Context and background
The Guideline Development Group (GDG) acknowledges that societal barriers are obstacles for full and equal participation in the community for a person with ADHD, rather than viewing ADHD symptoms as a personal impairment. In this guideline, we have attempted to balance traditional medical, biopsychosocial and social disability models, to ensure a considered approach to the identification, diagnosis and support of people with ADHD.
ADHD is classified as a neurodevelopmental disorder with onset typically before 12 years of age (American Psychiatric Association, 2013). The symptoms include difficulties with attention and/or hyperactivity and impulsivity, which are incongruent with a person’s age and interfere with activities and participation (American Psychiatric Association, 2013). For example, the symptoms of ADHD can interfere with cognitive and social development, academic and occupational achievement, or daily living and participation in leisure activities (American Psychiatric Association, 2013).
Inattentive symptoms include difficulty sustaining attention on tasks and directing attention, distractibility and organisational challenges. Hyperactivity refers to excessive motor activity and difficulties being still, particularly in structured situations that require self-control, as well as internal restlessness. Impulsivity refers to a reduced or inconsistent capacity to pause and reflect before acting, to ensure actions are in keeping with wanted consequences and longer-term goals.
Individuals with ADHD present with different combinations of symptoms. Some present with predominantly inattentive symptoms, some with predominantly hyperactive-impulsive symptoms and some with a combination of both.
There is a growing body of research exploring the numerous strengths and abilities of people with ADHD and positive aspects of ADHD features (Climie & Mastoras, 2015; Mahdi et al., 2017; Sedgwick, Merwood, & Asherson, 2019). Strengths related to ADHD features include the ability to generate novel ideas, adventurousness, and the ability to hyperfocus, which can result in high levels of productivity (Sedgwick et al., 2019).
ADHD occurs in approximately 6–10% of Australian children and adolescents and 2–6% of adults (Graetz, Sawyer, Hazell, Arney, & Baghurst, 2001; Sawyer, Reece, Sawyer, Johnson, & Lawrence, 2018). If left untreated, ADHD can result in significant lifelong functional impairment with poor long-term outcomes. The social and economic burden of ADHD in Australia is estimated at $20 billion per year (Deloitte Access Economics, 2019). There are effective non-pharmacological and pharmacological treatments for ADHD, which can reduce symptoms and improve function and participation, with better personal outcomes and a reduction in community and economic costs.
Purpose of the guideline
This is a guideline for the identification, diagnosis and treatment of people with ADHD. This clinical practice guideline for ADHD was developed to provide a roadmap for ADHD clinical practice, research and policy, now and in the future, and to help people in Australia who are living with ADHD, and those who care for them, to improve their health and wellbeing.
The goals of this guideline are:
- to standardise clinical practice across Australia by providing clear advice about evidence-based ADHD identification, diagnosis and treatment
- to integrate the voices and opinions of those with lived experience of ADHD into information for clinicians and decision-makers
- to focus on everyday functioning and quality of life as well as symptom-based outcome measures
- to address appropriate care based on age, gender, culture, setting and geography
- to identify areas of unmet need and opportunities for research, advocacy and policy development.
Intended users of the guideline
This guideline is mainly intended for clinicians, including medical and allied health professionals, nurses (including mental health nurses and mental health nurse practitioners), pharmacists, and for other people involved in the support of people with ADHD, such as educators. It includes guidance for clinicians in education, forensic and addiction service settings. We anticipate this guideline will also be used by people with ADHD and their families, parents and carers and partners.
Professionals with appropriate credentials and training can use this guideline to guide identification, diagnosis and treatment and provide support for individuals with ADHD. Health Service providers and policymakers can use it to guide local services and policy development. Those in organisations responsible for making funding decisions can use this guideline to develop a deeper understanding of the challenges faced by those with ADHD and the many approaches that, with adequate funding, will make a real difference for individuals and the community.
It is hoped that those who assist individuals with ADHD in educational, occupational, juvenile justice, community, disability and aged-care settings will be able to use this guideline to optimise the functioning and participation of people with ADHD and, ultimately, their wellbeing, welfare and productivity.
To whom the guideline applies
This guideline is relevant to the identification, assessment, treatment and support of young children (aged less than 5 years), children (aged 5–12 years), adolescents (aged 13–18 years), adults (aged 18 years and over) and older adults (aged 65 and over) with ADHD.
What the guideline does not address
This guideline does not provide full safety and usage information on pharmacological interventions. The guideline does not address drug dosages, including maximum daily limits. Before using pharmacological interventions recommended in the guideline, prescribers should consider each person’s clinical profile and personal preferences. It is recommended that prescribers consult guidance from Therapeutic Guidelines (www.tg.com.au) for detailed prescribing information, including indications, drug dosage, method and route of administration, contraindications, supervision and monitoring, product characteristics and adverse effects. Guidance can also be found in product information and from other web resources.
This guideline does not include a formal analysis of the cost-effectiveness of recommended practice versus current/established practice. Nor does it consider the economic feasibility and cost-effectiveness of recommendations, such as whether medications are on the Australian pharmaceutical benefits scheme (PBS) or the economic impacts of combined medication use. The clinical and organisational impact of cost on recommendations has been considered in GDG meetings using the GRADE approach. The guideline does not cover jurisdictional regulations regarding the prescribing of stimulants.
Consideration of issues relevant to Aboriginal and Torres Strait Islander peoples
Issues relevant to Aboriginal and Torres Strait Islander peoples have been addressed in this guideline through engagement with Aboriginal and Torres Strait Islander representatives via membership of the GDG. Recommendations specific for Aboriginal and Torres Strait Islander peoples have been developed and are documented in section 6.2.
Consideration of issues relevant to other groups
The following special-needs groups have been specifically considered in this guideline:
Other subgroups that have been considered throughout the guideline include:
- culturally and linguistically diverse communities
- people with co-occurring neurodevelopmental and mental health conditions
- women and girls
- people with low socioeconomic status
- children in out-of-home care
- older adults aged 65 years and above.
These recommendations are relevant for the identification, diagnosis and support of people with ADHD in all healthcare settings, including community-based health and hospital settings, public and private sectors, and in educational settings, occupational settings, detention settings and the general community.
The International Classification of Functioning, Disability and Health (ICF) Framework
The GDG adopted the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) as a conceptual framework to anchor discussions and deliberations. The ICF complements traditional diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders – fifth edition (DSM-5) (American Psychiatric Association, 2013) and International Statistical Classification of Diseases and Related Health Problems 11th edition (ICD-11 World Health Organization, 2018), offering a comprehensive, integrative framework of functioning and disability.
The ICF is a useful framework for explicitly identifying ways in which ADHD impacts everyday functioning and disability and the ways in which professionals, society, and the government might improve their response/s to these functional challenges. This framework may also serve a pragmatic purpose in aligning this guideline and its recommendations more closely with the priorities of Australian agencies, such as the National Disability and Insurance Agency.
Guideline development methods overview
The methods used to develop this guideline are aligned with the international gold standard Appraisal of Guidelines for Research & Evaluation (AGREE II) criteria, ADAPTE II, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to meet the comprehensive NHMRC criteria for approval of evidence-based guidelines. Where prioritised questions were addressed by the existing NICE guideline (NICE, 2018), the evidence reviews were updated and adapted to the Australian context. The steps are summarised in Figure 1 (See Methods section for details).
Figure 1: Guideline development process