Wed Oct 5

ADHD medications have doubled in the last decade – but other treatments can help too

Written by David Coghill, Financial Markets Foundation Chair of Developmental Mental Health, The University of Melbourne

A recent detailed analysis of prescribing trends for ADHD medications in Australia found prescriptions for ADHD medications doubled ^[1] from 2013 to 2020. While this is clearly an important finding, it needs to be considered within the context of overall rates of prescribing, the recommendations of guidelines and, importantly, the prevalence of ADHD.

ADHD stands for attention-deficit hyperactivity disorder. About 5% of children and adolescents and 2.5% of adults worldwide have ADHD ^[2]. While ADHD is a neurodevelopmental disorder that generally begins in childhood, the symptoms and/or difficulties associated with the disorder continue ^[3] into adolescence and adulthood.

In Australia, and many countries outside of North America, ADHD is still under-diagnosed in childhood. This means that for many, ADHD will be first diagnosed in adulthood.

International ADHD guidelines ^[4] list medications as the most effective approach to reduce core ADHD symptoms. But non-medication treatments can provide additional support to minimise the daily impact of ADHD symptoms.

So, what is ADHD?

The main features of ADHD are having real and substantial difficulty keeping attention and focus (particularly for activities that aren’t of high interest), poor organisational skills, forgetfulness, impulsivity (making decisions before thinking) and overactivity (restless, fidgety, always on the go).

We all experience some of these symptoms from time to time, but for those with ADHD, these symptoms are experienced at a high level most of the time, and impact negatively on daily life. ADHD is not new; reports of the condition we now refer to as ADHD can be traced all the way back to the 1700s ^[5].

Why are prescriptions for ADHD medication in Australia increasing?

Current ADHD guidelines ^[7] recommend medication as a first line treatment for ADHD. It would therefore not be surprising to see rates of prescription increasing, as as recognition improves and the rates of diagnosis track more closely with actual rates of ADHD.

Current data ^[8] suggest around 4% of children and adolescents are being treated for ADHD, which is reasonable considering a prevalence of around 5%.

For adults, however, the rates are much lower, around 0.4%^[9]. This means that fewer than one in five adults with ADHD are currently receiving ADHD medication. While this is an improvement on 2013 – when the rates were less than half of this – there is clearly some way to go.

What are the main medications for ADHD?

Several medications have been shown to be very effective at reducing ^[11] the core symptoms of ADHD in children, adolescents and adults.

Medications which are stimulants such as methylphenidate, dexamfetamine and lisdexamfetamine are now considered to be the first line ^[12] medications for ADHD. These medications are thought to work by increasing the efficiency in several key brain circuits through their action on the neurotransmitters dopamine (the chemical in the brain that makes you feel good) and noradrenaline (the chemical that when released increases alertness and attention). The effects of these medications are rapid and can be seen almost immediately ^[13].

Two non-stimulant medications are licensed for the treatment of ADHD, atomoxetine and guanfacine. The non-stimulants are less effective than the stimulants and typically take several weeks to have a clinical effect. For these reasons they are generally reserved as second line ^[14] treatments.

ADHD medications are not easy to obtain. They can only be prescribed to people who have received a diagnosis of ADHD. For many people this can be a long process due to a shortage of properly trained clinicians. Current guidelines require ADHD be diagnosed by a health professional who has experience ^[15] in the area such as a paediatrician, psychiatrist or psychologist.

The diagnostic process for ADHD should involve a detailed clinical history that explores when the symptoms started and how they impact on daily life. As part of the assessment of ADHD in children, information should be collected from parents and school. For adults seeking a new diagnosis, there is a need for evidence of symptom onset in childhood. This may involve the health professional reviewing old school reports or speaking with the adults’ parents.

What other non-medication supports should be offered?

Supports will differ for children/adolescents and adults. Regardless of age, modifications to the environment should be considered to best support the person. This could involve making modifications to the environment at school or in the workplace for adults.

Sleep deprivation can exacerbate the symptoms of ADHD and so lifestyle modifications may be considered to help reduce the impact of ADHD such as getting a good night’s sleep ^[17] and regular physical activity. Most people with ADHD also have one or more additional mental health difficulties (such as anxiety or depression ^[18]). These additional challenges need to be considered when planning treatment and supports.

For children with ADHD, the main evidence-based non-medication support that can be offered is support for parents ^[19]. This is not because ADHD is caused by bad parenting; there is no evidence to suggest this. Rather, parents often need the option for support because parenting a child with ADHD can be challenging at times.

Research shows ^[20] providing support for parents of children with ADHD is associated with more positive parenting behaviours and less strained parent-child relationships. For older adolescents and adults with ADHD, the main non-medication support that can be offered are cognitive behavioural therapies, which can help to minimise ^[21] the day-to-day impact of ADHD.

The treatment of ADHD should be comprehensive and will usually include both ^[22] medication and non-medication interventions. However, which treatment works best for which patient, depends on the individual and how ADHD affects their life.