2 November 2006
ADHD: A STIMULATING DEBATE FOR YOUNG PAEDIATRICIANS
As young paediatricians working with Indigenous children, we read with interest the debate concerning the use or misuse of stimulants in socially disadvantaged populations.1,2 Both contributors agreed that in an ideal world, clinicians would have access to multidisciplinary teams to assess, diagnose, manage and monitor children with attention deficit/hyperactivity disorder (ADHD) in a culturally sensitive way. We could also hope for a world in which all children had access to optimal health care, clean water, food security, a comprehensive education, a nurturing family and protection from poverty and armed conflicts.3 However, ADHD would still exist even in this world, as it is an organic disorder. It may be exacerbated by social disadvantage but it is certainly not limited to socially disadvantaged families. Both genetic and environmental evidence support the organic hypothesis. Monozygotic twins are approximately five times more likely to be diagnosed with severe ADHD than dizygotic twins.4 Both debate submissions concede that psychosocial and behavioural interventions have a much weaker effect than stimulants, further supporting an organic aetiology.
The MTA study quoted by both authors investigated children with ADHD from diverse backgrounds: 20% were African American; 19% were from families on welfare; and 21% had an annual parental income under US$20 000.5 In the subsequent article, also from the MTA group, the authors stated that the patterns of response to treatment from different socio-economic strata were similar (although raw data were not presented).6 In our experience access to other management options such as psychological support, behaviour programmes, assistance in the school environment and child psychiatry is limited even in socially advantaged areas. Aboriginal children should not be deprived of the benefit of stimulant medications when clinically appropriate, purely because access to other services is limited.
In this not-so-perfect world, young and ‘less young’ paediatricians have to manage ADHD and the myriad of other complex conditions comprising the ‘true morbidities’ of general paediatrics, based on suboptimal training,7 limited research and scarce resources. Restricting Aboriginal children’s access to the proven benefit of stimulants, on the basis of their social disadvantage, would only serve to perpetuate this disadvantage.