ADHD -Diagnosis, management, medications & ongoing care.

The prescription of Stimulant medication for ADHD and ADD is Government-regulated. A Specialist Paediatrician or Psychiatrist can make or confirm a diagnosis under the DSM 5 and prescribe stimulant medications for children and adolescents. A specially accredited GP can also diagnose and prescribe for ADHD for paediatric patients from the age of 8 years. Other non-accredited GPs are able to prescribe stimulant medications in accordance with a medication plan established by a paediatrician, psychiatrist or ADHD accredited GP.

Diagnosis- options

Diagnosis involves a standardised assessment over several lengthy appointments and the consideration of standardised questionnaire responses from parents, the school, or the child carer. If old enough, the patient’s responses will also be evaluated.

A psychologist can consider differential mental health and learning diagnoses and conduct a standardised diagnostic assessment for ADHD. They can provide a report and therapy and recommend supports or referral for medication. Their report will inform the paediatrician’s, psychiatrist’s, or accredited GP's diagnosis and medication recommendations.

Paediatricians, psychiatrists and accredited GPs can also conduct this standardised diagnostic assessment. They will also want to consider other differential mental health and learning concerns and may wish to refer your child to a psychologist for assessment of these.

Establishing, managing and reviewing a medication plan.

Medication management and review are conducted by Paediatricians, Psychiatrists, and, for children aged 8 years or older, accredited GPs.

Where a presentation is complex, an accredited GP may refer the child to a paediatrician or psychiatrist for diagnostic assessment and/or a medication plan.

When establishing or reviewing a medication plan, the specialist will need to review further standardised questionnaire feedback from the parent, school and, if old enough, the patient. The medication plan may need to be reviewed following the young person's growth and development, or when the benefits diminish or significant side effects emerge.

Some children and adolescents with complex and significant mental health concerns may benefit from management with a child psychiatrist instead of a paediatrician.

Establishing or changing the Medication Plan.

The regulations require a trial of therapy before prescribing Stimulants. While a management plan is being worked out, a number of appointments may be needed.

Renewing prescriptions under the Management Plan

Prescriptions are issued under a State Regulatory Authority. The Authority is usually held by the paediatrician, psychiatrist or accredited GP. Once a medication plan is established and stable, a non-accredited GP can prescribe medications in accordance with it. Some GPs are happy to do this and may also be happy to apply for Authority and “take it over” from the specialist.

Your child’s paediatrician, psychiatrist or GP may renew the script every 6 months if the medication is benefiting the child sufficiently and they are satisfied regarding their growth, blood pressure, side effects and that there are no significant adverse effects.

Hence, appointments are needed at least every 6 months for this necessary review for script renewals.

Other therapy and diagnostic considerations: the role of Allied Health

GP or self-referral to a Psychologist or Occupational Therapist:

A GP referral is not required. However, your GP may be able to write a referral that allows some Medicare rebates for therapy and mental health investigations. Discuss the possibility of a Mental Health Care Plan referral or a Team Care Plan referral. Medicare does not provide rebates for formal diagnostic assessment of ADHD, learning and cognition in the absence of mental health investigations.

Audiology and auditory Processing - a differential diagnosis that may need exploring with an Audiologist and ENT Specialist. Consider a GP referral to an ENT Specialist as ENT specialist referral to an Audiologist allows access to a rebate. Referral to an Audiologist can be by self-referral or under a Team Care Plan.

Paediatrician assessment and management-more details

The First Paediatrician Assessment Appointment (or several appointments)

When your child is referred to a paediatrician for concerns about Attention Disorder (ADHD/ADD), the paediatrician will conduct a general paediatric assessment to consider

• your child's emotional, cognitive, social and physical development and also whether there are medical concerns; 

• your child's sleep, nutrition;

• behavioural patterns and concerns;

• indications or diagnoses of Attention Disorder or other developmental or neurodiverse conditions such as ASD;

• any reports or diagnoses regarding ADHD/ADD from another provider.

The paediatrician will ask you and the child about your child's and family's medical and developmental history, as well as the child's history and patterns of behaviour, symptoms, and difficulties. 

They will consider other conditions that can look like ADHD/ADD but may require different management.

This may take several appointments.

Your child may need some blood tests or other investigations.

Sometimes a child is referred to a clinical psychologist for assessment of learning and cognition, or for assessment and therapy for mental health concerns such as anxiety, trauma, or attachment.

If your paediatrician considers further investigation of ADHD (or ADD) appropriate,  they will give you some questionnaires for you and your child's teacher to complete. Older children and adolescents should also complete a questionnaire. Input is needed from at least two domains, such as from home (by parents) and from school, kindy or childcare (by a teacher who knows the child well in that non-home setting.

The paediatrician will then ask you to book another appointment in a month or so.

Most paediatricians will write to your GP to update them on their assessment and progress.

Next stage of the assessment

Your paediatrician will review any allied health reports, test results, and evaluate the questionnaire feedback. This may lead to a provisional or confirmed diagnosis of ADHD and/ or other concerns.

Managing Attention Disorders:

The specialist will recommend or review a management plan that may include:

• Psychological or Occupational Therapy;

• Improving sleep behaviours, perhaps including with medication;

• Other therapies or assessments;

• Watch and wait to see if your child improves;

• A trial of short-acting stimulant medication or Vyvanse as per PBS prescribing rules;

• A trial of another Medication, such as for anxiety or nutritional supplementation;

• Letters to the school about the diagnosis or about medications, etc.

• Further questionnaires at a later date to assess how the management and therapies are helping your child;

They will normally write a Letter to your GP to advise of their progress with diagnosis and management.

A review appointment may be required to assess progress with behavioural management.  

If starting a trial of stimulant medication or other medications, the paediatrician (or psychiatrist) will need to review your child's progress with the medication in about 2 to 4  weeks to consider:

• Is the medication helping?

• Are there side effects?

• Dose changes or trialling a different medication.

• The benefit of taking an extra dose at lunchtime.

• If they have responded well to short-acting stimulant medication, would a change to long-acting doses of the medication be helpful?
  

A further specialist Review Appointment is then needed in about eight weeks.

This appointment is face-to-face. Stimulant medication can cause difficulty maintaining appetite, so your child’s weight and growth will be checked.  Other possible side effects of medication are monitored, including by checking your child's blood pressure. Is the medication helping significantly? Are side effects a concern? Together, you and the paediatrician may be happy to proceed with that medication or consider other medication or therapy options.

Once medication management stabilises, and if this is with stimulant medication, your child will need to attend review appointments. These will be at least every six months with their paediatrician (or psychiatrist) or their GP to

• to review your child's progress and the effectiveness of the medication

• monitor for any concerning side effects.

• to obtain a repeat prescription of the medication.

The medication plan will need review

• probably every 12 months or so

• when medication effectiveness declines or concerns about management re-emerge

• in response to growth and development.

Management of ADHD and ADD with stimulant medication involves a commitment to at least six monthly face-to-face review appointments with your prescriber. These appointments should be timed to allow script renewal before the previous prescription runs out.

Older adolescent patients

Once a young person turns 18 years of age, the prescription authority for stimulant medication should be transferred to a psychiatrist or their GP. They must be reviewed by their psychiatrist and GP from time to time, as required by Government regulations.