Appendix 3 - Proposed 'best practice' pathways for ADHD support

Appendix 3Proposed 'best practice' pathways for ADHD support

1.1The committee sought advice from specialist health and attention deficit hyperactivity disorder (ADHD) lived experience organisations about what a 'best practice' approach might look like, for all stages of assessment and treatment—from initial assessment and diagnosis, through to medication (as required) and other treatment, as well as ongoing support and treatment plans.

1.2This appendix includes flow diagrams, tables and other information provided in response to the committee's request.[1]

1.3ADHD Western Australia (WA) provided the committee with 'best practice' pathways for both adults and children with ADHD, as shown in Figures 3.1 and3.2. These pathways allow for both self-referral and general practitioner (GP) referral pathways, as well as wraparound services such as therapy and coaching, plus support for parents of a child with ADHD.[2]

1.4The ADHD Foundation also had a vision for more integrated, supportive and nuanced care, depending upon the level of need of the patient, as shown in Figure 3.3. It recommended the ongoing care of patients who are stable be transferred to GPs. The Foundation noted it 'sourced information internationally where other countries are also developing better understanding and best practice for those with ADHD' and based on client experiences presented the below patient experience flow chart.[3]

1.5The Australian College of Mental Health Nurses outlined its vision for improving access to services in primary health, through greater roles for Nurse Practitioners – Mental Health (NP—MH), and Credentialed Mental Health Nurses (CMHN), across all stages of a person's ADHD journey, as shown in Figure3.4 below.[4]

1.6The Royal Australian and New Zealand College of Psychiatrists emphasised to the committee that the Australian ADHD Professionals Association's (AADPA) Australian evidence-based clinical practice guideline for ADHD (Clinical practice guideline) is the best practice pathway for people with ADHD. It emphasised the importance of assessment, diagnosis, treatment and management occurring 'in a holistic, multi-disciplinary framework that incorporates the mental and physical health of the consumer. Care should be administered within a framework of trauma-informed and person-centred culturally appropriate care'. It also advised that information sharing between healthcare professionals and the individual and their family and carers should be paramount. Significantly, the pathway proposed by the college proposes that support be provided to people who do not receive an ADHD diagnosis (unlike other models).[5]

1.7The Royal Australian College of General Practitioners WA ADHD Working Group highlighted the need for an increased role for GPs in the coordinated care of people with ADHD, in order to provide accessible, person-centred, comprehensive care, particularly given healthcare workforce shortages. It noted, 'increasing specialist care is not only unrealistic but is likely to be unaffordable’ and pointed to the 'mainstreaming' of ADHD care in overseas jurisdictions. It discussed the importance of upskilling GPs, and the importance of funding and prescribing arrangements to facilitate this model. The working group referred to the Canadian ADHD Resource Alliance flow chart (for treating adults) as shown in Figure 3.6, and identified the clinical flow as follows (with some steps not relevant to some patients):

(a)Awareness-raising, especially amongst higher-risk groups

(b)Patient navigation to interested provider

(c)Brief risk assessment

(d)Comprehensive assessment

(e)Assessment for co-morbidities

(f)Diagnosis and recommendations

(g)Psycho education

(h)Discussion and shared decision making of treatment options

(i)Initiation of medication treatment

(j)Initiation of non-medication treatments

(k)Allied health or education supports – coaching, learning and teaching accommodations

(l)Review and Monitoring

(m)Family supports

(n)Specialist referral – referrals for opinions or ongoing care.[6]

1.8The Department of Health WA is considering a proposal to support greater involvement of GPs in the diagnosis and care of ADHD in children and adults, with the GPs to upskill and work alongside specialist paediatricians and psychiatrists. A simplified representation of the pathway is shown in Figure 3.7. However, the department noted that barriers including lack of Medicare funding, the need for agreed accredited education and training, and changes to prescribing regulations need to be addressed. Information provided by WAHealth also includes an analysis of issues and improvements to models of care for children and adults.[7]

1.9The Institute for Urban Indigenous Health (IUIH) provided further information about what it considers to be a best practice approach for ADHD assessment and treatment for Aboriginal and Torres Strait Islander peoples, with different pathways for adults, and children and adolescents, with care provided through primary healthcare clinics.

1.10The institute recommended that a greater range of healthcare professionals be trained and enabled to assess, diagnose and provide long-term care for ADHD, that culturally safe clinicians and culturally appropriate approaches be used to provide holistic care. It further recommended that First Nations children under six years should be able to access an early intervention support package through the National Disability Insurance Scheme, given their higher needs.[8]

1.11The IUIH's current protocols for ADHD are as follows in Figures 3.8 and 3.9.

Figure 3.1A child's ADHD diagnosis journey

Flow diagram from ADHD WA showing a child's ADHD diagnosis journey from initial symptoms to referral, assessment, diagnosis, support and treatment

Source: ADHD WA, answer to written question on notice, 12 August 2023 (received 27 September 2023).

Figure 3.2An adult's ADHD diagnosis journey

Flow diagram from ADHD WA showing an adult's ADHD diagnosis journey from initial symptoms to referral, assessment, diagnosis, support and treatment

Source: ADHD WA, answer to written question on notice, 12 August 2023 (received 27 September 2023).

Figure 3.3Visualisation of ADHD patient flow

Flow diagram from the ADHD Foundation showing the visualisation of an ADHD patient's ADHD diagnosis journey from initial symptoms to referral, assessment, diagnosis, support and treatment

Source: ADHD Foundation, answer to written question on notice, 12 August 2023 (received 27 September 2023).

Figure 3.4ADHD Expert NP – MH and CMHN access

Pathway from the Australian College of Mental Health Nurses showing an increased role for ADHD expert nurse practitioner - mental health and credentialed mental health nurses, from initial awareness to diagnosis and ongoing management

Source: Australian College of Mental Health Nurses, answer to question on notice, 12August 2023 (received 28September 2023).

Figure 3.5Pathway flow chart

Pathway from the Royal Australian and New Zealand College of Psychiatrists showing journey from identification of ADHD through to diagnosis, holistic care and ongoing support, based on the AADPA Clinical practice guideline.

Source: Royal Australian and New Zealand College of Psychiatrists, answer to question on notice, 12 August 2023 (received 28 September 2023).

Figure 3.6Canadian ADHD Resource Alliance ADHD diagnosis and treatment for adults