More than just a script

Shared care for youth with ADHD

Dr Rona Kelly

Paediatrician, Child and Adolescent Community Health

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ADHD is the most common neurodevelopmental condition affecting young people. Australian data shows 7% of children aged four to 17 years of age are affected by ADHD,¹ and rates of diagnosis are continuing to increase in adolescents and adults.²

All adolescents navigate psychosocial challenges as they grow towards maturity in adulthood. These include tasks such as achieving independence from parents, managing intimate and peer relationships, and developing a positive self-identity.³ However, teenagers and young adults with ADHD have a higher risk of negative health, mental health and wellbeing outcomes.⁴

Collaborative shared care for ADHD

Young people with ADHD benefit from regular review with a trusted doctor. In Western Australia, assessment, diagnosis and (in some individuals) initiation of medication treatment remains restricted to Approved Specialists, namely psychiatrists and paediatricians.

More recently, GP Specialists in Western Australia who have completed the RACGP program to become ‘Endorsed Prescribers’ will be approved to start stimulant medication for eligible youth and adults with a confirmed ADHD diagnosis from the age of 10 years.⁵ However, all GP Specialists have a role in collaborating with individuals, families and non-GP Specialists to ensure safe and holistic care for young people with ADHD.

A review appointment with a young person for their ADHD takes time. Beyond medication prescribing, exploration of the impact of their symptoms enables both the GP and the young person to understand where things are going well, and where they can be improved.

Understanding the young person’s daily life, their progress at school or in the workplace, their relationships at home, and their participation in social activities, builds a picture for the GP and gives space for the young person’s own self-reflection and self-advocacy.

“Clear communication and collaboration between specialists, the young person and their family is essential to enable youth with ADHD to thrive.

Psychosocial review: ADHD is a lifelong neurodevelopmental condition, with impacts on executive function, mental health and wellbeing. Non-medication supports, such as counselling, ADHD coaching, parent and self-education, and peer support can all act to develop a young person’s own suite of management strategies.

Medication review: The most prescribed medications for the management of ADHD symptoms are Schedule 8 psychostimulants, including Methylphenidate, Dexamfetamine and Lis-Dexamfetamine. Non-stimulant medications include Guanfacine and Atomoxetine. Review of medication effectiveness requires enquiry about the onset of effect, the symptoms that improve, the duration of medication effect, and adverse effects such as suppression of appetite and sleep issues.

This is done through interview and the use of symptom rating scales such as the SNAP-IV.⁶ Stimulant medication prescribing may uncover underlying mood disorders; it is imperative to monitor the mood and general functioning of adolescents and young adults. Poor compliance, medication misuse and drug diversion should also be considered.

Clinical review: An essential part of clinical review is to assess for adverse effects of the use of medication on health and wellbeing. Young people with ADHD, particularly those treated with stimulant medicines, must have regular monitoring of their growth at least every six months, including weight, height and BMI, with plotting on standardised growth charts. Cardiovascular parameters, such as resting blood pressure and heart rate, should also be recorded.⁷

Provision of a prescription: All GP Specialists must be registered with ScriptCheckWA, Western Australia’s real-time prescription monitoring system⁸ and be aware of the Monitored Medicines Prescribing Code.⁹ A GP Specialist must ensure the prescription being requested is current treatment, consistent with the Approved Specialist’s written instructions, and is due for renewal. If these criteria can be satisfied, PBS authority approval can then be requested.

Communication with an Approved Specialist: A key component of safe and successful shared care is communication between professionals.¹⁰ Provision of growth and cardiovascular parameters, as well as an update on progress and wellbeing, can be provided via a standardised proforma, an email to the young person’s specialist, or clinical letter.

“Understanding the young person’s daily life, their progress at school or in the workplace, their relationships at home, and their participation in social activities, builds a picture for the GP and gives space for the young person’s own self-reflection and self-advocacy.

Special considerations for adolescents and young adults

Growth faltering: Growth faltering is defined as inadequate physical growth for age and sex, based on serial measurements.¹¹ S8 stimulants are commonly associated with appetite suppression and reduced volume of food intake. Executive function difficulties can affect daily living skills such as meal planning, and sensory sensitivities to taste, texture and smell can negatively impact nutritional intake.

If weight or BMI measurements have crossed down one or more major percentile lines, i.e. weight loss or failure to gain expected weight, interventions include dietary recommendations and closer monitoring. Referral back to their Approved Specialist is necessary if these interventions do not result in adequate catch-up growth.

Substance use: A urine drug screen (UDS) should be undertaken by all individuals aged 16 years and older before starting S8 stimulant treatment.⁹ However, an interview during a GP review appointment may reveal a young person’s current substance use, and UDS can support the identification of any undisclosed substance use.

For a GP Specialist, continued prescribing in this circumstance is not appropriate. Review by the young person’s Approved Specialist is required, as continuing prescribing requires authorisation from the CEO.⁹

Psychosis: The risk of psychostimulant-induced psychosis in young people is not negligible and should be considered by all professionals prescribing medication. In a 2019 study of 13 to 25-year-olds who were prescribed stimulant medicine for the treatment of ADHD, the risk of new-onset psychosis was approximately 1 in 660 (0.15%).¹² A young person with ADHD who presents with hallucinations, delusions and disorganised thinking requires urgent psychiatric assessment.

Recognition, referral and ongoing management of ADHD and its associated co-occurring conditions is a key skill required of all doctors working in primary care. Clear communication and collaboration between specialists, the young person and their family is essential to enable youth with ADHD to thrive.

References available on request.

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