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  • Dr Martin Whitely

NHMRC doubles down on 'grossly misleading' claim that the new ADHD Guideline is ‘evidence-based'.

Updated: Apr 30, 2023

By Dr Martin Whitely Editor PsychWatch Australia


According to its website the National Health and Medical Research Council (NHMRC) provides Australians ‘with the best available evidence-based advice about improving health and preventing disease… [in part by developing] specific guidelines on various aspects of health, health care, health research and environmental health’.[1]


However, judging by its approval of the Australian Evidence-Based Clinical Practice Guideline for Attention Deficit Hyperactivity Disorder, published in October 2022, the NHMRC uses the term ‘evidence-based’ very loosely.[2]


In total, the supposedly 'evidence-based' ADHD Guideline makes 113 clinical recommendations on recognition, diagnosis, and treatment. 101 recommendations are based on the ‘opinion’ and the ‘experience’ of the Guidelines Development Group because ‘there was insufficient evidence to inform an EBR [Evidence Based Recommendation]’. Of the 12 recommendations designated as EBRs, none have high quality, three have moderate, and nine have low or very low quality, supporting evidence.

The most favourable interpretation of this is that three out of 113 recommendations are based on evidence of an acceptable quality.

It is also concerning that the Guideline makes ‘strong’ recommendations based on ‘low’ or ‘very low’ certainty of evidence. For example the 'strong' recommendation that 'methylphenidate or dexamfetamine or lisdexamfetamine should be offered as the first-line pharmacological treatment' for children and adolescents aged 5 to 17 years, is based on 'low’ quality evidence.[2, p.24 recommendation 5.3.1]


In other words, weak evidence justifies the strong recommendation, that 5 year olds, who are considered too impulsive/active or inattentive, are given an ongoing daily amphetamine habit, because 'if left untreated, ADHD can result in significant lifelong functional impairment'.[2, p.36] The recklessness of this 'strong' recommendation should be self-evident.

As well as being devoid of evidence, it deliberately excludes robust evidence that challenges the strongly held preconceived opinions, biases and economic interests of the Guideline developers. Specifically, high quality evidence from multiple international studies of an ADHD relative-age effect was deliberately excluded from the search for evidence.[3]


The ADHD relative age (or late birthdate) effect refers to the global phenomenon were it is normal for the youngest children in a school year cohort to be diagnosed with, and medicated for, ADHD at a higher rate than their older classmates.[4] The existence of the relative age effect in both high ADHD prescribing nations like the USA and in low prescribing countries like Sweden, Finland and Taiwan, raises serious issues about the validity of the diagnosis, and challenges the notion that low rates indicate sound diagnostic practices.


A genuinely evidence-based guideline would strongly advise clinicians, teachers and parents to consider the predictable behavioural implications of a child being younger than their classmates. At the very least, teachers and clinicians need to be aware of the potential for relative age related immaturity to be misdiagnosed as ADHD, and adjust their teaching and diagnostic practices accordingly. Deliberately excluding evidence of the relative age effect is the antithesis of scientific inquiry.


This is understandable given that the Guideline was developed by the Australian ADHD Professionals Association (AADPA). Its members earn income from diagnosing, treating or researching ADHD. The current AADPA President, Professor David Coghill, has financial ties to Shire/Takeda, Medice and Janssen-Cilag, Eli Lilly, Novartis. The immediate past President, current director and corresponding author for the Guideline, Professor Mark Bellgrove, has received travel support and speaker fees from Shire/Takeda Pharmaceuticals.


The ADHD drug companies have been major sponsors of (at least) the last three AADPA annual conferences (2022, 2021, 2019), and the one scheduled for June 2023. The results of leaving the Guideline's development for a controversial disorder to an organisation with extensive conflicts of interest and well known predetermined positions were predictable.


None of this seems to trouble the NHMRC. When a group of mental health practitioners and researchers (primarily psychiatrists), led by Adelaide psychiatrist Professor Jon Jureidini, wrote to it complaining that the description of the Guideline as ‘evidence-based’ is ‘grossly misleading’, the NHMRC doubled down on its approval. (Copies of the letter to the NHMRC and its response are below the references.)


The public and clinicians should have no confidence in either the so called ‘evidence-based’ ADHD Guideline, or the NHMRC. Responsibility for fixing this mess resides with the Albanese Government’s Minister for Health, Mark Butler.

This would require an about face by Minister Butler. In October 2022 he launched the Guideline with a glowing endorsement on the AADPA website and a media release declaring ‘this guideline sets the benchmark for best-practice evidence-based assessment, treatment and support for people living with ADHD…There are 111 [in reality 113] clinical recommendations addressing the ADHD journey across a person’s lifespan, from identification and diagnosis to an evolving support plan and information for family, friends, employers, and others in their life.”[5]


At the time Minister Butler was probably trusting that the NHMRC had done its job properly, and unaware of the dearth of evidence in the Guideline. However, in February 2023 he was provided with a copy of the letter to the NHMRC (see below) and his office has received a copy of this blog and he has been asked for comment for a follow up blog.

If and when he responds, PsychWatch Australia will publish his response. Either way Minister Butler will eventually have to confront the fact that the claim that the Guideline is ‘evidence-based’ is grossly misleading.


References

[1] NHMRC website. Health Advice page https://www.nhmrc.gov.au/health-advice (accessed19/4/2023)

[2] Australian ADHD Professionals Association. Australian Evidence-Based Clinical Practice Guideline for Attention Deficit Hyperactivity Disorder (ADHD). AADPA, 2022. https://aadpa.com.au/guideline/ (accessed Jan 2023)

[3] Australian ADHD Professionals Association. Technical Report: Australian Evidence-Based Clinical Practice Guideline or Attention Deficit Hyperactivity Disorder (ADHD). Melbourne: AADPA, 2022. p.11 https://adhdguideline.aadpa.com.au/about/technical-report/ (accessed Jan 2023)

[4] Whitely M, Raven M, Timimi S, et al. Attention deficit hyperactivity disorder late birthdate effect common in both high and low prescribing international jurisdictions: systematic review, J Child Psychol Psychiatry, 2019, 60(4), 380-391. https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.12991 (accessed Jan 2023)


[5] Butler M. Press Release, Better diagnosis, treatment and care for ADHD. 5 October 2022. https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/better-diagnosis-treatment-and-care-for-adhd (accessed Dec 2022).






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