Chapter 7ADHD under the NDIS
National Disability Insurance Scheme
7.1The National Disability Insurance Scheme (NDIS) provides funding supports and services for people aged between nine and 65 years who have a permanent and significant disability. In the context of mental health and psychosocial disability, the NDIS provides non-clinical supports that help people improve functional ability and long-term recovery, including supports to:
do activities of daily living – that is, go about your daily life
take part in your community, your social life, study and work
regain and rebuild skills and confidence in your usual activities of daily living.
7.2The Department of Health and Aged Care (Health and Aged Care) informed the committee that NDIS eligibility is based on functional need, not 'solely on diagnosis':
… eligibility for access to the NDIS is not based on the type of disability or on the presence of an underlying condition, illness or injury.
Rather, a prospective participant must meet each of the five criteria to satisfy the disability requirements. That is, the person must have an impairment(s) that are, or likely to be, permanent, and result in a substantial reduction in their functional capacity to undertake one or more of the following activities: communication; social interaction; learning; mobility; self-care; or self management.
7.3As of March 2023, people accessing the NDIS and listing ADHD as a primary or secondary condition were as follows:
Table 7.1Number of people with ADHD on the NDIS, as of 31 March 2023
(years) | | | | |
0 to 17 | 148 | 3447 | 3595 | 291 237 |
18 and over | 40 | 1229 | 1269 | 300 822 |
Total | 188 | 4676 | 4864 | 592 059 |
Source: Department of Health and Aged Care, Submission 125, p. 24
7.4The Australian Government has commissioned an independent review of the NDIS, due to report by October 2023. The review is looking at the 'design, operations and sustainability of the NDIS, as well as ways to make the market and workforce more responsive, supportive and sustainable'.
ADHD support and the NDIS
7.5Health and Aged Care advised that, as shown in the table above, ADHD may be a person's primary or secondary disability in an NDIS application:
… some NDIS participants list ADHD as their sole disability in their application to the Scheme. There may be other participants where ADHD is their secondary disability. Not all people with ADHD will meet the access requirements under the NDIS Act.
7.6Despite this, a key concern raised consistently by many submitters—across organisations, professionals and people with ADHD—was the lack of appropriate support given to people with ADHD under the NDIS.
7.7Many submitters and witnesses argued that the primary cause of this was that ADHD, in their understanding, is not included as a primary condition for NDIS eligibility and that only people with a dual diagnosis—such as autism and ADHD— were eligible to receive NDIS support.
7.8This chapter will discuss eligibility for the NDIS, as well as concerns regarding assessment processes and the supports that are available under the NDIS, should a person with ADHD be deemed eligible for a NDIS package. Thischapter also explores the calls made in evidence for ADHD to be listed as a primary condition for eligibility for NDIS funding.
ADHD as a primary condition
7.9Health and Aged Care submitted data showing that NDIS access was available to people with ADHD as their primary condition, albeit at very low numbers—currently 40 adults in Australia are on the NDIS with ADHD as their primary disability.
7.10The evidence to the committee suggests there is widespread confusion as to eligibility under the NDIS for those with ADHD. The ADHD Foundation, for example, submitted that despite ADHD being included in the DisabilityDiscrimination Act 1992, it is not included under the NDIS.
7.11ADHDAustralia similarly noted that 'the National Disability Insurance Agency (NDIA) does not recognise or fund ADHD as a primary disorder, though funding may be received for a coexisting condition'.
7.12WA Health submitted that 'at the current time, a diagnosis of ADHD does not qualify a person for the [NDIS]. Children with ADHD are currently not able to access NDIS services.'
7.13Likewise, the Canberra and Queanbeyan ADHD Support Group submitted that 'unless another disability or another mental health condition exists, children, adolescents and adults with ADHD that results in impairment cannot access NDIS services'.
7.14The understanding that ADHD itself is not eligible for NDIS funding is not only found in submissions to this inquiry. The ADHD Foundation includes the following advice on its website:
As most people are aware ADHD does not appear on the list of disabilities supported by the NDIS, which means that unless there is another disability which could be a primary disability, the ADHD cannot be considered by the NDIS.
7.15The Australian ADHD Professionals Association also published information that the lack of inclusion of ADHD on NDIS access lists reduces overall access to the NDIS:
ADHD is not on the list of eligible conditions for entry to the NDIS. Although this does not exclude those with significant impairment from accessing the scheme, it has meant that no meaningful communication has been possible to educate the NDIS in the needs of those who are disabled by ADHD.
7.16In its submission, the Institute for Urban Indigenous Health quoted information from NDSP Plan Managers, a NDIS registered provider specialising in Plan Management, which states on its website:
Since you can treat and manage ADHD with medication and psychotherapy, the [NDIA] doesn't list this disorder as a disability. Currently, the National Disability Insurance Scheme doesn't consider ADHD a permanent disability or impairment.
NDIS and ADHD: eligible or ineligible?
7.17The belief that ADHD does not attract NDIS funding appears to come from the NDIA's List A and List B—known as access lists. These lists are outlined in the box below, and they capture a range of conditions that the NDIA deem as 'likely' to meet disability requirements and make a person eligible for NDIS support. ADHD does not appear on either list.
7.18Access lists were implemented during the introduction of the NDIS to help expedite access to the scheme for specific cohorts of people. However, the lists do not override the provisions of the National Disability Insurance Scheme Act 2013 (NDIS Act)—that is, people with ADHD 'can still become NDIS participants if they meet the requirements' of the NDIS Act.
Box 7.1 – List A and List B, NDIS Access Lists
List A: Conditions that are likely to meet the disability requirements provides a list of a range of conditions that means the NDIA will 'likely decide you meet the disability requirements'. These include conditions such as: Intellectual disability Autism Cerebral palsy Spinal cord injury or brain injury resulting in paraplegia, quadriplegia or tetraplegia Permanent blindness in both eyes Permanent bilateral hearing loss Amputation or congenital absence of 2 limbs – for example, 2 legs, 2 arms, or a leg and an arm (not a leg and a hand, or an arm and a foot). List B: Conditions that are likely to result in a permanent impairmentlists another range of conditions that means the NDIA will 'likely decide you meet the disability requirements'. These include conditions such as: Conditions primarily resulting in intellectual or learning impairment—intellectual disability, pervasive developmental disorders such as autism, Asperger syndrome. Chromosomal abnormalities resulting in permanent impairment. Conditions primarily resulting in neurological impairment, such as Alzheimer's dementia, Creutzfeldt-Jakob disease, HIV dementia, Huntington's disease or Parkinson's disease. Conditions primarily resulting in neurological impairment. Degenerative diseases of the nervous system. Conditions resulting in physical impairment. Diseases of myoneural junction and muscle. Conditions resulting in sensory and/or speech impairment. Congenital conditions that cannot be corrected by surgery. |
7.19Section 24(1) of the NDIS Act sets out the disability requirements for entry to the NDIS. Eligibility is not based on the type of disability, condition, illness or injury. Health and Aged Care advised that conditions being included on List A or List B was not a pre‑requisite for NDIS funding.
7.20Health and Aged Care also noted that the access lists for the NDIS were introduced 'as a mechanism during the transition phase of the Scheme, to expedite consideration of access for specific cohorts' and the lists were not intended to be an exhaustive list of eligible conditions.
7.21However, it is notable that these lists still remain in use on the NDIA website, and the website does not state that the list of conditions is not exhaustive.
7.22Instead of being diagnosis or condition focused, where an applicant must show they have a specific condition from the access lists, each NDIS participant must meet each of the five criteria to satisfy the disability requirements:
(a)the disability is caused by an impairment;
(b)the impairment is likely to be permanent;
(c)the permanent impairment substantially reduces their functional capacity to undertake one or more of the following activities: moving around, communicating, socialising, learning, or undertaking self-care or self-management tasks;
(d)the permanent impairment affects their ability to work, study or take part in social life; and
(e)they will likely need support under the NDIS for their whole life.
7.23Health and Aged Care confirmed to the committee that ADHD as a 'primary disability' could be considered for NDIS funding, noting that there are 4864 NDIS participants who list ADHD as a primary or secondary disability—and as shown in the table above, '188 had ADHD as their primary disability (that is, the impairment that has the greatest impact on their daily life) and 4,676 listed it as secondary'.
7.24The NDIA expanded on how it makes eligibility assessments:
The [NDIS] act itself doesn't list disabilities. We have some lists that help us guide decision-making. We put those lists in place through the early days of transitioning and rolling out the NDIS: we've got lists A, B, C and D. They help us as a decision-making guide for people who may be testing access to the scheme, but you don't need to be on any of those lists, per se, to [get access to] the scheme. There are a whole range of impairments and disabilities that don't appear on any of those lists, but we still assess a person's functional ability and permanency to access the scheme. ADHD isn't on any of those lists—that's correct—but that doesn't preclude anyone with ADHD testing access to the scheme.
Operation of the access lists
7.25There have been longstanding concerns with the existence of the access lists, because over time the 'focus became on what diagnosis someone may have, rather than their individual support needs'.
7.26Clinical psychologist Dan Jones, who also has ADHD, pointed out that the use of 'List A' over time has changed the diagnosis‑agnostic principles under which the NDIS was first established:
Initially, the NDIS focussed on the level of functional impairment in their assessment of a person's eligibility for the scheme. Sometime later, the document titled ‘List A: Conditions that are likely to meet the disability requirements’ was released. This document may have been a well‑intentioned resource. Yet, in practice, this document and its consequences undermined the ‘diagnosis agnosticism’ in the original intent of the NDIS. No longer were conditions that do not appear on List A likely to meet the requirements of the NDIS, regardless of the functional impairment a person may experience. Interestingly, no exact policy shift or change led to this situation. It was merely a cultural change within the NDIS, driven by the production of a list of conditions that were never intended to restrict NDIS eligibility.
7.27Mr Jones was of the view that adding ADHD to the list of primary disabilities would continue to undermine diagnosis agnosticism–saying '[w]hat instead should be recognised and implemented is the understanding that it is the functional impairment that is, and should have always been, key'.
7.28A person with ADHD provided details on his case, which highlights that despite claiming that ADHD can be recognised as a primary disability for NDIS purposes, the reality is often very different. This person had made a first application for NDIS support solely under ADHD, which was rejected. Later,when a diagnosis of autism was added, although the level of functional impairment remained the same, the second NDIS application was approved:
In my experience, the NDIS claims to accept people into the scheme based on their "functional impairment," but in reality, it will ignore all evidence of functional impairment if there is no accompanying diagnosis of a condition that they bureaucratically recognise.
It took me more than three years to reapply to the NDIS after being rejected. My ADHD made it largely impossible for me to bring myself to rewrite the application. Nothing substantial had changed about my application, yet it was accepted the second time. The person who rejected me the first $me is directly responsible (albeit unwittingly) for three additional years of suffering, for me, without support. This is, frankly, ridiculous.
7.29Disability Advocacy NSW argued that ADHD should be added to List B (conditions that are likely to result in a permanent impairment) and further recommended the NDIS develop 'clear guidelines for health professionals to write reports for the purpose of a functional assessment' and work with 'professional registration bodies to develop training and tools that can equip allied health professional with the skills needed to write reports'.
7.30The Public Health Association of Australia (PHAA) made the important point that some specific cohorts are both under‑represented among NDIS participants, while also being either under‑diagnosed or having higher prevalence of ADHD. These include:
Aboriginal and Torres Strait Islander people, women and girls, LGBTIQ+ people, people from culturally and linguistically diverse backgrounds, people living in rural and remote areas, people who are incarcerated, and people experiencing homelessness.
7.31The PHAA was of the view that 'targeted strategies to promote equity of benefit from any changes to NDIS eligibility is paramount to avoid compounding disadvantage'.
Functional impairment vs. defined conditions
7.32Many organisations recommended that access to the NDIS should be based upon the level of functional impairment, not a particular diagnosis.
7.33 The Royal Australasian College of Physicians (RACP) argued that:
… those with complex ADHD should be eligible for the NDIS. A functional assessment should consider comorbidities with ADHD; for example, anxiety, learning difficulties and trauma, that require NDIS funding to support sufficient psychology, tutors/learning support and parenting support. People with ADHD may benefit from the support of a life coach to teach strategies to help them to function more efficiently.
7.34However, the RACP also recommended that people should be able to access 'local, accessible psychology, occupational therapy, and speech therapy support without having to gain access through the NDIS' and argued this was particularly important at the time of diagnosis.
7.35The Royal Australian and New Zealand College of Psychiatrists recommended that 'eligibility and access to support from the NDIS should be decided based on the functional needs of the person with ADHD, and not based solely on diagnosis'.
7.36ADHD Australia likewise argued that:
The NDIS was intended to provide support for people based on their individual support needs, not their diagnosis. Complex cases of ADHD meet the criteria in the NDIS Act, but the fact that ADHD is not included in the NDIA's lists of conditions for eligibility undermines the goals of the NDIS Act. ADHD does not affect people in the same way. Similar to Autism, there are different levels of functional impairment which affect the everyday challenges a person living with ADHD experiences. ADHD is a lifelong condition; where a person clearly meets the NDIS criteria, they should be able to access reasonable and necessary supports under the NDIS … Eligibility for the NDIS should be determined following the core principles of the NDIS Act; taking into account a person's strengths, challenges and functional capacity, instead of their diagnosis.
7.37The PHAA noted in relation to ADHD:
… it need not be argued that ADHD in isolation be regarded as a condition creating a general eligibility for NDIS support. Nonetheless, it will also be true that some individuals who meet NDIS disability or early intervention requirements will be people with ADHD, and that ADHD will contribute to their overall function. Any individual applying to access NDIS should be assessed in line with the functional domains as listed above; the impact of ADHD on function should be considered as any other condition. Taking an ADHD diagnosis and treatment course into account should be normalized as a part of dealing with any individual's overall NDIS support issues.
7.38WA Health observed that not all children with ADHD require NDIS support but that 'there are some children with ADHD and other complex neurodevelopmental issues (which may not fall under the current NDIS banner) where a functional assessment might indicate that they should be receiving additional disability-related services.
7.39Responding to these views, the NDIA advised the committee that eligibility assessments are already being conducted on functional needs rather than aspecific diagnosis:
Certainly as we are assessing someone's functional impairment, we're often looking much more at the level of function rather than the clinical diagnosis. What is the impact of a person's disability on a range of daily activities? That's really where we are trying to work with allied health professionals to get that level of assessment from a functional capacity rather than a diagnosis.
7.40However, the NDIA also conceded that there is no ADHD‑specific training given to staff who are making NDIS access decisions.
NDIS assessment process
7.41For those people with ADHD who did make an application for NDIS support, the committee was told they often experienced persistent barriers during the process.
7.42For example, a functional capacity assessment needed for an NDIS application was said to cost between $2500 and $3500, which can be prohibitive for low‑income families.
7.43Disability Advocacy NSW pointed out that accessing the NDIS requires aVineland functional capacity assessment to be undertaken, which is based on a deficit model. However, allied health professionals such as occupational therapists are trained to write reports from a recovery-based model and often 'struggle to conceptualise their client's condition in the manner required for diagnosis and access to support services, even when their patient experiences significant impairment because of their ADHD'. Disability Advocacy NSW has found that this leads to assessments that do not adequately demonstrate that the person with ADHD meets the requirements for supports and services via the NDIS.
NDIS packages
7.44As well as raising concerns about whether ADHD was eligible for the NDIS and the associated barriers to making applications, submitters and witnesses discussed what supports should be covered by a NDIS package.
7.45The NDIA notes that NDIS packages are only able to provide financial supports that are not the 'responsibility of other service systems to provide (for example, your state government, the education system, or the health system)’. The NDIA notes that:
We don't fund supports to treat your impairment.
Instead, the supports we fund can help you reduce or overcome the impact your impairment has on your daily life. They can also help you increase your functional capacity, independence, and your ability to work, study or take part in social life.
Your impairment will likely be permanent if your treating professional gives us evidence that indicates there are no further treatments that could relieve or cure it.
7.46The Australian Association of Psychologists Inc. recommended the NDIS 'recognises ADHD as a primary disability and provides appropriate support, including access to diagnostic assessments, evidence-based interventions, and ongoing care throughout the lifespan'. However, NDIS packages are only available after a diagnostic assessment regardless of which condition a person may have. Assessment funding via the Medicare Benefits Schedule is discussed in detail in Chapter 3.
7.47The ADHD Foundation noted that 'ADHD is highly treatable with up to 70% of symptoms able to be controlled by medication'. This could mean that those treatable symptoms do not meet the eligibility criteria for NDIS funding, as services available through the health system are able to manage those 70percent of symptoms. It does mean, however, that there is a possible remaining 30per cent of symptoms that cannot be alleviated by medication and may therefore be eligible for support under the NDIS.
7.48The PHAA contended that the NDIS should not shy away from providing ADHD support:
… evidence-based recognition of ADHD as a relevant condition for NDIS purposes will not result in the NDIS assuming any excessive degree of responsibility for people with ADHD generally. Adequately funded services with clear referral and access pathways in the mainstream health system will continue to be a major source of ADHD diagnoses and treatment.
Concurrent support pathways
7.49Many submitters argued that a key type of support that should be funded—either under the NDIS or by other mechanisms—was behavioural supports in the form of psychology support, cognitive behavioural therapy or ADHD life coaching.
7.50Dr Wee-Sian Woon, a GP and current Churchill Fellowship recipient investigating 'models of care to increase accessibility for diagnosis and management of ADHD in adults' recommended that for people with ADHD the NDIS should provide:
… access to an occupational therapist for assistance with work, finances and daily living, psychologist for Cognitive behaviour therapy, as well as ADHD coaching as another management option.
7.51The Consumer Health Forum of Australia submitted that while many people with ADHD might be advised by clinicians to seek an ADHD coach or occupational therapists, this didn’t necessarily assist with NDIS access:
… most consumers we spoke to had not been able to access funding through the National Disability Insurance Scheme (NDIS) unless they have a co‑occurring condition like ASD and so cost remains a barrier, even after diagnosis'
7.52Disability Advocacy NSW similarly noted that while psychology can be accessed via a mental health care plan, ADHD coaching is 'relatively new, and not accessible through MHCP [Mental Health Care Plans], and are currently self-funded'. Disability Advocacy NSW recommended that because many people may not qualify for the NDIS, qualified coaching 'should be subsidised under Medicare, as a vital first step in receiving a diagnosis which then provides pathways for support'.
7.53The RACP similarly advocated for NDIS funding for 'psychology, tutors/learning support and parenting support' and also 'the support of a life coach to teach strategies to help them to function more efficiently'. However, the RACP also noted that its members 'emphasised the need to provide local, accessible psychology, occupational therapy, and speech therapy support without having to gain access through the NDIS'.