Must Aussies Drug Their Kids?

There's a kerfuffle in Australia regarding these Attention Deficit Hyperactivity Disorder (ADHD) guidelines from the National Health and Medical Research Council. Family support groups are upset because the guidelines include this language: "As with any medical intervention, the inability of parents to implement strategies may raise child protection concerns." Critics are interpreting this to mean that parents will be forced to medicate their hyperactive kids, or risk losing custody of them. I think the criticism is overblown. First, it's just true that failing to help treat your child's mental health problems can indeed amount to child abuse, and can merit state intervention. Moreover, the language doesn't apply only to drug interventions, but to the full scope of ADHD interventions (psychosocial, educational, drug, and combination) which the guidelines contemplate. In fact, the real story here seems to be that these guidelines are not pushing Ritalin as a one-stop approach to ADHD symptom control, but are instead taking a nuanced approach to ADHD's situation within the child's broader mental health status. In this way they differ from previous draft NHMRC guidelines--guidelines which were ditched last year because they relied heavily on the work of a professor (Harvard Med’s Joseph Biederman) who was sanctioned for failing to declare conflicts of interest.

Conflict of Interest on NIH Guideline Panels

Here's a New York Times story from last week, reporting a very high prevalence of financial ties to industry among experts on NIH panels drafting guidelines on hypertension, obesity and cholesterol. (As the article notes, the panels were seated in 2008, before the current more rigorous guidelines on COI were put into place.) 20 members of the three panels, including some co-chairs, have been told they ought to recuse themselves from voting on crucial issues. 8 of 19 obesity panel members have ties to industry, as do 7 of 16 cholesterol panel members. Worryingly, 5 of 17 hypertension panel members have taken industry money since the panel was seated.

And government panels are among the least worrying on the COI issue. This piece from BMJ last month finds that, among 7 panels working on diabetes and 7 on hyperlipidaemia guidelines between 2000 and 2010, most panel members and half of all panel chairs had COI, and that the COI prevalence was lowest on government sponsored panels. It was highest on panels sponsored by specialty societies. It's time for a hard look, not only at standards but at remedies. Mere disclosure and self-recusal from voting doesn't help much, if the panelist has had the chance to frame the discussion. One panelist in the Times story is quoted as saying he severed his ties with industry in order to serve--but if he had the ties before, and will be free to have them again afterwards, what does the current severing really do to secure his independence? The best solution is probably the one used by NICE in the UK: no one who's received industry money in the last year is permitted to serve.

NHS Permits "Caesarian on Maternal Demand"

An update of a new guidance document being developed by the UK's National Institute for Health and Clinical Excellenct ("NICE") would permit caesarian section on maternal request, even when there are no medical indications for the procedure. In the US context, I'm skeptical even of the language of "maternal request" or "maternal demand," since I believe that there is significant evidence that physician preferences and reimbursement drive our sky-high c-section rates here in the US, and elsewhere (such as Brazil); and also that physician preferences and conversations can end up driving what is later called "maternal demand". The new guidelines make me worry that the official availability of c-section on maternal request in the UK will lead to some non-medically-indicated c-sections being performed for reasons other than "maternal request," like physician scheduling convenience. But it may work differently in the NHS; and anyway, the NICE guidelines include a number of steps to be taken before acquiescing in mom's request for CS, like counseling on fear of childbirth, and proper discussion of the comparative risks of CS and vaginal birth. Let's see what happens to the overall CS rate, and how many maternal requests for CS crop up, after the new guidelines are finalized.