The Australian Clinical Practice Guideline for ADHD: A Summary for Clinicians

A community-based cohort study tracking children with ADHD from age 7 to age 10 found that ADHD was associated with poorer academic functioning, poorer emotional and behavioural functioning, poorer social functioning, and higher rates of co-occurring internalising and externalising mental health disorders compared to children without ADHD. [Efron et al., 2020]; [Zendarski et al., 2022]

• A diagnosis of ADHD should not be made solely based on rating scales or observational data.
• Observations from more than one setting and reporter (e.g. a teacher, in the case of children) should be used to confirm if symptoms, function and participation difficulties occur in more than one setting.
• ADHD should be considered a possible diagnosis in all age groups, including adults over 65 years.
• Consider the varied presentations of ADHD. [See red flags in adults]
• Children and adults may not present with the most visible symptoms of hyperactivity/impulsivity. [See gender differences]
• Inattentive symptoms may not be identified until secondary school (or later), following increased demands for organisation and independent study or work.
• Individuals may have developed compensation strategies that may mask symptoms.
• Neuropsychological testing is not required to diagnose ADHD. A review by  The Canadian ADHD Resource Alliance Advisory Council (CADDRA) found no other strategies achieved additional benefit beyond that of clinician interview in combination with rating scales.
• Direct observations such as observing children in their educational setting, neuropsychological and psychoeducational assessments, computerised cognitive assessments, neuroimaging and electroencephalography (EEG) did not increase the accuracy of diagnosis.

Indications for Psychometric/neuropsychological evaluation:

• Identifying differential and co-occurring conditions when there is diagnostic uncertainty.
• Identifying specific language and learning disorders.
• Assistance with treatment planning and identifying and targeting intervention strategies to specific domains based on the cognitive strengths and challenges of the person.

Recommended Screening Scales:

Young children:

• Achenbach System of Empirically Based Assessment – Attention Problems scale
• Child Behaviour Checklist DSM Oriented ADHD subscale

Children and adolescents

• Achenbach System of Empirically Based Assessment – Attention Problems scale
• Child Behaviour Checklist – DSM Oriented ADHD subscale
• Strengths and Difficulties Questionnaires (Hyperactivity subscale)
• Conners’ 3 short form
• Swanson, Nolan and Pelham (SNAP) scale
• ADHD Rating Scale 5
• Vanderbilt ADHD Diagnostic Rating Scale

Adults

• WHO Adult ADHD Self Report Scale (ASRS) (Part A)
• Conners’ Adult ADHD Rating Scale – Short
• Wender Utah Rating Scale (WURS) – Short

Recommended Diagnostic scales

Young children

• Achenbach System of Empirically Based Assessment – Attention Problems scale
• Child Behaviour Checklist – DSM Oriented ADHD subscale
• Brown Attention Deficit Disorder Symptom Assessment Scale (BADDS)

Children and adolescents

• Vanderbilt ADHD Diagnostic Rating Scale
• Conners’ 3
• Swanson, Nolan and Pelham (SNAP) scale
• ADHD Rating Scale 5
• Brown Attention Deficit Disorder Symptom Assessment Scale (BADDS)

Adults

• WHO Adult ADHD Self Report Scale (ASRS) (Part A + B)
• Conners Adult ADHD Rating Scale
• Wender Utah Rating Scale (WURS)
• Brown Attention Deficit Disorder Symptom Assessment Scale
• Barkley Adult ADHD Rating Scale-IV

Rule out medical conditions: 

• Sleep disorders
• Hearing or vision impairment
• Thyroid disease
• Anaemia
• Epilepsy
• Acquired brain injury
• Foetal alcohol spectrum disorder
• Medications: Cognitive dulling (e.g., SSRIs, anticholinergic medications, mood stabilisers), psychomotor activation (e.g. decongestants, asthma medication, non-prescribed stimulants like caffeine).

Psychiatric Comorbidities:

Read in detail: ADHD and Comorbidities – Management Principles

Children and Adolescents with ADHD:

The most common co-occurring disorders are:

• Oppositional defiant disorder
• Language disorders
• Autism spectrum disorders
• Anxiety disorders
• Depressive disorders
• Substance use disorders emerging in adolescence.
• Specific learning disorders ( involving reading, written expression or mathematics difficulties).

For adults with ADHD, the most common co-occurring mental health disorders are:

• Depressive disorders
• Bipolar disorders
• Anxiety disorders
• Personality disorders
• Substance use disorders
• Medical conditions (see above)

General principles of management 

Read more on non-pharmacological strategies in ADHD.  

Lifestyle measures: 

• Diet
• Exercise or activity levels.
• Sleep patterns

Clinicians should offer guidance on lifestyle factors to help people with ADHD, including:

• Asking about sleep, offering strategies, and/or a referral to assist with sleep if indicated. [Diagnosis and Management of Insomnia]
• Individuals with ADHD have high rates of comorbid sleep disorders. Primer on Neurobiology and Neuropsychiatry of Sleep – Application to Clinical Practice
• Asking about diet and physical activity levels and offering strategies and/or referrals to assist with any challenges if needed.

Cognitive Behavioural Interventions: 

The term refers to a broad range of approaches that use cognitive and/or behavioural interventions to minimise the day-to-day impact on functioning from ADHD symptoms.

• Can reduce ADHD symptom severity indirectly
• Can impact broader functioning and wellbeing
• Cognitive-behavioural interventions can be offered to children with ADHD.
• Cognitive-behavioural interventions should be offered to adolescents and adults with ADHD.
• Younger children may benefit from a foundational focus on emotional literacy, proactive help-seeking, problem-solving and self-esteem growth.
• Children approaching adolescence may benefit from simple behavioural techniques. Through adolescence, increasingly sophisticated behavioural and cognitive restructuring techniques may be of benefit.

Adults :

• Interventional strategies include adjusting the environment (home, school and/ or work, social settings) to maximise the chances of success for the person with ADHD.
• Preventing or removing challenges likely to result from ADHD symptoms or enabling increased use of personal strengths and interests.
• Assisting the person to understand and recognise the impact of ADHD symptoms on their day-to-day lives:
• Cognitive processes involved in symptom experiences.
• Symptom fluctuation and difficulties due to external and environmental factors, e.g. stressors, sleep, exercise and hormones (for women), and relationships.
• Positive and negative impacts of compensatory measures and coping strategies the person has developed over time.

Parent and Family Training for Parents/families of young children with ADHD: 

Under 5 and 5-17:

• More intensive parent/family training programs should be offered to parents/families of children with ADHD who have a co-occurring oppositional defiant disorder or conduct disorder.
• Modifications can be designed and/or implemented by the person with ADHD or others in a supportive role. They can involve modifying: expected tasks and routines and the surrounding physical space, including its sensory elements.
• Communication and engagement strategies for others living with the person with ADHD.

Read medication management in detail. 

Prescribing for children and adolescents:

• Paediatricians and child psychiatrists may prescribe for persons under 18 years of age.

Prescribing for adults:

• Psychiatrists are primarily authorised to prescribe psychostimulants.
• In some circumstances, such as in regional/rural settings with no access to specialists, a general practitioner with appropriate training and authorisation may be authorised to initiate psychostimulant medication.

Medication management: 

Individuals with ADHD should be referred for a cardiology opinion before commencing stimulant medication if any of the following is present:

• History of congenital heart disease or previous cardiac surgery
• History of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
• Shortness of breath on exertion
• Fainting on exertion
• Palpitations that are rapid, regular and start and stop suddenly
• Chest pain suggesting a cardiac origin
• Heart murmur (not including innocent heart murmurs in children)
• Hypertension.

Principles of medication management in children:

• If ADHD symptoms cause significant impairment in more than one setting, a specialist with expertise in child development and treatment of ADHD in young children (either a paediatrician or a child psychiatrist) should assess the child to identify suitable treatment options.
• Medication should be used cautiously and monitored closely in children under 5 years.
• First-line medication for children aged 6 years and over should be stimulants.

Principles of medication management in adolescents and adults:

Methylphenidate, dexamphetamine, or lisdexamfetamine should be offered as the first-line pharmacological treatment for people with ADHD, where ADHD symptoms are causing significant impairment.

The decision to start with a short or long-acting stimulant formulation should be based on a clinical decision, together with the wishes of the person with ADHD or their parent/carer/family, by considering the advantages and disadvantages of each. For example:

• Short-acting formulation may be preferred when close monitoring is required
• Long-acting formulation may be preferred for convenience or when there is a medical contraindication
• Consideration of any potential cost implications

Modified-release once-daily preparations could be offered for any of the following reasons:

• Convenience
• Improving adherence
• Reducing stigma by removing the need to take medication at school or in the workplace
• Reducing problems of storing and administering controlled drugs at school or work
• Risk of stimulant misuse and diversion with immediate-release preparations
• Pharmacokinetic profile offers an advantage for symptom improvement.
• To extend the duration of effect: Short-acting and long-acting stimulants could be offered together to optimise the effect (e.g. a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of the effect). Consider risks if medications are used in combination.
• Some short-acting stimulants contain gluten and/or lactose; a long-acting preparation free of these should be used in someone with gluten or lactose intolerance.

Evidence-based stimulants available in Australia:

• Short-acting: Immediate-release Methylphenidate (Ritalin) or Dexamfetamine (dexamphetamine). 
• Long-acting: Modified-release Methylphenidate (Ritalin LA, Concerta XR) or lisdexamfetamine (Vyvanse). 

Indications for atomoxetine or guanfacine in adults with ADHD:

• Stimulants are contraindicated
• Cannot tolerate methylphenidate, lisdexamfetamine or dexamfetamine
• Symptoms have not responded to separate trials of dexamfetamine or lisdexamfetamine and methylphenidate at adequate doses.
• The clinician considers that the medications may be beneficial as an adjunct to the current regimen.

Clinicians should apply the same recommendations and principles of prescribing for adults over 65 years as for adults below 65, with careful monitoring of side effects.

Management of specific situations: 

Addressing reduced growth rate in children or adolescents: 

• Consider a planned break in treatment over school holidays to allow ‘catch-up’ growth
• Switch to alternate medication
• Consider non-medication causes.

• Treatment approaches for co-occurring conditions should follow best-practice guidelines for each co-occurring condition but with treatment delivery methods adjusted to account for ADHD symptoms.
• ADHD and Comorbidities – Management Principles

ADHD in the correctional system:

• Screening and assessment processes should be established to identify the presence of ADHD and co-occurring conditions
• Custodial staff and those within the criminal justice system (e.g. police, magistrates) should receive ADHD awareness training.
• Treatment in custodial settings should include pharmacological and non-pharmacological approaches equivalent to the treatment available in the community.
• Prisons should establish safe processes for administering long-acting stimulant medications to those with ADHD (similar to administering other controlled drugs and ensuring the safety of the person in prison receiving stimulant medication).
• Before administering stimulant medication, specific screening for comorbid substance use disorders should be undertaken.

There is now greater recognition of the importance of a timely diagnosis and management of ADHD across the lifespan.

There continue to be barriers and challenges in accessing treatment in the Australian setting.

The guidelines recommend the following changes at a systemic level:

• Funding should be made available to expand services for people with ADHD  to deliver timely and accessible assessment, support and intervention, and an ADHD helpline accessible to all Australians.
• Laws and regulations for prescribing ADHD stimulant medications and shared care should be uniform between the states and territories in Australia.
• Training should be available for all clinicians working with people with ADHD.
• Further ADHD research is needed to understand many aspects of ADHD better and to improve the quality of life for people living with ADHD.