Chapter 1Introduction and background
1.1On 28 March 2023, the Senate referred an inquiry to the Senate Community Affairs References Committee (the committee) to inquire and report on barriers to consistent, timely and best practice assessment of attention deficit hyperactivity disorder (ADHD) and support services for people with ADHD, with particular reference to:
(a)adequacy of access to ADHD diagnosis;
(b)adequacy of access to supports after an ADHD assessment;
(c)the availability, training and attitudes of treating practitioners, including workforce development options for increasing access to ADHD assessment and support services;
(d)impact of gender bias in ADHD assessment, support services and research;
(e)access to and cost of ADHD medication, including Medicare and Pharmaceutical Benefits Scheme coverage and options to improve access to ADHD medications;
(f)the role of the National Disability Insurance Scheme in supporting people with ADHD, with particular emphasis on the scheme's responsibility to recognise ADHD as a primary disability;
(g)the adequacy of, and interaction between, Commonwealth, state and local government services to meet the needs of people with ADHD at all life stages;
(h)the adequacy of Commonwealth funding allocated to ADHD research;
(i)the social and economic cost of failing to provide adequate and appropriate ADHD services;
(j)the viability of recommendations from the Australian ADHD Professionals Association's Australian evidence-based clinical practice guideline for ADHD;
(k)international best practice for ADHD diagnosis, support services, practitioner education and cost; and
(l)any other related matters.
1.2The committee was required to report by 27 September 2023. On 1 August2023, the Senate granted an extension of time for reporting, to 18 October 2023. On18October 2023, the Senate granted an extension of time for reporting, to 6November 2023.
1.3Details of the inquiry were made available on the committee's webpage and the committee invited organisations, key stakeholders and individuals to provide submissions.
1.4The committee received 701 submissions, which are listed at Appendix 1 of this report, and held the following public hearings:
29 June 2023, Canberra—professional and advocacy organisations, medical professionals, lived experience witnesses and government departments and agencies;
24 July 2023, Perth—professional and advocacy organisations, medical professionals, lived experience witnesses and the Western Australian Department of Health; and
26 September 2023, Melbourne—professional and advocacy organisations, medical professionals, and lived experience witnesses.
1.5A list of the organisations and individuals who attended these public hearings can be found in Appendix 2. The public submissions, additional information received by the committee and Hansard transcripts are available on the committee's website.
Acknowledgement
1.6The committee thanks all those who have contributed to the inquiry by making submissions, providing additional information, and appearing at public hearings.
1.7In particular, the committee thanks those submitters and witnesses who shared their moving, and sometimes challenging, personal experiences with ADHD. The committee appreciates that this may have been hard to do. Hearing about the experiences of people with lived experiences of ADHD has helped the committee to better understand the issues and identify possible solutions.
Report structure
1.8The report is comprised of nine chapters:
This chapter outlines the conduct and scope of the inquiry, and provides background information on ADHD in Australia, including the health and education contexts, as well as a brief review of other inquiries into ADHD and related matters;
Chapter 2 examines the impacts of ADHD on society with particular reference to workplaces, education and justice, and takes a more detailed, person-centred look at how ADHD and barriers to diagnosis and support impact individuals and their families;
Chapter 3 identifies the barriers to obtaining an assessment and diagnosis for ADHD, including the shortcomings of the health and medical system;
Chapter 4 takes a similar approach to discussing the barriers people face when trying to access ADHD treatment and support services;
Chapter 5 reviews the evidence received by the committee on how barriers to assessment, diagnosis and support services could be reduced or removed;
Chapter 6 discusses development of the workforce—including healthcare professionals, education and justice workers—through training and education and other strategies could improve access to care;
Chapter 7 examines the evidence received about the consideration of ADHD in the National Disability Insurance Scheme (NDIS);
Chapter 8 looks at how data, research and ADHD care models used overseas could improve the support of people with ADHD in Australia; and
The report concludes with Chapter 9, presenting the committee's views on the evidence it received and its recommendations.
Notes on references
1.9References to the Committee Hansard may be references to a proof transcript. Page numbers may differ between proof and official transcripts.
Definitions
1.10A range of terms and concepts are used throughout this report which are useful to define further, as follows.
Allied health care—health care provided by university-trained professionals who are accredited with a national accreditation body and/or part of a national professional association with defined membership criteria and/or clear national entry-level competency standards and assessment processes. A referral from a doctor is not generally required. It includes (but is not restricted to) physiotherapists, psychologists, occupational therapists and social workers.
Primary care—health care people seek first in their community outside of a hospital or specialist, such as that provided by General Practitioners (GPs), community health care centres and walk-in clinics, pharmacists, mental health services, and allied health professionals.
Secondary care—refers to care provided by specialists or other health professionals which are not a first point of contact, such as psychiatrists, paediatricians, or allied health professionals.
General practice—refers to care provided by a medical doctor with a speciality in providing comprehensive physical and mental health care in the community to individual patients. General practice—sometimes called family medicine—is often the patient's first point of contact in matters of personal health. GPs practice preventative medicine, coordinate the care of patients and refer them to specialists (amongst other matters). The term can also be used to describe a field of specialty medical practice.
Comorbidity—a medical term meaning a co‑occurring or coexisting condition or illness.
Specialists—medical doctors who work in a specific area of medicine, including psychiatrists and paediatricians. A referral from a doctor is generally required to see a specialist and Medicare should cover at least some of the costs.
Neurodiversity—diversity of human minds and all the unique and different ways that people can exist, think, act, process, feel and function.
Neurodivergent—an umbrella term to describe an individual whose mind or functioning diverges from dominant societal norms, standards or expectations including learning, processing, interpreting, feeling, behaving, communicating and more.
Neurotypical—describes an individual who is functioning within dominant societal norms.
Neurodiverse—describes a group or population of people who all have different minds or brains compared to each other. Society is neurodiverse, an individual cannot be neurodiverse as they only have one brain.
Neuronormativity—a set of standards, expectations and norms that centre certain ways of functioning as the right way.
What is ADHD?
1.11ADHD is a chronic and complex neurodevelopment condition. The diagnostic criteria focus on persistent patterns of inattention and/or hyperactivity‑impulsivity. ADHD can impact all elements of a person's life, including the way emotions and senses are regulated.
1.12ADHD impacts executive function and may initially become apparent due to how differences in executive function manifest. Common examples of differences in executive function include, but are not limited to:
ability to transition from one task to another;
ability to recognise and manage time conventionally;
ability to retain information in short term memory;
ability to manage competing tasks; and
tendencies to hyper focus on tasks and topics of interest.
1.13Currently, most people are diagnosed with ADHD before 12 years of age. However, through learnt behaviours—such as masking, individual environments and access to healthcare, many people are diagnosed much later in life or not at all. Orygen noted that although diagnosis usually occurs before 12 years of age, 'the symptoms can be hidden by a supportive and structured environment'.
1.14Access to healthcare, supports and other environmental and social factors determine the impact of ADHD in adulthood. ADHD does not resolve once a person reaches adulthood.
1.15The committee notes that not all people with ADHD define their experience through medical models of understanding and acknowledges that understandings of ADHD are constantly evolving.
1.16The committee further acknowledges that identity in the ADHD community is a varied and deeply personal experience. People with ADHD may or may not identify with their diagnosis, as members of the disability community, or as neurodivergent people.
1.17People with ADHD pay attention in non-linear ways based on interests and capacity, where tasks are easier to engage in if they can be done according to their own timeline, capacity and interest. People with ADHD may experience differences in sensory filtering and may engage in stimming to regulate, focus or gain sensory input.
1.18The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM‑5) diagnosis criteria for ADHD includes hyperactivity, restlessness, impulsivity, being easily distracted, and/or varying levels of self-regulation of emotion.
1.19There are three presentations of ADHD considered for a formal diagnosis:
the predominantly inattentive presentation;
the predominantly hyperactive-impulsive presentation; and
the combined presentation (symptoms of both inattentive and hyperactive‑impulsive subtypes).
1.20No single cause of ADHD is known at this point. The research supports that ADHD is an interaction of genetic, social and environmental factors—and is 'highly heritable' (estimated at between 70 and 80 per cent).
1.21Throughout this inquiry people with lived experience of ADHD have shared the complex challenges they have experienced as a result of government systems failing them. Due to the impacts felt across education, healthcare, employment and justice systems, and as a result of stigma and the expectations of neuronormativity, individuals report challenges with personal relationships, their mental health, finances and self-esteem.
1.22As noted by the Canberra and Queanbeyan ADHD Support Group, ADHD can be 'successfully managed through life if accurately diagnosed in the first instance, with early interventions using a multimodal approach', which means using ‘all the tools in the toolbox'. This can include pharmacological and non‑pharmacological (behavioural) supports and management.
1.23Chapter 2 explores these aspects of ADHD further through the experiences of people with ADHD, and its impacts on their lives and their families.
Diagnosis of ADHD
1.24In Australia, ADHD is predominantly diagnosed by a paediatrician, psychiatrist or psychologist. The assessment process relies on a range of information gathered from the individual, parents, spouses, teachers and other family members. A full assessment includes:
… clinical examination; clinical interviews; assessment of familial and educational needs; and assessment tools and rating scales.
1.25In Australia, ADHD is primarily assessed and diagnosed using the AmericanPsychiatric Association's DSM-5 introduced in 2013, although the World Health Organisation's International Classification of Disease (ICD-11) is also used. Changes in diagnostic tools over the years has likely resulted in an historical underestimation of the prevalence of ADHD.
1.26As outlined by the Australian ADHD Professionals Association (AADPA), the following key criteria from the DSM-5 are considered when diagnosing ADHD:
(1)A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. (Children: must have at least 6symptoms and adults must have at least 5 symptoms to meet criteria in the domains of inattention and/or hyperactivity-impulsivity).
(2)Symptoms were present before the age of 12 years.
(3)Symptoms are present in at least two settings [such as home, school or work].
(4)There is evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
(5)A diagnosis is not better explained by another condition.
Coexisting conditions
1.27For around 65 per cent of people with ADHD, it coexists with another physical and/or mental condition. This can increase the complexity and add to the impact of ADHD. The Royal Australian College of General Practitioners observed that 'people living with ADHD require individualised care which also diagnoses and treats these [coexisting] conditions alongside the ADHD'.
1.28Common coexistences or comorbidities in children include oppositional defiant disorder (40 to 60 per cent of children with ADHD), learning disabilities (46percent), autism (28 per cent), conduct disorder (27 per cent), anxiety (18percent), depression (14 per cent) and speech problems (12 per cent).
1.29The committee heard that coexisting conditions are common in young people with ADHD, and delays in accessing assessment and treatment for ADHD can often lead to more complex mental health disorders, compounding the challenges they experience participating in education, and impacting their capacity to participate in and benefit from treatment.
Typical assessment and diagnosis pathways
1.30Based on submissions to the inquiry, everybody has a different ADHD assessment and diagnosis pathway and story to tell. However, there are typical pathways that many, although not all, people seem to go through.
1.31ADHD assessment and diagnosis pathways are different for children and adults. Some people who suspect they or a family member has ADHD choose to take a medical pathway, seeking formal assessment and medical diagnosis by an appropriately qualified clinician—typically a paediatrician or psychiatrist. Amedical diagnosis enables people with ADHD to access pharmaceutical support, and additional supports in some cases.
1.32However, the committee recognises and respects that not everyone chooses to follow a medical pathway, with some choosing to seek their own supports, and others seeking screening and assessment (for example with a psychologist) and behavioural, diet, exercise and/or other supports rather than medication.
1.33For people who seek a medical diagnosis of ADHD, there appears to be a wide variety of pathways to formal identification of ADHD—with pathways often unclear and opaque. Figures 1.1 and 1.2 below outline typical routes to formal diagnosis for adults and children:
Figure 1.1Typical ADHD assessment and medical diagnoses pathways for adults
Source: Community Affairs Secretariat
Figure 1.2Typical ADHD assessment and medical diagnoses pathways children
Source: Community Affairs Secretariat
1.34As can be seen above, even with access to public services, assessment and medical diagnosis of ADHD in children is challenging and complicated, given the potential for coexisting conditions, different state and territory prescribing regulations, and development milestones which also need to be assessed for.
1.35Some of the disparities of the diagnostic and support processes between children and adults, and between the public and private health systems and discussed further in Chapters 3 to 5.
Prevalence of ADHD
1.36The prevalence of ADHD varies depending on the methods used to assess the condition. Prevalence estimates vary both domestically and internationally—ranging from between one and 20 per cent of the population in some countries,and two to five per cent of the population worldwide. It has been reported thathigher income countries tend to have higher prevalence rates of ADHD. InAustralia ADHD occurs in approximately six to ten per cent of children and adolescents, and two to six per cent of adults.
1.37Deloitte Access Economics (Deloitte) estimated that in 2019 there were 814500Australians living with ADHD, including 533 300 adults (aged 20 years and over) and 281 200 children and adolescents (aged up to 19 years), as illustrated in Figure1.3. ADHD Australia reported that today, around one in 20—or over 1.25million—Australians are now living with ADHD, with the ADHD Foundation suggesting it could be as high as 1.5 million Australians. Thismakes ADHD 'the most common neurodevelopmental disorder in children and adolescents' and 'suggests that it is one of the most common adult psychiatric disorders'.
1.38ADHD is diagnosed two to three times more often in males than females with an overall estimated prevalence in Australia of 4.9 per cent of males versus 1.5percent of females.
Figure 1.3Estimated prevalence of ADHD, by age and gender, 2019
Source: Deloitte Access Economics, The social and economic costs of ADHD in Australia, p. ii.
1.39It was submitted to the committee that insufficient research has been conducted on ADHD prevalence amongst First Nations peoples. However, there are indications that the prevalence may be higher, but under‑recognised, than for non-Indigenous people.
Social and economic costs of insufficient support
1.40As pointed out by a number of submitters to the inquiry, 'failure to provide adequate and appropriate ADHD services can have significant social and economic costs for individuals, families, and society'.
1.41The costs to individuals can be high. People with untreated or poorly managed ADHD can struggle to continue their education, maintain employment and reach their full potential—with 'long-term economic consequences for both individuals and society'. Particularly for those with coexisting conditions, unsupported ADHD can result in lower wellbeing, higher healthcare costs and decreased quality of life. ADHD can also significantly impact families and relationships, leading to increased stress, conflict and negative wellbeing, resulting in adverse outcomes for all family members.
1.42The evidence to the committee shows that these costs have deep and pernicious impacts on individuals' lives that cannot be understated. For this reason, Chapter 2 of this report is dedicated to describing those costs to individuals living with ADHD or caring for someone with ADHD.
1.43However, these costs are not only borne by individuals. It can be useful to identify the societal costs associated with ADHD to raise awareness of the socioeconomic impacts of the condition, with a view to facilitating early assessment and support to reduce 'the burden and lifelong impact that ADHD may have' on individuals and society.
1.44Deloitte estimated that, based on the prevalence of people diagnosed with ADHD, the total cost of ADHD in Australia in 2019 was $20.42billion, or $25071 per person living with ADHD per annum, as broken down in Figure 1.4 below.
Figure 1.4 Total costs of ADHD in 2019, by component
Source: Deloitte Access Economics, The social and economic costs of ADHD in Australia, p. iii.
1.45Employers were estimated to bear the bulk of financial costs (39 per cent), followed by governments (30 per cent), and individuals and their families (20per cent).
Productivity costs
1.46Deloitte reported that costs were concentrated in people aged between 25 and 44years, with productivity costs due to ADHD the highest, at 78 per cent of financial impact. This total includes the costs of reduced workforce participation, reduced productivity at work, loss of income, and the value of informal care provided by carers. Productivity costs were estimated to be $9.98billion in 2019, or $17 483 per annum for every Australian living with ADHD.
Health system costs
1.47In 2019 Deloitte estimated six per cent of costs could be attributed to the health system, at $814.5million.
1.48In this estimate, Deloitte included costs incurred in hospitals ($361.1million) and out-of-hospital care ($361.9 million)—the latter including GP, specialist, allied health and complementary or alternative medicine provider visits, including services accessed through Medicare.
1.49Health system costs also included $90.6million per annum on core ADHD medications, $64.1 million of which was government expenditure including through the Pharmaceutical Benefits Scheme (PBS), along with an estimated expenditure on government-funded research of $820 000 in 2019.
1.50The $361.9 million attributable to out-of-hospital costs is broken down further in Figure 1.5 below:
Figure 1.5Core out-of-hospital health costs attributable to ADHD
Source: Deloitte Access Economics, The social and economic costs of ADHD in Australia, p. 21.
1.51However, based on studies conducted overseas and a range of evidence provided to this inquiry, out-of-hospital health costs may be significantly higher than reported by Deloitte.
1.52Regarding the $90.6 million total cost of ADHD pharmaceuticals, including those supplied through the PBS, details on the drug type are presented in Figure1.6:
Figure 1.6Core ADHD medications costs FY2019
Source: Deloitte Access Economics, The social and economic costs of ADHD in Australia, p. 23.
1.53Costs associated with assessment, diagnosis and support, including for specialists, GPs and medications, are discussed in more detail in Chapters 3 and4.
Education, justice and other costs
1.54Deloitte noted that it took a conservative approach when estimating the non‑medical costs of ADHD in 2019, due to the limited Australian evidence available. Nevertheless, it estimated the 2019 costs of ADHD in relation to education, crime and justice as follows:
education—$106 million, at a cost of $4 764 per student per annum;
crime and justice—$307 million, including costs relating to policing, prosecution, courts, legal aid, community service orders, incarceration, and medical treatments;
deadweight loss from government expenditure on services and programs—$1.41 billion, including costs associated with reduced taxation revenue, and deadweight losses associated with taxation required to fund public systems (such as health, justice and education); and
other financial costs—conservatively estimated at $1.82 billion, including other costs to society, and costs associated with education and crime which were not considered in the above due to lack of Australian data.
Policy context
1.55Enabling and providing mental health assessment, diagnosis and support, including for people with ADHD, is the joint responsibility of federal and state and territory governments under the National Mental Health and Suicide Prevention Agreement 2022–2026 and Addendum to the National Health Reform Agreement 2020–2025, with responsibilities as outlined in Figure 1.7.
Figure 1.7Overview of Australia's health system—roles and responsibilities
1.56The arrangements recognise that collaboration is required across sectors, jurisdictions and governments. Evidence to the committee detailed later in this report supports the view that more needs to be done to:
… reduce system fragmentation, gaps and duplication across the public and private sectors, and across prevention, primary and secondary care specialist settings with an increased focus on prevention, early intervention and effective management of severe and enduring conditions in the community and tertiary settings.[43]
Healthcare
1.57The following section outlines the healthcare services which are available to eligible people with ADHD in Australia.
Medical treatment
1.58Through Medicare, the Australian Government provides patient rebates on some costs associated with diagnosis, treatment and management of ADHD, including:
bulk billed GP services, including bulk billing of longer consultations for eligible patients;
services provided by GPs and referred allied health practitioners to manage and treat patients under the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS [Medicare Benefits Schedule] (Better Access) initiative. This allows eligible people to access two or more courses of treatment within a calendar year, with a limit of 10 subsidised services;
rebates for up to two services for family members to improve clinical care of people treated through the Better Access initiative (for example, parent‑management training), from 1 March 2023; and
rebates for eligible people for investigative interviews carried out by a psychiatrist with family members during diagnostic evaluation.
1.59Once the annual threshold is reached, the Original Medicare Safety Net fully covers a person's out-of-pocket costs, with different thresholds depending on family status, whether they hold a concession card, and Family Tax Benefit PartA eligibility. Once the Extended Medicare Safety Net (EMSN) threshold has been reached a person will receive a rebate of 80 per cent of out-of-pocket expenses for out-of-hospital services or the EMSN cap for that service (whichever is lowest) per annum.
1.60Additional support is available under the MBS for people with ADHD in conjunction with other, coexisting neurodevelopmental conditions, including rebates associated with:
consultations with GPs;
psychiatrists and paediatricians;
telehealth video psychiatry services including for people in regional, rural and remote communities, and patients of Aboriginal Community Controlled Health Services; and
the assessment of patients under 25 years of age who have a suspected complex neurodevelopmental condition and access to allied health services.
Primary Health Networks
1.61These services are funded to provide mental health and suicide prevention services, including as part of the treatment and support of people with ADHD. Primary Health Networks can provide short-term assistance to help people function day to day and other psychosocial supports, as well as identifying local referral pathways, and helping people find which services are available to them locally.
Other free and low-cost services
1.62The Australian Government jointly funds a range of other existing and upcoming services with state and territory governments, which provide services to people with mental health conditions, including ADHD:
Head to Health Kids Hubs (zero to 12 years) to complement existing maternal and child health services, with 17 hubs to be implemented by 2027–28;
Head to Health Adult Mental Health Centres which will provide multidisciplinary care, with 15 centres operational and a total of 61 sites implemented by 2026–27; and
digital mental health supports including supports for people with complex mental health needs, online treatment programs and moderated peer support forums.
Pharmaceutical treatment
ADHD medications
1.63Psychostimulant medications commonly used to treat ADHD are classified as Schedule 8 'controlled drugs' under the Poisons Standard, administered by the Therapeutic Goods Administration. As explained by the Department of Health and Aged Care (Health and Aged Care):
Schedule 8 medicines are generally regulated through the Therapeutic Goods Administration. They're usually drugs that are listed as having a high addiction possibility. That's the broad, lay description. Basically, they're regulated as a schedule 8 drug because they have evidence to suggest a high rate of addiction and so need to be prescribed carefully. The actual prescription arrangements of schedule 8 listed drugs are regulated at the state and territory level.
1.64Health and Aged Care confirmed that scheduling of drugs is 'intended to promote uniform access across Australia' under the nationally agreed Scheduling Policy Framework. It also advised 'states and territories determine which healthcare professionals can prescribe medicines that are in the Poisons Standard, the controls over prescribing practices' and the enforcement of those controls.
1.65Under state and territory laws, 'prescription of psychostimulants is generally limited to psychiatrists and paediatricians', with varying state-based requirements. GPs and other primary care practitioners are permitted to prescribe psychostimulants in some jurisdictions, under limited conditions.
1.66The Australian Government is considering options to improve uniformity in the implementation of scheduling controls across states and territories to improve access to appropriate medications for people with ADHD. Changes to prescribing arrangements are a matter for state and territory governments and would require significant legislative reform.
1.67The AADPA has compiled a comprehensive resource that details regulations nationally, and is close to completing a national prescribing manual for ADHD medication to complement its clinical practice guideline.
1.68Prescribing arrangements are discussed further in Chapters 4 and 5.
Pharmaceutical Benefits Scheme
1.69The PBS supports access to medications, including those used by people with ADHD, by subsidising their cost. People taking medication subsidised in the PBS make a co-payment towards the cost of the medication, with the co‑payment reduced or medications provided for free once a patient or their family reaches the annual PBS safety net threshold.
1.70Not all adult ADHD medications are subsidised under the PBS, and there are limitations based on both age and dosage. For example, atomoxetine and guanfacine are only subsidised for adults as a second-line therapy, where a diagnosis was made between the ages of six and 18 years. Patients diagnosed as adults cannot access these medications through the PBS.
1.71Changes to the PBS in 2021 and May 2023 have meant that adults with a retrospective diagnosis of ADHD after the age of 18 years can access some long‑acting ADHD medications under the PBS that were not previously available, where these medications are prescribed by their health professional.
1.72Further changes to the PBS listing of medications can be made; changes must be initiated by an application for PBS listing from a pharmaceutical company or companies, or other stakeholder or stakeholders (such as individuals, professional organisations and/or consumer groups).
Healthcare workforce
1.73The Australian Government also has responsibilities for healthcare workforce training and development (in conjunction with states and territories). Workforce development requirements and initiatives are covered further in Chapter 6.
National Disability Insurance Scheme
1.74Some people with ADHD have access to the NDIS, whether their ADHD is considered their primary or secondary disability. However, there are others with ADHD who do not meet the legislated criteria for accessing the scheme.
1.75Evidence received by the committee about the interaction of ADHD diagnosis, treatment and support with the NDIS is discussed in greater detail in Chapter7.
Recent budget measures
1.76In the 2023–24 Budget, the Australian Government provided funding to tackle a range of issues, which are likely to impact people with ADHD:
tripling of bulk billing incentives under the MBS to support people under 16years, pensioners, and Commonwealth concession card holders to see their GP;
rebates for longer consultations of 60 minutes or more to enable GPs to provide higher quality of care for people with chronic conditions and complex needs, including those with ADHD;
reforms to expand the use of skills of the primary care workforce and improve access to multidisciplinary care;
$91.3 million to improve psychology training;
$17.8 million to upskill the broader health workforce in mental health; and
$4.3 million per annum over four years, invested in the Higher Education Disability Support Program to support more students with disability to 'access, participate and succeed in higher education'.
1.77These measures built on measures announced in the October 2022–23 Budget, which included:
$74.1 million in incentives to support doctors, nurses and allied health professionals to work in regional and rural communities;
$185.3 million to support more doctors, nurses and allied health professionals to work in regional and rural communities; and
$11.7 million for additional advanced skills training for rural GPs and generalists, including in paediatrics and mental health; and
$485.5 million to provide an additional 20 000 Commonwealth Supported Places in higher education institutions in 2023 and 2024, including for students with disability.
Community-based services
1.78Other not-for‑profit and community-based organisations and lived experience advocacy groups provide services to people with ADHD, which may be partly funded by government and/or membership fees and donations. They offer a range of services, including:
ADHD Foundation Helpline—staffed by volunteer councillors with lived ADHD and neurodiverse experience; the national Helpline supports people who need support and may be in crisis with provider recommendations, and accurate information about ADHD and related conditions, with an estimated 70 000 annual inquiries;
advocacy services—for people with ADHD and their carers to stimulate the development of responsive health services;
education and training—including webinars, newsletters and blogs with accurate and useful information about ADHD and its management, as well as paid programs for employers, such as services provided by the ADHD Foundation;
online—resources, advice and support for people with ADHD and their carers; peer support and self help, such as that provided by the ADHD Foundation; and
research—into ADHD, services available and service-user sentiment.
Education
1.79States and territories are responsible for providing and regulating school education. The federal Department of Education sets the education strategy for schools, as well as the national curriculum, national education priorities, disability support programs, and provides funding for schools, along with the state and territory governments.
1.80As part of Australia's Disability Strategy 2021–31 there are commitments to ensure that children with disability can access inclusive education from early childhood, and to improve educational outcomes for children with disability.
1.81All education providers from kindy to university are required to comply with the Disability Standards for Education 2005 which require them to provide education in a safe environment and make reasonable adjustments to allow students with disability (including those without a diagnosis)—such as ADHD—to 'access, participate, and learn on the same basis as students and children without disability', and with 'opportunities and choices which are comparable with those offered to students without disability'. This includes consulting with the person with disability, making reasonable adjustments, and eliminating harassment and victimisation.
School Resource Standard and other support programs
1.82Funding implementation is provided through the School Resource Standard (SRS) student with disability loading, which totals around '11.2 per cent of total Australian Government recurring funding in 2023'. The loading is calculated on the basis of data reported in the Nationally Consistent Collection of Data on School Students with Disability (NCCD). Data about students with disability, including those with ADHD, is provided by teachers and other classroom professionals, who indicate the level of support required by students (out of four levels).
1.83The loading amount per student is dependent on the level of adjustment required by the child using information reported in the NCCD. The dollar value of support ranges from zero dollars for students who are supported 'within quality differentiated teaching practice' (for example, explicit minor adjustments by teachers and the school such as personalised learning requiring no additional resources), through to over $40 500 for students needing extensive adjustments.
1.84It was estimated that in 2019 around 37 500 students with ADHD would have been eligible for this additional support.
1.85In 2023, the estimated disability loading by NCCD by student and level of adjustment was estimated as shown below in Table 1.2:
Table 1.2Final 2023 students with disability SRS loading by NCCD level of adjustment
| | | | | |
Primary student | $13 048 | $0 | $5480 (42%) | $19 050 (146%) | $40 710 (312%) |
Secondary student | $16 397 | $0 | $5411 (33%) | $19 021 (116%) | $40 665 (248%) |
Source: based on Department of Education, Schooling Resource Standard, 16 August 2023 (accessed 11September2023).
1.86The Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (Disability Royal Commission) noted the Australian Government has commissioned a report into the National School Resourcing Board's 2018 examination of the SRS settings. The report (Student with disability loadings settings review) has not been made public, however the Royal Commission understood there was 'ongoing work comparing funding and actual costs of adjustments for individual students with disability', as of September 2023.
1.87The Disability Royal Commission made several recommendations in relation to the Disability Standards for Education, the NCCD and SRS student with disability loading to make education more inclusive and accessible to disabled students and ensure transparency.
1.88The Department of Education also administers the Inclusion Support Program, which helps address the needs of early childhood education and care participants, by providing $133 million per annum to service providers.
1.89The National Early Childhood Program for children with disability or developmental concerns is also being implemented across Australia by the Department of Social Services and the Department of Education. It is aimed at children with disability aged up to eight years of age, to better support them and their families through better information, workshops, and supported playgroups and music groups.
Previous inquiries and reviews into ADHD
1.90A range of parliamentary committees have considered matters that relate to issues which have arisen in this inquiry. For example, this committee has previously inquired into the accessibility and quality of mental health services in rural and remote Australia. Additionally, the Senate Select Committee on Autism received evidence about ADHD as a coexisting condition.
Disability and Education
1.91The Senate Education and Employment References Committee recently received evidence about the impacts of ADHD in the context of increasing disruption in Australian school classrooms, and on school refusal/school can't. In its final report into school refusal, the committee found that school refusal is 'most prevalent among students with disability (particularly neurodivergent students) and those with mental health challenges. The inquiry heard that school refusal is a stress response by students who are not getting the adjustments they need at school, exacerbated by 'significant challenges in accessing support from the health system'.
1.92The committee made 14 recommendations, including the need for further research into the awareness and understanding of school refusal to be conducted, an investigation into the increase in subsidised mental health care visits for students experiencing school refusal, and the need for:
… state and territory governments [to] review their child health and development screening programs to identify opportunities to improve early identification of autism, ADHD, specific learning disorders, and anxiety disorders, in order to provide the classroom support these students might need.
1.93The committee also recognised the costs and difficulties of obtaining a disability diagnosis:
The committee acknowledges that the process of receiving a formal disability diagnosis is expensive and can have extended wait times. To this end, the committee recommends that state and territory education authorities and the non-government school sector work together to identify and implement measures to build the capacity of schools to provide reasonable adjustments for students in line with the requirements of the Disability Standards for Education 2005. This could include the provision of additional specialist support staff in schools and/or providing teachers with the opportunity to acquire Universal Design in Learning skills through additional professional development.
1.94The Joint Standing Committee on the National Disability Insurance Scheme has also received evidence from people with ADHD as a comorbidity to another disability for which they receive support under the NDIS.
1.95Other relevant inquiries are outlined below.
Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder in Western Australia (2004)
1.96In 2003 the Western Australian Parliament established an inquiry into ADHD in WA. The report of October 2004 considered the extent of ADHD, application of different diagnostic tools, availability of various treatments (including the lack of publicly funded services and the high use of stimulant medication), investigation of any links with drug addiction, the need for a more defined state policy, the role of the educational system and how to improve social wellbeing.
1.97The committee made a number of findings that remain relevant, particularly in relation to the need for more person-centred services, shortages of medical specialists and health professionals, the need for multidisciplinary assessment and treatment teams, misinformation and stigma associated with ADHD, and the economic and educational disadvantages experienced by people with ADHD.
The social and economic costs of ADHD in Australia (2019)
1.98Deloitte was commissioned by the AADPA to examine the socioeconomic cost of ADHD in Australia. The report provided an overview of ADHD prevalence in Australia as well as the financial, productivity and wellbeing costs.
Productivity Commission: mental health inquiry
1.99In 2020 the Productivity Commission handed down its report into the economic impacts of mental ill-health. The inquiry's terms of reference were broad and considered a range of mental health conditions and their impacts, including ADHD.
1.100The report investigated a number of areas for improvement including moving to a person-centred mental health system, supporting telehealth and online treatment, prevention and early intervention (for example, through the schooling system and youth employment), tackling physical and substance use comorbidities, integrated care models and addressing health care workforce issues.
1.101The report also looked at how services could be reoriented and how other support services could be activated, including in relation to:
community engagement;
supporting carers and families;
income and employment support;
addressing housing and homelessness;
addressing mental health in the justice system; and
investigating how better governance, funding, research, monitoring and evaluation could improve mental health outcomes.
Australia's children (2020)
1.102This report by the Australian Institute of Health and Welfare examined recent data on children and their families across a wide range of domains, including health, education, and social support, household income and finance, parental employment, housing and justice, and safety.
1.103One of the key findings of the report was that ADHD ‘was the most common disorder for children (8.2%). It was also the most common disorder among boys (11%)'. The report also found that that prevalence of ADHD decreased between 1998 and 2013–14, from 13 to 9.2 per cent.
2020 Review of the Disability Standards for Education 2005 (2020)
1.104In 2020, the Department of Education reviewed the Disability Standards for Education 2005 (Disability Standards)(which sit under the Disability Discrimination Act 1992) to determine if they were effective in supporting children with disability to access and participate in education.
1.105Key findings included that more accessible information, improved consultation principles, better issues resolution and complaints processes, and options to transfer information about reasonable adjustments be put in place when a student transitions within the education system to better empower students with disability and their families.
1.106There were also findings aimed at educators, to improve their awareness of obligations under the Disability Standards, as well as funding, training and guidance on implementation of the Disability Standards.
1.107The report called for better accountability for implementation of the Disability Standards, mandatory compliance data reporting, and national alignment of education policies and regulations in order to drive systematic change in the education system.
1.108The report discussed the challenges of students with 'invisible disabilities—including ADHD—and the difficulties of accessing reasonable adjustments, as well as a need for educators to have more training or information to understand the needs of students with diverse needs, in particular for First Nations students.
1.109As a result, the Australian Government has released new resources for students and families, as well as educators, and is progressing amendments to the Disability Standards to incorporate early childhood education and care.
Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability
1.110The Disability Royal Commission commenced in April 2019, and considered a broad range of evidence in relation to disabled people, including people with ADHD.
1.111The Disability Royal Commission tabled its final report on 29 September 2023, making 222recommendations on 'how to improve laws, policies, structures and practices to ensure a more inclusive and just society that supports the independence of disabled people and their right to live free from violence, abuse, neglect and exploitation'.
1.112The Disability Royal Commission inquiry was wide-ranging and large-scale, however in its findings and recommendations it shared some key overlaps with evidence received by this Senate inquiry. This included the need for the human rights of disabled people to be upheld, for society to be more inclusive and respectful, and for disability to be treated as part of human diversity.
1.113Other significant findings related to the need for disabled people to be empowered to have choices and independence, and to participate in co-design and co-production of laws, policies, services, systems, and research in order to share decision-making power and responsibility to ensure the most effective outcomes; and for the medical model of disability to be dismantled in favour of social model of disability to help reduce stigma and promote inclusion.
1.114The Disability Royal Commission make specific findings and recommendations important to First Nations disabled people and highlighted the importance of cultural safety and training. It also specifically considered matters relating to inclusive education and employment and the need to increase support and remove barriers to mainstream systems to improve outcomes and enable meaningful inclusion.
1.115The Disability Royal Commission particularly noted that cultural change is required in schools to ensure the differing requirements and needs of individual students are accommodated and supported. The commission acknowledged that education needs to be delivered more inclusively, and that education standards will need to be strengthened and educators upskilled to meet these challenges.
1.116In concluding its work, the Disability Royal Commission recommended that the Australian Government and state and territory governments table and publish their written responses to the final report by 31 March 2024, including details of whether the recommendations are accepted, rejected or subject to further consideration, and how recommendations might be implemented.
1.117The Disability Royal Commission also recommended that implementation of the recommendations should be overseen by the Disability Reform Ministerial Council, with regular reporting on implementation progress and independent evaluation of outcomes after five and ten years.
Select Committee into Child Development Services WA (continuing)
1.118The WA Legislative Council is currently looking at the provision and accessibility of health and wellbeing services to children through its Select Committee into Child Development Services—including services relating to ADHD and other neurodiverse conditions. The committee is due to report in December 2023.