NSW ADHD Industry Reviews its Own Practice

Then New South Wales Health Minister Reba Meagher responded to Judge Paul Conlon's comments by setting up a committee to review NSW ADHD diagnosing and prescribing.  The review was conducted without public input and was restricted to a literature review, a survey of prescribers who described their prescribing practices and a review of the data from the NSW Stimulants Committee.  

In January 2008 Martin Whitely wrote to Minisiter Meagher outlining his concerns with the makeup of the review committee stating: "At least three of the five members of the review committee are, I believe, likely to seek to develop recommendations that if implemented will increase child drugging rates without addressing the real needs of NSW children... It is a clear conflict of interest for members of the committee to work with drug companies or receive funding either directly or indirectly from ADHD drug manufacturers. In the interests of transparency and objectivity any member of the Review Committee who also has an advisory role for drug manufacturers or receives any direct or indirect funding from drug manufacturers should be excused from serving on the Committee. In that way, potential conflicts of interest, will be seen, to have been avoided."

Seven days after Martin Whitely sent the letter to Reba Meagher the review report was published.  The report identified that the review chairperson Professor Mitchell and two other committee members, Doctors Patrick Concannon and Paul Hutchins have served as advisors to manufacturers of ADHD drugs.[3]  In addition many of the members were ADHD prescibers who were in effect reviewing their own practice.  All of the participants declared their connections to ADHD drug manufacturers but astonishingly claimed there were no conflicts of interest. 

Predictably the review concluded that, "the overall impression was of conscientious doctors giving plenty of time trying to offer the best total management in these very complex situations, in spite of their frustration at the lack of additional resources when they felt that the child and family would have benefited from them."[4] 

However, the review was hardly thorough or comprehensive.  The audit of patients was restricted to 137 of the 19382 (0.7%) patients and was restricted to a file review only.  In other words only the clinician's file notes were reviewed.  There was no fresh diagnosis of the children by interviewing parents and teachers. Participation in the audit and the practice survey by prescribers was voluntary with only 207 of 367 prescribers cooperating.[5]  The review described the 56% response rate of prescribers as "excellent", despite the obvious bias that those who were confident in the rigour of their practices were more likely to participate.[6]

The review contained virtually all the ADHD industry standard tactics and used discounted and discredited research to further the argument that ADHD drugs were not creating criminality and drug abuse, but were in fact underprescribed. In a disturbing display of ignorance the review quoted the 14 month results of the MTA study as supporting the use of medication alone whilst completely ignoring the 3 year follow up results that showed no long term benefits only stunted growth and a slightly higher risk of drug abuse.[7],[8] (refer to pseudoscience)

The report also used the standard ADHD industry tactic of stating prescribing rates are less than prevalence rates. It quotes the flawed Commonwealth Government commissioned research that estimated an 11.2% prevalence estimate without identifying the complete absence of measurement for dysfunction in that estimate. The report stated that, "In Australia, the Child and Adolescent Component of the National Survey of Mental Health and Well-being reported ADHD to be present in 11% of children and adolescents. Most studies have found a higher prevalence of ADHD in boys than girls, particularly in those presenting to clinical services."[9] and "As the prevalence of ADHD in Australia is up to 11% of children and adolescents, we would consider that the rate of prescribing of stimulants for ADHD in NSW (0.5% to 1.5%) is conservative."[10] 

Some of the other more notable features of the review were;

* "Ninety-three percent of prescribers used DSM-IV or ICD-10 criteria to make the diagnosis of ADHD."[11] The obvious question is on what basis are the other 7% using as the basis for diagnosing ADHD if they are not using DSMIV or ICD10?

* "When conducting a routine review of a patient on stimulants 67% of prescribers normally assessed blood pressure."[12]  Given that the risks of cardiovascular adverse events, particularly strokes and heart attacks, are increased significantly by using stimulants, it should have rung alarm bells that a third of prescribers don't routinely assess blood pressure.

* "The following details were recorded at review sessions, Weight (79%), Height (68%)."[13]  Given that growth retardation is an established side effect of stimulants it should be mandatory that reviewing doctors measure weight and height.

* "When making the diagnosis of ADHD 76% of clinicians assess vision and hearing."[14]  Almost a quarter of clinicians don't even bother checking if a child's lack of attention is caused by their inability to see or hear properly before giving them amphetamines.

* When prescribing stimulants, only 70% of clinicians provide current Consumer Medicine Information.[15]  Providing Consumer Medicine Information to parents and patients requires minimal effort and the failure to do so by 3 in 10 surveyed clinicians reflects a complete disregard for the principle of informed consent.

(The above figures were based on clinicians self reporting their practice habits and are therefore are likely to overstate practice competence.)

One of the most worrying aspects of the review was the wiilingness of clinicians to prescribe a cocktail of psychotropic drugs in conjunction with stimulants.  The proportion of surveyed clinicians who prescribe other drugs with stimulants was; Clonidine (75%), Atypical antipsychotics (71%), SSRI antidepressants (66%), Anti-epileptic medications (55%), Tricyclic antidepressants (27%), Other antidepressants (14%), Conventional antipsychotics (12%).[16]  Some of these drugs are contraindicated for stimulants and/or are not recomended for use in children. 

The patterns of prescribing were similar to those in Western Australia with a minority of prescribers specialising in ADHD so that "for 7% of practices, patients with this condition comprised 51-90% of their patients and for one practice (0.5% of the sample) having patients with this condition accounting for more than 90% of their patients."[17]  The review also confirmed that New South Wales paediatricians, like their Western Australian colleagues, were far more likely to be frequent prescribers than a child psychiatrist with 34% of paediatricians and only 5% of child psychiatrists prescribing to 100 or more patients. [18]

The report stated that; "many of the children and families were battling with very complex situations - in the diagnosis of the child, the comorbidities, and the interactions between the parents, siblings and the identified child. For many, the ADHD was a small part of the overall clinical picture but its ramifications were disproportionate — many children had significant learning difficulties, social problems, and other developmental conditions and were living in dysfunctional and sometimes chaotic families, including changes in carers. Several children were being reared by grandparents and a number were in foster homes or experiencing multiple placements. Domestic violence and parental substance abuse were not uncommon."[19]  However, typical of ADHD industry approach, these complexities were in practice ignored with pharmaceutical interventions being the simple solution to life's complexities. 

Given Professor Mitchell's and Doctors Hutchins and Concannon's pharmaceutical company connections, the findings of the review were hardly suprising.  However, the treatment of Judge Conlon, subsequent to making his comments, was suprising and reflects the ADHD industry's desperation to shut down debate.  On February 25 2008, The Sydney Daily Telegraph reported that as a result of a complaint, by an undisclosed ADHD support group, Judge Conlon was "gagged" from making further comments on his experience of ADHD medications leading to drug abuse and criminality.[20]  Judge Conlon had called on the medical profession to apply greater 'professional vigour'. His reward was a 'gag' and a whitewash review by ADHD industry insiders. 

Sydney Repeats Perth's Mistakes

Everything that is happening in Sydney has happened and been exposed in Perth. Sydney hasn't learned from Perth's mistakes it is repeating them. During the 1990's through to 2003 Western Australian child prescribing rates were much higher than New South Wales rates.[21]  Since 2003 Western Australian child prescribing rates have fallen dramatically however, rates in New South Wales have skyrocketed. For 2007 child prescribing rates were roughly equivalent.[22]   However, since 2007 New South Wales total Pharmaceutical Benefit Scheme subsidised scripts rates have more than doubled whereas in Western Australia they have increased less than 20%.[23],[24]  Whilst there is no measure of actual child prescribing numbers for WA or NSW later than that for 2007, all the available evidence strongly indicates per capita child prescribing rates in NSW, now exceed those WA, making Sydney Australia's new ADHD child drugging capital.