What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition characterised by differences in brain and cognitive development. Symptoms include difficulties with focusing and sustaining attention, and hyperactive and impulsive symptoms, which are greater than that expected for a person’s age or developmental level. For most people, ADHD symptoms continue into adulthood and are lifelong.
People with ADHD can struggle to focus and concentrate, control their impulses and make decisions that take into account longer-term consequences. They can experience difficulties with planning and prioritising, getting organised, and time management. These difficulties can impact the ability to study, work, manage responsibilities, develop and maintain social relationships, enjoy leisure time and relax. They can also negatively impact self-confidence and self-esteem.
Around 6-8% of Australian children have ADHD, and around 3-5% of Australian adults have ADHD which means more than around 1 million Australians have ADHD.
What is the guideline?
Considerable gains have been achieved in the identification and care of people with ADHD; however, many people still do not receive guideline-recommended care. The goal of this guideline is to improve the identification, diagnosis and treatment and support of people with ADHD. The guideline includes recommendations for young children, children, adolescents and adults. This factsheet contains a summary of the guideline recommendations for clinicians.
What the guideline says
Several groups of people are at higher risk of having ADHD compared to people in the general population. This includes people with other neurodevelopmental conditions, people with mental health conditions and some medical conditions. People in some settings will be at higher risk of having ADHD, such as those in prison, people using addiction services, or children and adolescents in out of home care. Girls and women with ADHD may be at risk of under-identification.
Screening the general population for ADHD is not currently recommended as current screening tools are not accurate enough for the costs and risks of screening to outweigh the benefits. Screening for ADHD in higher-risk groups could help to identify people with ADHD early so they can receive support. Screening for ADHD in people in high-risk groups should occur when symptoms continue despite treatment, there is difficulty adhering to treatment, and some signs of ADHD are present. When screening indicates ADHD may be present, people should undergo a diagnostic assessment.
What the guideline says
A thorough assessment by an appropriately trained and credentialled clinician is needed to make a diagnosis of ADHD. Clinicians should gather a thorough developmental, mental health and medical history with a clinical and psychosocial evaluation of ADHD symptoms. A medical assessment should be conducted to exclude any possible medical causes of symptoms. Clinicians should check the symptoms result in clinically significant functional impairment in at least two areas such as academic, occupational or social domains. Rating scales can assist with diagnosis but should not be used alone. The assessment should include identification of personal strengths. Multiple informants such as teachers, parents, or partners for adults, should be used.
A person with ADHD may have one or more other neurodevelopmental, mental health, or medical conditions that make diagnosis and treatment more complex. Careful assessment of possible co-occurring or alternative conditions is required. Where other conditions are identified, best-practice treatment for these conditions should be offered, with adjustments for ADHD symptoms.
After a diagnosis, clinicians should provide the person and their carers with education and information on the causes and potential consequences of ADHD, and information about evidence-based treatments, in a way that provides hope and motivation. Clinicians should provide information about available supports. Information should be provided in a tailored way so the person can best understand it, such as through using plain language and providing small chunks of information when needed.
3. Treatment and support
What the guideline says
Clinicians should explain and offer both medication and non-medication (e.g. psychological) treatment options. Sometimes only one of medication or non-medication treatment will be needed, or is available; or medication may be needed first due to the severity of symptoms. Medication treatment is most effective in reducing core ADHD symptoms and non-medication treatments can provide support to minimise the daily impact of ADHD symptoms and associated difficulties.
As a child with ADHD grows up, their clinicians should plan for a smooth transition from health services for children to health services for adolescents, and later to adult health services. It is best if one person takes responsibility for coordinating between the old and new service, and collaborates with the person, their family, and all those involved in their care.
4. Non-medication treatment
What the guideline says
Non-medication treatments have value beyond improving ADHD symptoms, and can improve broader aspects of functioning for individuals and/or their families. Clinicians should offer guidance on lifestyle changes such as promoting a healthy and active lifestyle, including considering sleep patterns, as these have the potential to improve day-to-day functioning.
Parent/family training should be offered to parents/carers of children and adolescents with ADHD to support the functioning of the family and child with ADHD. Parents should be informed that the need for parent/family training does not imply bad parenting but aims to optimise parenting skills to meet the additional parenting needs of children and adolescents with ADHD. Parent/family training should be specific to the needs of parents/families with children with ADHD. A focus on individual strengths, values and interests should be balanced with any focus on challenges, for both the parent/carer and child. Parent/family training should include components of education about ADHD, environmental and behaviour modifications and information on positive parenting approaches.
Cognitive behavioural intervention approaches should be offered to adolescents and adults with ADHD. Clinicians delivering cognitive-behavioural interventions to children and adolescents should consider the developmental capabilities of the person, including their capacity to self-reflect and their awareness of, and ability to influence, their thinking processes. Cognitive-behavioural interventions should be specific to the needs of the person with ADHD. A focus on individual strengths, values and interests should be balanced with any focus on challenges. Components could include education about ADHD, environmental and behaviour modifications, and psychological adjustment and cognitive restructuring.
Making modifications in a person’s school, university or workplace can help the person with ADHD succeed. This can include physical changes or educating other people on how to most helpfully interact with the person.
5. Medication treatment
What the guideline says
Before prescribing medication to help people treat their ADHD symptoms, clinicians should carefully assess the person’s general health and should explain all the treatment options, including potential benefits and side effects. Clinicians and people with ADHD (or their parents/carers) should make treatment decisions together after discussing all relevant issues. Choice and dosage of medication must be optimised for each person.
For children aged 5 years and over, adolescents and adults starting treatment for ADHD, the first medication should be stimulants (methylphenidate [short or long acting], dexamfetamine or lisdexamfetamine), unless the person is unable to take these medications due to other health problems. The dose must be carefully adjusted for the person. The decision whether to start with short-acting or long-acting stimulant medication should be based on the individual person’s suitability. If one type of stimulant medication has not improved the person’s symptoms enough or has side effects, the other should be trialled.
If methylphenidate, dexamfetamine and lisdexamfetamine are not effective for the person, or they are unable to use these medications, second-line medications – atomoxetine or guanfacine, can be tried. In children and adolescents, clonidine is also a second-line medication that may be offered. For adults, there are third and fourth-line medications that could sometimes be helpful.
After someone has started ADHD treatment, their clinician should carefully monitor whether the medication is effective, whether there are any unwanted effects, and the person’s heart rate, blood pressure, and height and weight in children.
Parents and carers should oversee ADHD medication for children and adolescents. Adolescents should be encouraged to take responsibility for taking their medications. Sometimes, a person with ADHD, in discussion with their clinician, will decide to stop medication for a short time. This needs careful planning, and for some medications, the dose must be carefully decreased over time to avoid health harms.
Resources for clinicians
The guideline has several resources for clinicians to support clinical quality improvement in ADHD identification, diagnosis, treatment and care. You can access these resources here.
For more information please email the guideline team: email@example.com
AADPA has produced this clinical practice guideline to support the delivery of appropriate care for a defined condition. The clinical practice guideline is based on the best evidence available at the time of development. Healthcare professionals are advised to use clinical discretion and consideration of the circumstances of the individual client, in consultation with the client and/or their carer or guardian, when applying information contained within the clinical practice guideline. People with lived experience should use the information in the clinical practice guideline as a guide to inform discussions with their healthcare professional about the applicability of the clinical recommendations to their individual situation.