Response to the Clinical Practice Points draft document of the NHMRC.
Dr Kim Pedlow MBBS(UWA), FRACGP, FACCRM, Dip Obs(Advanced)COG, Clinical Lecturer RCS (UWA)
Thank you for the opportunity to respond to the latest document from the NHMRC trying to
promulgate and disseminate credible ADHD guidelines to the Australian community.
I sat on the original working group housed in the College of Physicians. I watched the
assault by the Church of Scientology who influenced the MOH to remove Dr Darryl Efron as
chair. He was ably replaced by Dr David Forbes from Western Australia. However we lost a
number of our ranks at that time due to real or perceived pressure from the associated
controversy. We eventually got underway and produced what I thought were reasonably
accurate and conservative guidelines.
My imperatives through this process were as follows
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That we produce a set of guidelines which made diagnosis and management
accessible to rural Australians. Similarly underprivileged Australians needed to be looked
after.
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We needed to ensure that children and adults seeking assistance in this area were
attended to by health professionals trained in the area.
To this end I engaged the other members of the committee in long conversations
explaining that in rural Australia there are very few Fellows of the Royal Australian College
of Physicians and that if diagnosis and medical management was restricted to members of
this college then the following would occur.
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Large numbers of rural and underprivileged people would be unable to access
necessary services for geographical and financial reasons.
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By giving blanket, one size fits all style credentialing to fellows of the Royal
Australian College of Physicians regardless of whether the doctor has training in the area
caused me great difficulty.
I went on to explain that I am a rural generalist with special interests in obstetrics and
paediatrics. In my town of Geraldton there is now a post at the local health service for GPpaediatricians. This is along the lines of GP obstetrician and anaesthetist.
I look after 250 families affected by attention deficit hyperactivity disorder and for the last
20 years have been part of a strong network of teachers, psychologists, other allied health
workers, doctors and community members. Our task is to care for members of the local
community affected by attention deficit hyperactivity disorder and the common
associations of learning difficulty and behavioural problems.
I am therefore from a very different culture to the members of the current working group of
the NHMRC.
On reading your document I find myself agreeing with much of what you say. However the
constant reference to specialist clinician for diagnosing and medical management will make
it very difficult for the majority of my patients to access treatment in a timely and equitable
manner. I can find no reference to shared prescribing.
May I suggest that instead of specialist clinician that the working group substitutes
clinician trained in the diagnosis and management of ADHD.
I remind the working group that large numbers of psychiatrists and paediatricians have had
little or no training in the area and to give them the unqualified blessing of your committee
causes me difficulty. Scope of practice is the important thing here. My suggestions are more
in tune with the current attitude in the United States of America. It is my understanding
that the silo model taken up by the current committee is more along the English way of
doing things. If this was widely applied to rural Australia our health system would fall apart.
On a less important note I have concerns about the emphasis on direct observation of the
affected child as mentioned several times. It’s true one can get some idea of hyperactivity,
impulsivity and so on but I have found it more valuable to seek information particularly from
trained observers such as teachers, reliable family and friends as to the unfettered
behaviour of the affected child or adult.
I thought also that the conclusions of the MTA trial were slanted in favour of diminishing
the role of medication. Your paragraph gave the impression that there was not much to
choose between pharmacological and non-pharmacological strategies. I suggest that you
revisit this document.
I sincerely hope and trust that these comments are taken in a constructive manner. I have
nothing against the College of Physicians but my reality is that they play very little part in
delivery of service in my area.
Yours sincerely