Guide to the subtleties of ADHD

ADHD is easy to treat, but hard to treat well, according to experts. Now a new guide for clinicians aims to make it easier to optimise care.

By Andrea Downey


It affects one in 20 Australians, yet diagnosis and prescribing for attention deficit hyperactivity disorder varies across the country, with patients often having to see multiple medical professionals before finding a treatment plan that works for them.

Professor David Coghill

This process alone can cause stress, anxiety and disengagement from care among people who may already struggle to put their health first.

But now a new ADHD prescribing guide aims to improve diagnosis and access to ADHD care by empowering medical professionals, with a practical guide for the safe and responsible use of medications and holistic treatments.

The guide, developed by the Australian ADHD Professionals Association (AADPA) – an advisory group of cross-disciplinary health professionals including pharmacists, clinicians, academics, researchers and people with ADHD – provides the most up-to-date set of protocols and advice for diagnosis and treatment.

It is a response to the Australian Evidence-Based Clinical Practice Guideline for ADHD, published two years ago, and covers topics such as diagnosis, assessment, medication choice, dosing, monitoring, adverse effects, switching, stopping, and specific populations.

AADPA board president Professor David Coghill said it was intended to complement, not replace, the clinical judgment and expertise of healthcare professionals who prescribe or manage ADHD medications.

Improving prescribing 
Dr Roger Paterson

Contributing author Dr Roger Paterson, a Nedlands-based child and adolescent psychiatrist with a special interest in ADHD, said the guide aims to standardise the quality of prescribing for patients without stifling individualised care.

“Our principal has always been that bad practice anywhere is a threat to good practice everywhere,” he told Medical Forum.

“We knew that prescribing of stimulant medications and non-stimulant ones was very variable. There’s still room for an individual clinician’s variation on a theme, but at least the theme is more standardised.”

Dr Paterson, who is also chair of the ADHD WA professional advisory board, said there is often a “misunderstanding” that if one of the stimulant treatments for ADHD – methylphenidate, dexamphetamine or lisdexamphetamine – does not work, then the other would not either.

Yet in compiling the guide the authors found it did not matter which medication a prescriber started with, as long as they were flexible to change the medication if one was not working. They also found some patients responded better to short-acting medication, whereas others had better results with long-acting medication.

Trial and error

“ADHD is easy to treat but hard to treat well, Dr Paterson said. “What that means is the clinician has to be very active initially when choosing medication, with a process of trial and error and titration of dosage to reach what is called the optimal dose.

“The danger of not doing that is you get sub-optimal treatment.”

Kate Tognarini

AADPA director, pharmacist and co-lead author Kate Tognarini also emphasises the importance of clinicians feeling confident in prescribing to help patients reach their full potential.

“When a person suspects they, or a family member, might have ADHD they are at the start of what can be a confusing and at times overwhelming journey,” she said. “This guide is another piece of the puzzle to allow health professionals to support them in the best way possible.

“The titration of the dose is really important. A lot of professionals will start stimulants or non-stimulants, and they don’t really titrate it to a dose that’s working optimally, we often are happy with any improvement.

“Getting to that perfect dose with the least side effects – that will translate to more optimised care when dealing with medication. Of course, there are all the non-pharmacological therapies that go hand-in-hand but at least this is a start.”

The guide also has advice on prescribing non-stimulant medication for those who have had an adverse reaction to stimulants, or in circumstances such as parents opting not to treat young children with stimulants. 

More than medication

While the primary focus of this guide is medication, AADPA encourages a holistic approach to the management of ADHD using a mix of non-pharmacological methods including psychoeducation, cognitive therapy and ADHD coaching.

Any interventions should balance, focusing on an individual’s strengths and include components of education about ADHD, as well as environmental and behavioural modifications, AADPA recommends.

“When the doctors do their diagnostic assessment, their number one treatment before they talk about medication is psychoeducation,” Dr Paterson said.

“You’ve got to explain to the patient what they’ve got and how it’s best treated, and that’s usually a combination of medication and non-medication treatments such as counselling or coaching.”

Ms Tognarini, who was diagnosed with ADHD at the age of 47, said that pills do not teach skills, though they make the implementation of strategies a lot easier.

“Medications target the core symptoms of ADHD – things like planning and organisation – the holistic or non-pharmacological strategies are things like working with a counsellor or coach to put strategies in place so that the medication is then working a lot better,” she said.

Lived experience

A person’s lived experience of ADHD is vital in helping doctors understand their patients. To support this understanding, the guide includes examples of lived experience.

Perth-based contributing author and appointed director on the AADPA board Lou Brown shared her own experiences of ADHD in the guide. She said her diagnosis at the age of 47, after her son was also diagnosed, changed her life.

“When I first took medication, it was like I could pause, stop and think for the first time,” she told Medical Forum.

“I said to my partner ‘What is this? It’s like this space to think where I could consider my options and make a decision’. It had never been there before.

“But I actually didn’t know what to do in that situation because I had never learned, I had never been able to stop and think and have the ability to regulate my attention.”

After her son’s diagnosis, she became so anxious about his future due to her own negative experiences that she found it difficult to leave the house. Without holistic interventions, her experience today would be very different.

“I went to counselling to help accept that, and I did a coaching course. I also have some really good friends who I could speak to and ask, ‘What would you do in this situation?’ or ‘Could you explain this to me?’.” 

Ms Brown, who is now an ADHD coach, said she often hears from people who have different experiences of prescribing.

“There can be expectations that medication takes all symptoms away and makes everything feel like normal but someone who has ADHD is likely to never be neurotypical, and that’s OK,” she said.

“Medication is just one support strategy that you can use to work out how to live successfully with ADHD. 

‘If someone is just given medication and all those other things aren’t addressed you can feel like a failure because you’re taking your medication but you’re not perfect.”

Put into practice

So, what can doctors and prescribers take away from the guide? 

Firstly, the treatment of ADHD is never a one-size-fits-all approach, every patient is unique, and treatment needs to reflect their own lived experiences and areas they feel treatment can enhance their life.

Dr Paterson said that initially it was going to help specialists – the psychiatrists and paediatricians who are doing most of the diagnostic assessments and early titrations because they do not get a lot of training in ADHD when they are registrars.

“It’s going to be useful for them to flick through particular topics of interest, starting with medication and titration and then how to deal with certain situations, side effects, unusual developments,” he said.

“But it’s also going to be very useful to GPs who are going to be very new to co-prescribing, because more and more the specialists are stabilising the patients then asking the GP to get involved to a certain level.”

Ms Tognarini hopes the guide will have far-reaching benefits for patients.

“One is to get more prescribers confident in prescribing in this area and hopefully that will improve access Australia-wide,” she said.

“Hopefully more GPs will be comfortable getting into this area and working in co-share arrangements with psychiatrists or paediatricians to manage all of the medication questions that can come up.”

But while it will be a useful resource for the pharmacological and non-pharmacological treatment of ADHD, Ms Brown emphasised the importance of compassion in care.

“The language used around medication and ADHD can empower or it can crush,” she said.

“Treat people with compassion, empathy and understanding and do not look at them as a group of symptoms that need to be addressed or removed.

“You can have doctors who will give you medication and all they’re focusing on is assessing your symptoms, but you need a holistic approach, it also needs to be about what the person with the condition wants to achieve.”

AADPA hopes that the guide will serve as a first step toward national prescribing standards for ADHD medications and improve the quality and consistency of care for people with ADHD and their families.

It eventually plans to translate the guide into a smaller patient resource. 

Find the guide here: aadpa.com.au/product/adhd-medication-prescribing-guide/


What the guide says on changing medication for optimal results

It is advised that when switching from one formulation of methylphenidate to another, the prescriber matches the immediate release dose across the different formulations.

There is no way to calculate a dose equivalence between dexamphetamine and lisdexamphetamine. This means that it is not possible to predict the dose of one based on response to the other.

For people who require higher doses for optimal treatment, guidelines often overlook the potential for conflict between adhering to a maximum dose and the principle of establishing the optimal dose by titration. 

Clinicians who are experienced in dose titration may feel confident in choosing to continue dose titration into a higher dose range than is officially sanctioned, particularly when the alternatives may be suboptimal treatment.

Examples of non-medication interventions:
  • Lifestyle changes

Lifestyle factors include diet, exercise or activity levels, and sleep patterns. Lifestyle changes have the potential to improve day-to-day functioning for people with ADHD.

  • Education about ADHD (psychoeducation)

This ensures people diagnosed with ADHD are told what their diagnosis means, common difficulties arising from ADHD, common strengths, increased health risks associated with ADHD such as anxiety, depression and substance misuse, and possible impacts on relationships, school and the workplace.

  • Parent-family training

This aims to help parents meet the additional needs of children and adolescents diagnosed with ADHD and may look at the effects of the diagnosis on the child and the whole family.

  • Cognitive Behavioural Interventions

This is a broad range of approaches that use cognitive or behavioural interventions to minimise the day-to-day impacts of ADHD. This usually includes environmental modifications, behavioural modifications, and psychological adjustment and cognitive restructuring. Environmental modifications involve adjusting home, school, work or social settings to maximise success.

Behavioural modifications may include strategies to help compensate for cognitive difficulties and improve social communication, while psychological adjustment can help people develop skills such as problem solving and managing stress.

Source: Australian Evidence-Based Clinical Practice Guideline for ADHD Factsheet