Safe, comprehensive, and equitable ADHD care

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) in Australia and Aotearoa New Zealand is a common neurodevelopmental condition that may persist throughout the lifespan. Its clinical presentation is frequently complex, with symptoms overlapping with a wide range of psychiatric and physical conditions, including mood and anxiety disorders, autism spectrum disorders, learning difficulties, trauma-related presentations and substance use disorders. These overlaps make accurate diagnosis and effective treatment inherently challenging, requiring a thorough, comprehensive assessment grounded in clinical expertise. 

ADHD care gaps are highlighting broader mental health system pressures. Demand for assessment and treatment is high, but many individuals miss out or wait extended periods for appropriate care, where they face long public waiting lists with limited public service availability, and significant private sector costs. Young people often fall between child-adolescent and adult services and are often unable to afford private psychiatric services.

Concerns are emerging about brief or online-only assessments, rising stimulant prescribing, or models that diagnose with limited options for ongoing treatment or follow-up. While self-rating scales and social media awareness campaigns may encourage help-seeking, they can also contribute to over-identification, anxiety, and an increased demand for confirmatory diagnostic assessments and stimulant medication prescriptions.  

These challenges reflect broader structural failures within the mental health system; limited access to specialist psychiatric care, workforce shortages, and insufficient public-sector capacity. Inconsistent jurisdictional prescribing rules and reactive policy shifts across states and territories in Australia further confuse and frustrate consumers, carers and clinicians. 

System level reforms have been introduced in Aotearoa New Zealand, including a national framework for ADHD treatment (created in collaboration with the RANZCP) and expanded authority for GPs and Nurse Practitioners to diagnose and prescribe ADHD medications. These reforms must be supported by robust governance, appropriate training and access to specialist reviews. 

Meaningful investment is required in specialist psychiatry, multidisciplinary teams, and public and private mental health infrastructure to support high-quality ADHD care. 

More information about ADHD is available at RANZCP Position Statement 55: ADHD across the lifespan.

Position

Comprehensive assessment is essential

The RANZCP affirms that accurate diagnosis of ADHD requires a comprehensive psychiatric assessment. This includes a developmental and biopsychosocial-cultural history, exploration of mood, anxiety, psychotic and trauma-related symptoms, evaluation of learning difficulties and neurodevelopmental conditions; assessment of substance use and physical health contributors; and careful consideration of social determinants of health. Collateral information from family, teachers, or others is often essential. Functional, social, and occupational impacts must also be evaluated and integrated into a diagnostic formulation. 

This depth of assessment is essential to avoid both over-diagnosis and under-diagnosis, and ensures appropriate, safe, evidence-based treatments, including the safe prescribing of stimulant medication. Errors in diagnosis, whether through insufficient assessment or mislabelling, pose significant risks to individuals and to health systems.

Structured shared care 

Improved access to psychiatric services depends on structured shared-care models across public and private health systems in which psychiatrists or paediatricians confirm diagnosis, assess comorbidities, and develop treatment plans. GPs and other clinicians should manage stable cases within their scope of practice, while complex or high-risk presentations remain under specialist oversight, with clear referral and escalation pathways.

The RANZCP supports expanded GP roles with mandatory accredited training and CPD including modules in comprehensive psychiatric evaluations, in which ADHD assessments sit, as well as appropriate governance structures, and specialist access pathways being in place. Comprehensive assessments must reflect the time and depth required, often up to 1-2 hours, and avoid over-medicalising distress driven by environmental, educational, relational or social stressors.

Safe prescribing requires diagnostic confidence

Stimulant medications should only be prescribed after a comprehensive biopsychosocial assessment and informed consumer and carer discussions about non-pharmacological and non-stimulant treatment options. 

While stimulant medications can be highly effective, they carry known risks, including appetite suppression, sleep disruption, cardiovascular complications, potential misuse, diversion or dependency, and exacerbation of underlying psychiatric conditions such as anxiety, mania or psychosis and related symptoms.

Given the rapid rise in stimulant prescribing, initiation should occur only when diagnostic confidence is high. Specialist involvement is necessary for complex presentations, while stable cases may be managed in primary care. Mandating periodic specialist reviews for all cases, as occurs in some jurisdictions, can create unnecessary bottlenecks without demonstrable safety benefit.

Key considerations

Safety and clinical rigor

• ADHD assessment must be comprehensive and contextualised within a full psychiatric evaluation.
• Treatment should incorporate pharmacological, psychological, and social interventions. 
• Stimulant medication prescribing requires careful titration, monitoring, risk and side-effect management.
• Prescribing monitoring is required with high-risk medication such as stimulants, to mitigate risks of substance harm and dependence. 
• Misdiagnosis or inappropriate prescribing creates significant risks for individual and systems.

Equity and access

• ADHD remains underdiagnosed in women, culturally and linguistically diverse groups, First Nations communities, and people living in rural and remote areas, reflecting broader inequities in access to specialist psychiatric care.
• Public mental health systems are severely constrained; young adults experience particular disadvantage.
• A substantial expansion of multidisciplinary public and private mental health services is required.
• Increased access must not come at the expense of diagnostic accuracy, safety or quality.
• Service models that prioritise profit over comprehensive assessment and follow-up care undermine public trust and safety. The RANZCP does not support profit driven practices and reaffirms that ADHD care should prioritise safety and access of the patient. 

Recommendations

1. Harmonise national prescribing and referral pathways.
2. Maintain specialist oversight for complex, comorbid or high-risk presentations.
3. Expand GP roles with accredited training, CPD, and robust escalations pathways.
4. Recognise that challenges in ADHD care reflect broader systemic failures. Meaningful investment is required in specialist psychiatry, multidisciplinary teams, public mental health infrastructure, including expanded community-based psychiatry clinics, and workforce growth. 
5. Embed lived-experience voices at all stages of reform, design, implementation and evaluation.
6. Invest in a nationally coordinated system to monitor diagnosis patterns, prescribing trends, adverse events, and service utilisation, alongside the impact of recent policy and regulatory changes, to ensure ADHD care remains safe, equitable, and evidence-informed across all jurisdictions.  

Conclusion

Psychiatrists bring specialised expertise in navigating the complexity, comorbidity and clinical risks inherent in many ADHD presentations. The RANZCP supports care models that expand access without compromising diagnostic rigor, safety, or continuity of care.

A nationally consistent, well-governed mental health system - anchored in comprehensive assessment, structured shared care, evidence-based practice and national data collection - is essential to meeting the needs of individuals, families, and communities across Australia and Aotearoa New Zealand.

Disclaimer

This information is intended to provide general guidance to practitioners and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.