ADHD clinical practice guidelines ‘long overdue’

There is a growing concern among clinicians that many people – predominantly children, but also adults – are not receiving the care they require for both diagnosed and undiagnosed attention deficit hyperactivity disorder (ADHD).
 
Dr John Kramer, Chair of RACGP Specific Interests ADHD, ASD and Neurodiversity, is part of the ADHD Guidelines Development Group. He told newsGP that new guidelines are ‘long overdue.’
 
‘It’s 20 years since there’s been any official guidelines in Australia for the management of ADHD and, in that time, much greater awareness of the condition has developed,’ Dr Kramer said.
 
‘Therefore, more people are being diagnosed – the instances haven’t gone up, we’re just getting better at spotting it.’  
 
Despite this growing awareness, Dr Kramer concedes that there are many people in the community still undiagnosed.
 
One of the major challenges is that patients are unable to access paediatricians or psychiatrists.
 
There are typically long wait times and cost barriers for many people looking to access these services privately. These issues are further exacerbated in rural and regional areas.
 
To help ease some of the access issues, a recent RACGP submission highlights ‘a significant need for GPs to be better supported to play a greater role in this area [of diagnosis]’.
 
But part of the problem, according to Dr Kramer, is that ADHD is ‘barely taught’ at university.
 
‘Doctors, nurses, OTs [occupational therapists] and speech pathologists have very little exposure to ADHD in their undergraduate courses, so they come out without any specific knowledge,’ he said.
 
‘Sadly, the same applies to postgraduate study in paediatrics, psychiatry, and general practice too.
 
‘There’s very little material out there on the subject of ADHD and all the other conditions that go along with it.’
 
The RACGP’s submission echoes the ‘need for GPs to be able to access appropriate education and training’.
 
‘There’s a fair bit of reform needed in public mental health services,’ Dr Kramer said.
 
‘When you talk to GPs around the country – and it’s not just in relation to ADHD, it’s in relation to all mental health services – there’s a lot of deficiencies in public mental health.
 
‘GPs are not typically involved. The one exception is clozapine patients, and I think that’s because public mental health had so much to do with schizophrenic patients. They needed someone else to help with the workload, so GPs stepped up.’
 
Such a model, whereby GPs do some extra training around managing patients with chronic mental health conditions to help meet the demand, is one of the suggestions the guidance development group is working through.
 
A major barrier to achieving more GP involvement remains the lack of consistency across the states and territories – a concern also raised in the RACGP’s submission.
 
‘Regulatory barriers also need to be addressed as there are limitations in different states and territories regarding stimulant prescribing,’ the submission states.
 
‘Shared-care arrangements should also be supported, in the form of clinical protocols and funding systems, so GPs can access timely assistance from paediatricians and psychiatrists to support diagnosis and management, and mitigate risk of both over- and under-treatment.’
 
Dr Kramer says an example of shared-care arrangements can be found in Queensland, where GPs can prescribe stimulants for children if they have been assessed by a paediatrician in the past.
 
‘[The patient’s] management can be handed over to a GP that’s willing to take it on,’ he said.  
 
‘But a lot of GPs feel uncomfortable doing that. So, I guess another of our aims is to make GPs feel less uncomfortable because if they can take on some of that workload it’s going to be good for the patients because they’re being managed within their medical home.’  
 
Dr Kramer also stresses that treatment of ADHD needs to be multimodal.
 
‘The idea of pharmacological treatment versus non-pharmacological treatment is a bit of a myth because you never do one or the other absolutely. You do a mixture of things,’ he said.
 
‘If a child has a milder form of ADHD – say, if it’s affecting their learning predominantly, rather than their behaviour and they’re not developing any mood disorders or anything like that – you probably wouldn’t be using medication.
 
‘But you would be arranging these other assessments – speech, OT, etc – because you need to see what else is holding the child back.
 
‘One of the important things to remember about ADHD is that comorbidities are the norm. In other words, if you think a child has ADHD, the job’s only half done.
 
‘You’ve got to keep looking until you find out what else there is. It might be a specific learning difficulty, things like dyslexia, it might be other behavioural things, like oppositional defiant disorder, or sometimes they will have autism.’
 
Since it’s young children who commonly present with ADHD, the RACGP submission recommends that ‘guidance for GPs on management options in addition to that for medication choice would be useful’.
 
‘This is especially important for GPs in rural and remote area where access to other specialists is limited,’ the submission states.
 
The public commentary period on the guidelines has recently concluded. The ADHD Guidelines Development Group is currently processing the submissions and will meet to discuss in the coming weeks.
 
The new clinical practice guidelines will then be presented to the National Health and Medical Research Council.
 
Dr Kramer said the Guidelines Development Group is hoping they’ll be approved and released around July or August.
 
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