Attention deficit-hyperactivity disorder (ADHD) is a neurodevelopmental condition that affects 2.5-5% of people. Less than half of people with ADHD have been diagnosed and treated - though more and more people are presenting for help.
Authors
Adam Guastella
Professor and Clinical Psychologist, Michael Crouch Chair in Child and Youth Mental Health, University of Sydney
David Coghill
Financial Markets Foundation Chair of Developmental Mental Health, The University of Melbourne
Like other neurodevelopmental conditions, there are long delays to diagnosis. The current pathways to diagnosis and care can involve multiple assessments from different professionals who are in short supply, making the process confusing, expensive and time-consuming.
Yet many Australians have a GP on local clinic they can access. That's why some medical groups are advocating for GPs to have a role in the diagnosis and management of ADHD.
But while GPs should have an expanded role in the ongoing management of ADHD, it's important for specialists to diagnose and initiate treatment.
What is ADHD?
ADHD is associated with inattention, or difficulty holding and sustaining concentration over periods of time, particularly on tasks that are less interesting or require significant mental effort.
It is also often associated with hyperactivity and high levels of impulsivity and arousal, and difficulty planning, coordinating and remaining engaged in tasks.
In order to meet criteria for ADHD, these difficulties must be present over a long period and have a negative impact on a person's day-to-day life. This is why an ADHD assessment requires a clinical interview from specialists, and should never be done by questionnaires alone.
ADHD assessments are performed by psychiatrists, paediatricians and clinical and neuropsychologists with specialist training.
An ADHD assessment must be comprehensive enough that if a diagnosis is made, it can be followed up with a management plan that:
- addresses the person's individual needs
- is culturally appropriate for them and their circumstances
- takes into consideration all of the issues identified.
When a diagnosis of ADHD is made, medication is often part of the management plan. Stimulant medications are usually the first-choice medication. Psychological therapies may also be recommended.
Treatment can ease some of the struggles
ADHD increases the risk for poor academic, occupational, social and mental health outcomes, and has even been associated with higher rates of accidental injury and death.
However, these risks decrease when ADHD is effectively treated. One front-line treatment, stimulants, have about a 70% efficacy rate for managing symptoms. Research shows stimulants can effectively reduce many of the adverse impacts of ADHD.
Stimulants have a good safety profile, with relatively few serious side effects in most children and adults.
However, stimulants can be very hard to access. States and territories have different laws about stimulant prescribing, and your prescription from one state may not be honoured in another.
Why are medications difficult to access?
Stimulants are tightly regulated because they have been assessed as having the potential for abuse. Prescribing or supplying them requires prior authorisation by the state authorities and must be in accordance with criteria set out by each state.
While GPs and nurse practitioners can apply for authorisation in some situations in some states, the legislation generally identifies specialists (paediatricians and psychiatrists for children and adolescents, and psychiatrists for adults) as the main prescribers.
Currently, there are too few specialists, in both rural and urban areas of Australia, to ensure access to ADHD medication.
As our recognition of ADHD increases, especially in adults, alternative approaches are needed, since this skills shortage is unlikely to resolve soon.
So what role should GPs have in managing ADHD?
We advocate for a "collaborative care" model, with GPs playing a greater role in managing patients' ongoing ADHD care, including prescribing and monitoring medication.
However, it's important for specialists to perform the initial diagnosis and identify the right treatment for the patient. Diagnosing ADHD can be complex - other psychiatric and medical conditions may need to be ruled out. And it can be difficult to match patients with an appropriate treatment.
GPs are specialists in chronic disease management and already provide ongoing care for many chronic physical and mental health conditions. GPs are generally easier and cheaper to access than other specialists, know their patients well and are embedded in their communities. Models of collaborative care for ADHD are already common in many other countries including the United Kingdom and United States.
A collaborative care model would also allow specialists to spend more of their time on initial consults and the management of complex cases, rather than the ongoing management of less complex cases.
For collaborative care models to work, national programs will be required that can train and register GPs in ADHD management, to meet the needs of their patients with ADHD and, most importantly, improve patient outcomes.
Resources and support will be needed to ensure practitioners are supported to deliver shared care for ADHD. If GPs don't receive adequate support, fewer may be willing to provide this care.
Ultimately, the model could transform access to effective treatment for people with ADHD and their families.
Adam Guastella is scientific director of Neurodevelopment Australia and the Child Neurodevelopment and Mental Health team of the University of Sydney.
David Coghill has consulted with Takeda, Medice, Novartis and Servier. They have received research funding from the NHMRC. They are the president of the Australian ADHD Professionals Association.
