Chapter 6Workforce development and accessing care
6.1Chapter 5 discussed in detail the deficit, in overall workforce numbers, of professionals who can conduct ADHD assessments and noted that this causes significant delays in people having their ADHD identified in a timely way. Chapter 2 touched on some of the evidence about the experiences and negative consequences for people with ADHD of poor interactions with healthcare professionals. These impacts can range from poorly identified ADHD, through to traumatic experiences of being stigmatised by the very healthcare professionals that people sought support from:
The long wait times and shortage of mental health practitioners have made it difficult for me to engage in daily activities, ultimately affecting my work and personal relationships. The limited options have also left me without any say in my care, forcing me to continue searching for a professional to address my post-diagnosis needs adequately.
6.2The committee heard from many sources that the two key causes of poor assessment and treatment outcomes for people with ADHD is a healthcare workforce not large enough to meet demand, combined with a lack of appropriate training for professionals who engage with people with ADHD.
6.3As shown by the evidence presented in this chapter, this is not limited to the key healthcare professionals most likely to support people with ADHD, such as general practitioners (GPs), psychiatrists and psychologists. It also includes allied healthcare professionals and more broadly, professionals such as teachers and people working in the justice system.
6.4This chapter looks at how care services for people with ADHD should better consider neurodiversity, and examines the need for culturally responsive tools and services in First Nations communities. It also puts forward the suggestions from evidence about collaborative and other new models of care.
6.5This chapter further discusses the two key areas which were highlighted as ways to improve the workforce: the first being improvements in training (to increase quality of services, especially in education), and the other to increase overall numbers of healthcare professionals (increase quantity of services) to alleviate the long wait times for people to access care.
6.6Recent key initiatives of the Australian Government to build capability and capacity in the healthcare workforce are also discussed later in this chapter.
Improving support for people with ADHD
6.7The quality of care received by people with ADHD from healthcare professionals appears to vary greatly—ranging from care that has made them feel supported and accepted, to care that has made them feel discriminated against, dismissed, and less. The committee heard that there are changes which could be made to the way support and care is provided to people with ADHD.
Neuro-affirming and neuro-accessible approaches
6.8A number of people with ADHD highlighted to the committee that society, and the health care system in particular, needs to be more inclusive of neurodivergence, and called for support to be given in a neuro-affirming and neuro‑accessible ways, including through reform of deficit-based assessment and research tools.
6.9MrStuartSchonell from Advocacy WA highlighted the role of Australia’s international obligations in supporting neurodivergent people:
According to the UNCRPD [United Nations Convention on the Rights of Persons with Disabilities], disability is a social concept. It's not viewed anymore as a medical-deficit concept, and it results from interaction between an impairment and attitudinal or environmental barriers that hinder full and effective participation in society, and this is exactly where ADHD falls.
6.10Jessica, and other submitters to the inquiry told the committee that the way some services are being delivered is not helping people, saying 'I just want to make this really clear … The help we are getting is not neurodivergent friendly'. MsLouise Brown agreed, advising 'sometimes care might be provided and it's available, but I don't think it's actually been developed from a neurodiverse perspective or based on that framework'.
6.11Ms Matilda Boseley, a person with ADHD, journalist, author and advocate, drew attention to the changing way in which the ADHD community is discussing ADHD. She highlighted that a more healing and validating approach is being taken, one which recognises ADHD brain difference as intrinsic to identity.
6.12This was reaffirmed by Yellow Ladybugs. which wrote about service-user demand for a social rather than medical model of disability and the ADHD community's desire for a more supportive, neuro-affirming and neuro‑accessible approach:
Our community have spoken loudly about their desire for clarity, positive identity and self-compassion, and for a quality of life where they can help themselves live, rather than just survive …
We want all neurodivergent people to be properly supported according to their needs, and to build a society that values and empowers the neurominority (rather than the notion that neurodivergent people should aspire to live, learn, work and socialise in the way that the neurotypical majority do). The neurodiversity paradigm also embodies the social model of disability, and the recognition that it is our society’s systems and attitudes that are responsible for the challenges experienced by neurodivergent people including barriers to diagnosis, lack of inclusion in school and employment and access to support services.
6.13A more inclusive view was also supported by Dr Elizabeth Deveny from the Consumers Health Forum of Australia, who reflected that:
The key to success will be prioritising the lived experience of consumers in this discussion and empowering them to lead and evaluate all changes. Creating a more inclusive health system with services that acknowledge and cater for all neurodiverse people would be a very positive outcome for health consumers.
6.14A range of submitters called for better collaboration between governments and lived experience non-profit support organisations, and people with ADHD in the design of programs and models of care, to ensure services are fit for purpose and meet the needs of people with ADHD. This approach is supported by the Australian Evidence-Based Clinical Practice Guideline For Attention Deficit Hyperactivity Disorder (Clinical practice guideline) developed by the AustralianADHD Professionals Association (AADPA). The Health Care Consumers' Association called for more 'consumer-centred' care and 'a greater focus on the experience of the individual seeking diagnosis and care and on strengths focussed treatment and management'.
Implementing holistic support
6.15It was put to the committee that more holistic and tailored support for people with ADHD would help better equip people with ADHD to better respond to the demands of study, work, and living their lives. Mary, a witness at the Perth hearing, supported this approach:
There needs to be a holistic approach. We need a holistic approach for the management of ADHD in both diagnosis and prescription, not just medication but inclusive of behavioural therapies, counselling, parent support, lifestyle adjustment and educational support.
6.16Ms Louise Brown of Thriving With ADHD called for more holistic care that:
takes in account a person’s individual biological, psychological, educational, social, spiritual and cultural background, and needs and wants [and]
includes all aspects of a person’s functioning, activities, participation, abilities and disabilities and the context in which they occur.
6.17Holistic support is also better for supporting people who have co-occurring conditions alongside ADHD, and for those who are at higher risk, such as First Nations peoples, people from a culturally and linguistically diverse (CALD) backgrounds, and people living in out of home care or custodial settings.
6.18However, the Australian Psychological Society acknowledged that finding the right combination of supports could be challenging:
The specific support required can be further complicated due to high rates of co-occurring mental health and learning disorders and a lack of understanding about the intersectional impacts for people with ADHD who potentially already experience stigma as a result of this diagnosis. This can result in difficulties drawing direct cause and effect relationships between ADHD symptoms and the impacts of these problems on an individual’s life.
6.19Submitters suggested that people's health literacy is generally low, particularly in First Nations and CALD communities. DrRuthVine from the NationalMental Health Commission advised that improved health literacy would improve outcomes for people with ADHD and contribute to more holistic care, in line with the Clinical practice guideline. Dr Vine emphasised the value of:
… people's encouragement to try non-medication avenues first, particularly straightforward structural things like how to manage comorbid anxiety, sleep and exercise and how to structure your working day and so forth. Ithink there is an issue about health literacy.
6.20The Australian Association of Psychologists Inc. (AAPi) agreed that more information and support was needed, advising that 'access to parent education programs, support groups, and counselling services can be essential for understanding and managing the condition', but that access to such resources varies greatly, 'leaving many families without adequate support networks'. ProfessorCatherine Elliott from Telethon Kids Institute agreed, saying 'it's really about supporting the whole family unit and really empowering parents so that they can provide the support to their children really early, before they get to that crisis point'.
6.21AADPA also endorsed a more holistic approach, inclusive of psychoeducation alongside medication and non-medication approaches:
While medication treatments can also lead to improved functioning and a better quality of life they are, on their own, unlikely to improve all aspects of someone's life. For younger children, parent training approaches can help improve parent child relationships and improve positive aspects of parenting as well as reduce oppositional behaviours. Cognitive behavioural approaches can help older children, youth and adults with ADHD manage and organise their lives and address many of the negative feelings and beliefs that are present for many people with ADHD.
6.22ADHD WA highlighted that pre-diagnosis services such as group therapy could help people while they are waiting for a diagnosis, saying:
… we have the opportunity to expose them to programs that would hold them and enable them to thrive and not lose two years of education and/or we look at an adult not being able to stay engaged in employment.
6.23AAPi agreed that more holistic support would be beneficial and help to address stigma:
I think that this is a community wide stigma, where people with ADHD are seen as lazy or just not trying hard enough … whereas, if they're supported, if there is educational support going in in the schools, if they're provided with small-group education, if they're provided with literacy support, etcetera, their outcomes are going to be much better across the long term.
6.24Holistic support would also be valuable in assisting people with ADHD to transition from adolescence to adulthood. Evidence argued that specific training, processes (including information sharing processes) and resources on the transition of people with ADHD from adolescent to adult services, as well as the use of healthcare professionals who can bridge these services—such as GPs and nurse practitioners—and/or shared care were suggested as ways to improve the transition experience.
6.25Submitters also suggested that mandatory hand‑over processes and incentives be put in place to ensure that other patients transition smoothly between healthcare professionals, and receive continuity of care.
Developing culturally responsive tools and services
6.26As outlined in Chapters 3 and 4, the committee heard that current diagnostic tools, clinical protocols and services for First Nations peoples with ADHD are inadequate. The Institute for Urban Indigenous Health recommended 'valid, robust, and culturally responsive rating scales for the comprehensive screening and assessment of ADHD among this population'—including children, adolescents and adults.
6.27The Royal Australasian College of Physicians (RACP) also suggested that the:
… development of a specific cultural assessment for ADHD for First Nations people should be considered. Assessments should be holistic, considering physical, mental, emotional, social, cultural, family and Country connections.
6.28Mandatory cultural responsiveness training and upskilling was also recommended by the Institute for Urban Indigenous Health to improve the accuracy of ADHD assessment and diagnosis in First Nations peoples, and to improve the quality of care and support.
6.29The institute also called for a range of measures to improve the accessibility of assessment, diagnosis and support services to First Nations children and young people to enable early intervention in developmental delays and the transition from child to adult ADHD services.
6.30NACCHO, the Institute for Urban Indigenous Health and ADHD Australia likewise drew attention to the need for culturally safe supports for First Nations peoples living with ADHD, as well as the families, elders, kinship networks and communities, developed in partnership with First Nations peoples.
6.31The Institute for Urban Indigenous Health argued that care must be based on 'evidence-based policy, which account for social factors, place, and align with Aboriginal culture to provide optimal care' and in order to 'maximise treatment effectiveness' and address First Nations peoples' 'holistic conceptualisation of good health and wellbeing and the intimate interconnection between health and spirit, kin, country, and culture'.
6.32The college also noted the lack of statistical data about the extent of ADHD in First Nations communities, ADHD in indigenous girls and women, and the need for research and the presence of First Nations voices in research on ADHD in First Nations peoples. This is discussed further in Chapter 8.
Upskilling healthcare professionals
6.33A well-trained and available workforce of health professionals will be crucial to ensuring that assessment and support services for people with ADHD are both timely and fit-for-purpose. Further to the evidence of Chapter 3 to 5 in particular, the following sections discuss the evidence received about healthcare workforce development and the various ways in which the professional workforce offering care for ADHD might be increased and receive improved training.
6.34The committee was consistently advised that a wide range of healthcare professionals need education and training about ADHD, noting that 'training in the assessment and management of ADHD is only integrated into Australian healthcare provider education programs in a cursory way'.
6.35The committee heard that outdated information and attitudes have contributed to the poor experiences some people have had with healthcare professionals, including being 'gas lit', dismissed, and accused of drug-seeking behaviour. Women and gender diverse people have especially experienced difficulties because their ADHD symptoms have not been recognised by healthcare professionals.
6.36People with ADHD called for increased training and awareness of ADHD, including sensitivity training, for healthcare professionals. One person wrote 'the first time seeing my GP about ADHD I felt completely dismissed and unheard. I left feeling depressed, lost and like I was never going to find answers to the way I was feeling'. Beth also wrote about her experiences which, based on evidence to the committee, were not unusual:
I have been shocked at some of the attitudes held by neurotypical health professionals who do not understand, and who minimise the negative impact of ADHD on someone’s life experience. My own GP was surprised and confused when I requested a referral for assessment and queried why I would bother. He did not understand how much it had crippled my whole life.
6.37As discussed in this chapter, accredited education and training for healthcare practitioners such as GPs, is essential where shared models of care are implemented to ensure that GPs have the knowledge and confidence to safely assess, diagnose, prescribe medications and manage supports for people with ADHD.
6.38As summarised by the ADHD Foundation, 'education and training of the workforce now and into the future as a core requirement within government agencies and training facilities in health, justice, education and law' is required to address the understanding, stigma, and need for better support for people with ADHD.
Increasing the healthcare workforce
6.39Many professional submitters argued there is a significant shortfall in healthcare professionals, across all professions and geographic locations. Some suggested this could be addressed by encouraging existing professionals to engage with ADHD care through an increase to government financial support—via mechanisms such as the Medical Benefits Scheme (MBS).
6.40The need to invest in a workforce that cares for people with ADHD was stressed by many of the organisational submitters and witnesses, with recommendations to increase the health workforce through an increase in Australian Government‑funded university places. AAPi noted that the 'availability, training, and attitudes of treating practitioners are essential factors in ensuring access to ADHD assessment and support services in Australia' and stressed that addressing workforce shortages was also crucial to ensuring that individuals with ADHD could access the support they need.
6.41The Royal Australian and New Zealand College of Psychiatrists (RANZCP) similarly submitted that there is a national shortage of psychiatrists, as noted by the Productivity Commission and the National Skills Commission, contributing to the long wait times for patients around Australia. RANZCP recommended the Australian Government take steps to address this shortfall, and the Institute for Urban Indigenous Health called for primary healthcare professional bodies to be included in high-level discussions with health policy makers on workforce development options.
6.42WA Health argued that there is a well-known shortage of paediatricians in WA both in the private and public sectors and submitted that this has a significant impact on access to ADHD services.
6.43The committee heard how the lack of specialist medical professionals can have real-life, negative consequences on people living with ADHD.
6.44One person submitted that the shortage of paediatricians meant that when a family's regular provider stops service, such as due to retirement, it can be very difficult to find a new practitioner. A parent from WA wrote of their 'constant fear that our children's Paediatrician will finally burn out and retire, leaving us without anyone to prescribe their medication for months or even up to a year'. Another parent expressed concern for when their child would age out of being treated by their paediatrician, due to the lack of psychiatrists in their area.
6.45A person with ADHD also made the point that the shortage of healthcare professionals 'also exacerbates the burden on existing healthcare resources, leading to suboptimal care for individuals with ADHD'.
6.46Some existing government-led initiatives to increase workforce numbers are discussed later in this chapter.
Training the healthcare workforce
6.47Professionals and people with ADHD noted that a lack of ADHD‑specific training can result in a reduced number of professionals available for assessment and support services for people with ADHD, and may also result in harmful health care support where a person sees a poorly trained professional.
6.48The WA Health noted that training for general paediatrics is broad, and many trainees may have limited exposure to ADHD‑specific training. It also advised that the training for a GP is similarly limited, unless they seek further ADHD‑specific training themselves.
6.49Disability Advocacy NSW similarly asserted that there is a 'fundamental lack of understanding and knowledge of what ADHD is among many GPs, psychologists, psychiatrists and other allied health professionals who conduct assessments', based on 'older, outdated notions of ADHD that do not align with modern diagnostic criteria'.
6.50Consumers of Mental Health WA recommended that 'the education of medical professionals is updated regularly and incorporates a broader range of symptoms and behaviours that can frequently be displayed by those with ADHD'. It went on to note that this recommendation:
… was developed from a number of consumers' responses, which highlighted a frustration with their experience of psychiatrists who held narrow views about the potential symptoms of ADHD, especially in relation to the variety of different ways ADHD can present in women and minorities.
6.51The Children’s Hospital at Westmead explained that while there are good, quality training programs about ADHD, accessing them requires proactive professional development by an individual or organisation.
6.52Professor David Coghill, President of AADPA was emphatic on the importance of professional training:
… education in ADHD is lacking. It is lacking in all stages in professional development. It is not given in universities to those who are in the first part of their training, but also it is not part of the professional training of many of the groups that we traditionally think of as managing ADHD. You may be surprised to hear—or perhaps you wouldn't—that training in ADHD is not part of psychiatry training in general; it is not part of paediatric training in general; it is not part of psychology, nurse or allied health training. Because of that, and because of the stigma that there has been traditionally about ADHD, there are a lot of myths and barriers there. We hear this all the time. We think it is a big issue. That is why one of our approaches is to say that education has to be a core part of people's training, but it also has to start early, and it has to continue.
6.53To address this knowledge gap and shortfall, the AADPA recommended that:
… education on the assessment and management of ADHD needs to be routinely integrated into either basic and specialist training programs for paediatricians, psychiatrists, psychologists, general practitioners and nurses so that members of these professional groups feel adequately trained and skilled in providing assessments for ADHD.
6.54The AADPA further suggested that appropriate education also needed to be provided to those healthcare professionals who were already in practice.
6.55headspace National recommended that the healthcare workforce upskill in access to—and familiarity with—tools and resources which 'assist in identifying when a young person needs to refer to a clinician for assessment', upskilling through Primary Health Networks, and keeping abreast of current research and expert updates. It further recommended that education include psychometric tool use and the collation of childhood information, school reports and investigations.
6.56However, NursePrac Australia advised the committee that 'there are currently no Australian standards for the training of healthcare professionals in the diagnosis and treatment of ADHD'. Dr Simon Towler of WA Health likewise called for the development of a robust training and education framework, stating:
WA would welcome Commonwealth support to work with the specialist college and professional bodies to endorse accredited training packages and to support the development and evolution of shared care models for ADHD for use locally and nationally.
6.57ADHD Australia echoed these views, offering support for 'consistent, funded and high-quality professional training for healthcare workers' so that they could identify and accurately diagnose ADHD, recognise coexisting conditions, and ensure people with ADHD receive appropriate support.
6.58Witnesses also called for increased education and professional development for healthcare professionals to reduce bias and stereotyping and the reliance on outdated information, which they saw as preventing or delaying diagnosis of ADHD.
6.59For example, drawing on her personal experiences, Rhiannon noted that training should focus on reducing 'stigma and stereotypes associated with ADHD and other forms of neurodivergence, especially in relation to gender bias'.
6.60Some submitters observed that a lack of specific knowledge about how ADHD presents, particularly in women and gender-diverse people, had led to poor diagnosis outcomes for individuals. They called for improved education for health professionals, including GPs and allied health professionals, to support better diagnosis and support for women, as well as gender-diverse individuals.
6.61The Tasmanian Association for the Gifted noted that ADHD can interact with giftedness in children, to either mask the ADHD of a gifted child, or the gifted characteristics lead to a misdiagnosis of ADHD. The association recommended improved training for psychologists, psychiatrists, paediatricians, counsellors, and teachers, so they could 'properly identify the unique characteristics, behaviours, and development typical of the gifted population'.
6.62The need for improved professional development training for specialists who may have trained some time ago was also highlighted. Noting that current training does provide adequate ADHD-specific learning modules, RANZCP conceded that 'there is a gap, in the sense that we have a number of psychiatrists who haven't been exposed to this' and that catching them up does take some time.
First Nations
6.63The lack of a culturally safe approach to ADHD was noted by multiple First Nations organisations, with improved training a recommended solution.
6.64The Institute for Urban Indigenous Health submitted that there was a lack of 'ongoing cultural responsiveness training and upskilling, to ensure quality of care and support for First Nations peoples with an ADHD diagnosis' by paediatricians and psychiatrists.
6.65The National Aboriginal Community Controlled Health Organisation (NACCHO) called for improved 'consideration of cultural differences in perceptions of disability and ADHD by Aboriginal and Torres Strait Islander people'.
6.66Ms Nadine Blair of NAACHO told the committee that the best care for First Nations people with ADHD was provided by an Aboriginal Community Controlled Health Organisations (ACCHOs), and thus there was a need to support the upskilling of those healthcare professionals. She called for:
… the capacity for AACHOs to build multidisciplinary teams, like RECS [Remote Early Childhood Services program] or CYATS [Child and Youth Assessment and Treatment Service] deliver currently, to be able to better assess and diagnose neurodivergent conditions in their communities. That means building the public and allied health workforce. ACCHOs already deliver culturally safe care and they deliver it in a person centred way … So the ability to increase workforce actually would make a huge difference.
6.67The First Nations Disability Network similarly recommended that it is:
… vital to establish culturally responsive assessment protocols that are strengths-based and consider the unique circumstances and experiences of First Nations people. Assessment needs to be holistic and grounded in an understanding of cultural identity and cultural explanations of ADHD symptoms, considering physical, mental, emotional, social, cultural, family and Country connections.
6.68The Institute for Urban Indigenous Health suggested that 'completion of a recognised and endorsed ADHD training program', which includes consideration of factors which may impact on an accurate diagnosis (including for First Nations peoples) such as 'physical health, mental health, and other inter-related complexities (i.e., trauma, attachment difficulties for children)' would be appropriate to increase the range of health professionals who can diagnose or provide long-term management of ADHD.
6.69Yellow Ladybugs also suggested that such training be trauma-informed and neuro-affirming, with the involvement of the neurodivergent community.
Additional needs
6.70The committee heard that for people within the ADHD community who have additional needs, the ability to find an appropriately trained professional becomes ever harder.
6.71For example, DrKay‑Sheree Spurling submitted that despite the prevalence of ADHD amongst people with substance misuse disorders, there was little understanding of ADHD in the alcohol and other drugs (AOD) services sector, alongside historical attitudes about medication‑seeking behaviour.
6.72Suicide Prevention Australia encouraged better training for GPs to enable them to 'identify people with an elevated risk of suicide and have the confidence and expertise to discuss suicide with patients', given that nearly half of all people who die by suicide have contacted a primary healthcare provider within onemonth of their death, and many people with ADHD are at increased risk of suicide. Such training would 'equip general practitioners with the ability to communicate effectively with people showing signs of distress to help prevent the immediate risk of suicide'.
General practitioners
6.73Despite the vital role GPs provide in primary care, it was stressed to the committee that there is a need to better inform GPs about how to treat and support people living with ADHD.
6.74For instance, RANZCP indicated that 'there is a significant gap in the knowledge and skills between primary and specialist sectors in relation to ADHD assessment and treatment, despite [GPs] being the first contact for patients'. RANZCP recommended training initiatives at the national and state level to upskill GPs, to ensure that psychiatrists were not the only providers of continuing management and care of ADHD patients, as this reduces their capacity for new patient assessment and support.
6.75This view was supported by the experience of people with ADHD, with the Canberra and Queanbeyan ADHD Support Group reporting that 'most GPs are not well informed or trained to identify ADHD and related conditions or how to obtain reliable assessment or accurate diagnosis'.
6.76The Central and Eastern Sydney Primary Health Network separately acknowledged that, anecdotally, GPs do not have the confidence to conduct preliminary ADHD screening assessments, and that in its region, 'only half of referrals include adequate information and results from preliminary assessments that could be completed by GPs or primary care nurses'.
6.77WA Health highlighted the urgent need for comprehensive training of GPs and was in favour of greater emphasis and investment in:
… specific training of registrars [trainees] in psychiatry, paediatric and general practice and upskilling of qualified specialists in the areas of neurodevelopmental issues, especially ADHD. Undergraduate training and practice in integrated and multidisciplinary care could better support more contemporary models of care.
6.78These observations were supported by Dr Tim Leahy from the Royal Australian College of General Practitioners (RACGP) WA ADHD Working Group, who noted that several elements would need to be put in place for this to be successful, including: upskilling for GPs; federal and state policy and funding, including MBS items; funding for collaboration, and communities of practice between GPs and specialists to discuss patients and to upskill; timely assistance from specialists, and the availability of other allied health and mental health supports.
6.79The RACGP WA ADHD Working Group suggested that GPs should provide the majority of care to the more than 50 per cent of patients whose care is 'relatively straightforward'. The working group acknowledged:
… there will never be enough paediatricians and specialists to address the unmet need. There is a real cost too, in GPs not being used to their full scope. A significant number of GPs want to do more. One thousand college GPs recently attended an upskilling on ADHD-not the usual 40 or 50 but 1,000.
6.80Dr Dianne Grocott suggested a three-tier approach to training GPs, with differing levels of competency and roles in the treatment of ADHD:
(1)ADHD aware GPs—can identify ADHD, screen and refer to psychiatrist; when PSM [psychostimulant medication] optimised Schedule 8 permit with support letter from psychiatrist;
(2)ADHD competent GPs—can identify, perform a full assessment, refer to psychiatrist and manage PSM under psychiatrist guidance; initiate and titrate PSM with Schedule 8 permit with support letter from psychiatrist; and
(3)… ADHD specialist GPs—can identify ADHD, perform a full assessment, initiate and manage PSM autonomously, and refer to psychiatrist only if needed; autonomous Schedule 8 permit, like psychiatrists.
Training pathways for GPs
6.81The Department of Health and Aged Care (Health and Aged Care) submitted that GPs already receive training and education in ADHD as part of their studies, and GPs could pursue further mental health training through continuing professional development (CPD).
6.82Health and Aged Care noted that a range of existing and planned ADHD‑related training was available through the General Practitioners Mental Health Standards Collaboration (GPMHSC), a multidisciplinary body managed by the RACGP. The GPMHSC has developed a General Practice Mental Health Training Framework for the delivery of primary mental healthcare within the context of general practice.
6.83RANZCP is currently developing a nationally recognised Diploma in Psychiatry for medical practitioners, including GPs and emergency medicine specialists, in areas of workforce shortage. The diploma, due to be available to trainees in 2024, is anticipated to include an ADHD focus including:
a description of ADHD epidemiology, aetiology, symptoms, phenomenology, course, assessment, psychiatric and medical comorbidity and differential diagnosis;
ADHD interventions with reference to evidence-based treatment guidelines
principles for use of stimulants and other medication for ADHD; and
guidance on the development of structured mental healthcare plans with patients diagnosed with ADHD based on the formulation and/or diagnosis, using evidence-based approaches.
6.84Health and Aged Care noted that the diploma is 'designed to offer an advanced level of training in mental health for doctors—general practitioners in particular—who are supporting or treating and potentially diagnosing people with complex mental health issues' and argued that while it was 'not intended to be a substitute for psychiatry care … certainly, in areas where access to psychiatry is challenging, this will be a really important advancement'.
6.85Health and Aged Care further noted it has undertaken a review of GP training in mental health to assess the adequacy of the training. It has highlighted 'some opportunities to improve the core mental health training at each of those levels, and that is something that we would be working with relevant colleges to look to address'.
6.86As of 1 July 2023, a free national support line was made available for GPs to:
… access clinical advice from psychiatrists to better support GPs to manage and monitor patients. GPs can seek advice from psychiatrists on a range of subjects including ADHD as well as mental health, safety, medication, psychosocial advice, treatment, diagnosis and referral pathways.
6.87WA Health noted that enabling GPs with an interest in ADHD-related issues to undertake further training or accreditation would be a 'longer-term sustainable solution' to ensuring the supply of well-trained GPs available to meet the community’s needs. However, WA Health informed the committee that it was 'unaware of any specific accredited ADHD training packages in WA to support the upskilling of GPs and other health professionals' but outlined the following training available elsewhere:
RACGP Specific Interests Group ADHD, Autism Spectrum Disorder and Neurodiversity: offers a webinar series on identification and co management of ADHD in general practice, which include both paediatric and adult ADHD. This training is a CPD activity available to all GPs.
The Victorian Adult ADHD Interest Group is reported to be developing an accredited GP training course on ADHD. This group is noted to be collaborating in the design of best practice models for ADHD assessment and holistic management.
An ADHD training package currently in development by the New South Wales (NSW) Health and Education Training Institute, to support a pilot program delivering a shared care ADHD model of care in regional NSW.
Existence of ADHD training modules developed by Queensland Health under Project ECHO (Extension for Community Healthcare Outcomes) which was established to provide interprofessional training support for GPs.
6.88However, as noted by WA Health, there is no agreement on 'what constitutes sufficient or adequate accredited training' to ensure competency to diagnose ADHD. The service thought that there is a role for the Australian government to coordinate agreement on training, and to fund training and development of healthcare professionals:
It is imperative that robust dialogue occurs between various specialist, medical and Nurse Practitioner colleges to agree on what best practice requires in terms of education and training across various stages of the ADHD care pathways of the future. Commonwealth Government support is vital in influencing such changes as a way of supporting innovation and change in an area of emergent need.
6.89WA Health further expanded on training requirements, advising:
Best practice requires the above [diverse developmental and condition presentations and the ability to differentiate these from normal childhood development] experience / training, which is not substituted by brief training (such as a weekend course in ADHD). Ongoing and engaged connection with, and supervision from, a community of practice working in developmental paediatrics is required …
… further GP involvement in ADHD assessment could be considered if funding (Medicare and state contributions) was available to allow GPwSI [GPs with a special interest] to work in public paediatric development services for at least 1 day per week over a 6-month period to further their training in managing, screening and assessing ADHD and comorbidities.
GPwSI would need to remain involved with specialist paediatric support, connected to such clinics with a community of practice oversight. In the absence of such training and oversight, there is risk of misdiagnosis, missed comorbid diagnosis and/or overmedication of children.
Psychologists
6.90AAPi pointed to a study which found that the supply of psychological services has not kept up with demand. The study found that 'the proportion of adults in NSW experiencing psychological distress increased by 72% between 2013 and 2021' while at the same time the 'number of psychologists per 100,000 people increased by only 33 per cent'.
6.91The Australian Psychological Society commended the 2023–24 Budget spend of $91.3 million to grow the psychology workforce as it would 'begin to address issues associated with waitlist times and the shortage of psychologists available to meet the current demand for services'. However, the society observed that for ADHD, while there were 'approximately 45 000 registered psychologists in Australia … not all psychologists undertake ADHD assessments'. Toaddress this, it said further work was needed to ensure that more psychologists 'have a relevant area of practice endorsement, and/or competence in the assessment and diagnosis of neurodevelopmental conditions as demonstrated by appropriate qualifications, training, and experience'.
6.92The AAPi recommended 'a minimum number of Commonwealth-supported places for students studying psychology' so that places with no or reduced fees could be reserved for people wanting to train as psychologists; this should 'align with and be determined by workforce demands and job vacancies as outlined in the report, Under Pressure: Australia’s Mental Health Emergency'.
6.93AAPi commented on the need for continuing education and professional development opportunities to 'be available to practitioners to enhance their knowledge and skills in ADHD assessment and evidence-based treatments'.
Collaboration between professions
6.94Successful shared care arrangements require initial training of health profession graduates and postgraduates in integrated care and multidisciplinary environments. The committee received evidence about the benefits of health care professionals sharing care responsibilities for people with ADHD.
6.95A recent RANZCP position paper called on system changes to 'enable shared care arrangements to facilitate more equitable provision of ADHD assessment and treatment' and was further supportive of moves to develop the capacity to recognise and treat ADHD by professions outside of psychiatry and paediatrics.
6.96AADPA similarly noted that in locations such as Canada and the UnitedKingdom, 'general practitioners and nurses make significant contributions to the assessment processes' where 'nurses are trained to gather information required for assessment and monitoring of treatment and work in collaboration with senior medical staff to conduct the assessments'.
6.97The Australian Association of Counsellors recommended increased collaboration between medical professionals and registered counsellors in the support of people with ADHD, as a way to address the workforce shortages within the mental health sector.
6.98The Australian Adult ADHD Interest Group noted that it has developed training modules for a 'multidisciplinary community of practice' model that provides:
… professional education across the board for all multidisciplinary team members to make sure that all of the providers, whether they're community support workers, clinicians and other specialists, apart from the GPs, all have a standard of practice that we're meeting …
6.99The interest group noted that additional financial support for this kind of training is required, and argued that such programs were likely to reduce the need for downstream NDIS funding, as people with ADHD were more likely to be supported early enough to not develop more serious functional impairments.
An expanded role for nurse practitioners
6.100The Australian College of Mental Health Nurses drew attention to the high level of education, qualifications and expertise of credentialed mental health nurses and mental health nurse practitioners, in providing mental health care.
6.101The Australian College of Nurse Practitioners called for increases to the number of appropriately trained and experienced clinicians who can diagnose ADHD, as well as promoting better collaboration between primary health care providers and specialists, and more telehealth services where people are 'underserved'.
6.102The college emphasised that recognising the role of nurse practitioners, including through the MBS and PBS, would have flow‑on effects for people engaging with other institutions such as the Department of Veterans' Affairs, and Centrelink, and would enable nurse practitioners to provide subsidised care and improve access to healthcare for people with ADHD.
6.103Orygen also saw a potential role for nurses in providing primary health care and support after diagnosis and stabilisation by a specialist.
Other care models
6.104In addition to these collaborative approaches, the committee was informed of other innovative ways in which models of care for ADHD could be implemented.
6.105For example, RACP recognised that a range of services are likely to be required in supporting people with ADHD, advising that 'we are likely to need varying models in different places—metropolitan versus regional—and clinical nurse specialists may work well in some places'.
6.106Healthcare professionals also suggested a greater role for communities of practice to upskill health professionals. WA Health called for communities of practice which are 'exposed to assessment and treatment options, learn about ADHD, be able to work in their own practices like that, and have that supervisory model that we already give to our registrars'.
6.107There was support for the development of community hubs providing GP support and screening, supported by allied health and nursing services, overseen by paediatric diagnostic treatment management. It also envisaged that as part of a hub arrangement, there would be access to virtual healthcare, community and education support and linkages to mental health services. DrWee-Sian Woon suggested that hubs 'would allow other comorbidities to be concurrently identified and appropriate managed'.
6.108PHNs were also suggested as a model of care. Submitters noted that PHNs already interface education, disability and health services, already participate in federal-funded health initiatives and already have existing relationships with primary care clinicians, placing them well to provide integrated support for people with ADHD.
6.109For First Nations peoples in particular, NACCHO and the Institute for Urban Indigenous Health highlighted the critical role of community-controlled health organisations. They noted that being part of the local community brings considerable benefits for patients—there is a trusted relationship, services are culturally safe, services are delivered to the local community, and are more holistic because the service can connect with the family. Their reach into communities is well recognised, with over 50per cent of First Nations people preferring to attend an Aboriginal Community Controlled Health Organisation rather than a non-Indigenous practice.
6.110The Hon Jay Weatherill from Thrive by Five explained how this was important in caring for First Nations children who may have ADHD:
Interestingly, the models that occur in some Aboriginal communities are actually quite good models because they tend to look at the child in the context. They don't separate them out into various silos. They tend to have Aboriginal-controlled organisations where trusted relationships are formed and the various supports et cetera are brought in rather than people having to get on the end of a large number of queues to try to find their support.
6.111The Institute for Urban Indigenous Health and NACCHO called for more investment and capacity building in the community-controlled health sector—in line with Closing the Gap Priority Reforms—and recommended that government and stakeholder research, policy and planning be done in partnership with First Nations peoples and the sector.
Non-health professionals
6.112Many submitters saw the need for appropriate training of professionals who often interact with people with ADHD, outside of healthcare fields. Inparticular, educators and those in the justice system were identified as such workers. There was a large body of evidence received by the committee endorsing the need for more support for children and people with suspected or diagnosed ADHD in educational settings.
6.113Submitters also noted that useful resources for workers, including those working in education and justice, are difficult to find:
There's a huge gap in being able to provide practical and accessible resources for employers in the workplace, managers, line managers and so forth; for police and first responders in the community; for clinicians who are in practice day to day, general practitioners and so forth; and for teachers in classrooms and so on.
Improving support in schools and educational institutions
6.114Submitters commented on the important role that educators play in both identifying and then providing support for children with ADHD. Chrissubmitted that '[t]eachers and daycare workers are sometimes the only people who will ever see an ADHD child, and are often the only professionals who would pick up that a child has ADHD'.
6.115ADHD Australia echoed this, saying that schools and the schoolroom is often the first environment where ADHD behaviours are observed. It suggested that improving awareness in schools and 'developing the expertise and knowledge of teachers is one of the most effective ways to increase student achievement, reduce classroom disruption and facilitate more positive outcomes for students living with ADHD'.
6.116Maddison likewise noted that:
Schools and workplaces also play a crucial role in supporting individuals with ADHD, but often lack the resources, understanding, or accommodations necessary. Teachers and employers may not be adequately equipped to support students or employees with ADHD, leading to academic struggles or occupational difficulties.
Training for educators
6.117Submitters explained that a lack of training could result in educators becoming a barrier to ADHD identification. This was highlighted by Cameron's experience with their daughter, where the daughter's teacher did not associate her quiet, well-behaved manner with ADHD, which ultimately meant:
… her access to diagnostic services and medication for her ADHD was delayed, meaning she was required to repeat Grade 3 and continues to have challenges with reading, writing, and spelling to this day (despite her effective treatment).
6.118Teachers, too, indicated that they want more support to assist students with ADHD, with ADHD Australia reporting that 87 per cent of teachers did not feel that their training prepared them to support students with ADHD, and 93percent thinking that they would benefit from additional professional development.
6.119Adjunct Professor Lorana Bartels wrote about a recent survey of 1024 teachers, which found that '87% had students who were formally diagnosed; of these, 7%reported six or more diagnosed children per classroom'. She further submitted that:
… there appears to be inadequate support and training in the classroom, with 28% of the 1024 teachers who responded to the survey indicating that their school did not provide any of the following:
learning support resources onsite or online to support students with ADHD;
learning support resources onsite or online to support teachers; and
professional learning.
6.120The Victorian Student Representative Council pointed to studies showing easily adaptable learning strategies that teachers could implement to better accommodate the learning styles of students with ADHD, suggesting that 'more in-service learning for educators may be beneficial to students with ADHD'.
6.121Mary, a mother of a child with ADHD, expanded on this, adding 'teaching degrees need to include thorough training on ADHD, its complexities and how it presents differently for different people' as well as teaching methods for neurodiverse brains.
6.122The Central and Eastern Sydney Primary Health Network thought that building capacity in teachers would help in the provision of wrap‑around support to children with ADHD and their families, to ensure that they do not fall behind their peers. The network suggested that teachers were willing to be upskilled and said that:
… a national standard of training for educators would ensure continuity in support for children moving between education settings, with benefits for children, their families, and teachers.
6.123The benefits of such training were made clear in evidence. In calling for better educator training and resources, Alexander said that:
It would be good to see more training handed to teachers to help recognise ADHD in its early stages; I could only imagine how my life would be different if it was recognised in early primary school or earlier.
6.124The Department of Education advised that current teacher training is delivered by universities and the Australian Government does not specify the course content of initial teacher education. However, the department pointed out that a review was currently underway and 'there is nationally agreed accreditation of initial teacher education programs, so there are standards and procedures that are set'. More recently, there has been the initiation of a Teacher Education Expert Panel, which has been tasked with exploring recommendation15 of the Quality Initial Teacher Education Review. It will investigate 'programs that deliver confident, effective and classroom-ready graduates' including how to meet the needs of students in the classroom.
Access to education supports
6.125As discussed in Chapter 4, it is apparent that more accessible information about access to supports in schools is required. Despite the Department of Education advising that new information and resources are available to help students with disability, their families and educators understand the support available, feedback to this inquiry appears to demonstrate that these materials are not hitting the mark.
6.126In particular, more accessible information for parents and families is needed to help them understand how to access support, and how the development of an Individual Education Plans and the Students-with-disability Student Resource Standard loading could help their child.
6.127Orygen noted the importance of in-school supports to young people with ADHD, suggesting that schools were ideally placed to provide information about ADHD to families. Orygen also submitted that improved knowledge and understanding of ADHD in teachers and teacher-assistances, as well as in vocational training organisations and universities, would help to ensure students were supported and remained engaged with their education and training.
Areas for education reform
6.128Submitters, such as the Victorian Student Representative Council, called for 'education that is meaningful, flexible and relevant to their needs' and for education to be delivered in a way that enables the full and equal participation of students. Ms Louise Brown clearly outlined what is required:
What children with ADHD need is care and support at home and in the classroom that validate their feelings and experiences, scaffold their developmental delay and lag in cognitive skills and foster in them, in a collaborative manner-not in an 'I'm going to teach you how to do this' manner but getting them to work out and learn this process and develop self-awareness and self-empowerment in the process-the personal insight, knowledge and skills they require to develop in a healthy manner, reach their full potential and thrive.
6.129A number of recommendations aimed at consistently improving inclusion and the experience for students with ADHD were made, including:
improving the way education is delivered to take account of neurodiverse students, with trauma-informed practices;
professional development for teachers and school staff to ensure they understand the diverse learning needs of students, can make effective accommodations (including through the use of adaptive technologies), can support an ADHD diagnosis, and can advise families where to go to receive more help;
improving access to a range of supports in schools, including IndividualEducation Plans, school psychologists, occupational therapists, education assistants and notetakers;
improving the availability of accessible information to students and their families to help them better understand ADHD, seek support, and understand referral pathways, and neurodivergence; and
teaching children and young people in school about neurodiversity and how different brains work, to help break down stigma.
6.130In addition, several education policy changes were recommended including:
improving student-to-support worker ratios in schools by setting a national standard benchmark;
improving school funding for additional support for ADHD students;
providing Australian Government funding for new research into improving school-based services, including addressing stigma, school exclusion and school refusal (research is discussed further in Chapter 8); and
changes to teaching qualifications to include training on ADHD and how it presents differently, as well as teaching for differentiation and diversity.
Justice and protection systems
6.131As highlighted in Chapters 1 and 2, poor identification and treatment of ADHD can often result in a person having an increased interaction with the justice and/or child protection systems. Echoing the findings of the Disability Royal Commission, there is an over-representation of people who interact with police, courts and prisons, who have unidentified ADHD.
6.132It was argued in evidence to the inquiry that it is therefore of critical importance to ensure that the justice system workforce is properly trained to both identify people who should be referred for ADHD assessment, as well as being trained to meet the needs of people, post‑identification.
6.133For example, ADHD Australia acknowledged that people living with ADHD are often under- or mis-diagnosed in the justice system. It further advised that the lack of training and understanding creates challenges with communication, justice systems and processes, with people with ADHD at risk of 'disproportionate sentencing' and inadequate support, putting them at higher risk of recidivism. To address these issues ADHD Australia recommended improved access to nationally consistent training and resources for justice system workers.
6.134inSync for Life also pointed to a lack of understanding of ADHD in the justice system:
Professionals in the justice system, such as law enforcement officers, lawyers, and judges, may have limited knowledge and awareness of ADHD and its manifestations in adults. This can result in under-recognition and underreporting of ADHD symptoms during the assessment process.
6.135inSync for Life recommended ADHD-specific training for prison staff on 'recognizing the specific challenges faced by individuals with ADHD as well as 'strategies for effectively communicating and interacting with individuals with ADHD, promoting understanding and empathy'.
6.136RANZCP recommended that information on ADHD:
… and its treatment and support options throughout the lifespan is included in the curriculums of mental health/developmental disorder training for educators … and other relevant professions such as social work, justice system, and child protection.
6.137The First Nations Disability Network remarked on the over-representation of First Nations people with ADHD in the criminal justice system and recommended that:
Comprehensive, culturally responsive disability awareness training, with specific modules on ADHD and its related co-occurring conditions should be developed and delivered to educators, legal professionals, law enforcement personnel, and other relevant stakeholders across all state and territory education and criminal justice systems to enhance their knowledge of ADHD and its implications for First Nations people.
6.138The Institute for Urban Indigenous Health similarly saw the need for 'timely and quality ADHD supports for First Nations children in out-of-home care or in the youth justice and prison system'.
Government healthcare workforce initiatives
6.139Health and Aged Care submitted that the Australian Government has ongoing 'initiatives to increase the number of psychiatrists and paediatricians through additional specialist training places and development of rural and regional training pathways'.
6.140Health and Aged Care further advised that the Australian Government is investing in a range of measures designed to improve the health workforce approach to ADHD. These include 'initiatives to increase the number of psychologists and psychiatrists, upskill the broader health workforce to deliver high-quality mental health treatment, and support GPs to manage more complex patients, including those with ADHD'.
6.141The National Medical Workforce Strategy 2021-2031 and the National Mental Health Workforce Strategy have been agreed by all governments across Australia. Both consider 'structural issues and how to address maldistribution in specialities and location, as well as training pathways and how to attract, train and retain workforce'. The National Mental Health Workforce Strategy is anticipated be published in coming months.
6.142The Australian Government has also funded:
the RACGP to develop a General Practice Mental Health Training Framework, and are working to develop accredited skills training for GPs interested in ADHD, while developing a nationally recognised Diploma in Psychiatry for medical practitioners to improve access and quality of care;
establishment of a national support line for GPs to access clinical advice from psychiatrists, so they can provide better support to patients;
RANZCP to implement the Psychiatry Workforce Program to increase the psychiatry workforce, especially in regional, rural and remote areas;
internships and subsidised supervisor training places for psychologists; and
redesign of psychology higher education pathways.
6.143More generally, the Australian Government is providing additional funding to upskill and support the broader health workforce in relation to mental health, including continuation of the Mental Health Professionals Network and the Mental Health Professional Online Development Program.