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sMater - ADHD Diagnosis and Care - Dr James McAuliffe
In this week's episode of sMater, psychiatrist Dr James McAuliffe unpacks the evolving landscape of ADHD—from childhood to adulthood—and the growing role of GPs in diagnosis and care.
Tune in for practical insights and strategies to better support our patients.
GP Education activity log:
- Podcast title - sMater: ADHD diagnosis and care
- Provider - Mater Misericordiae Ltd
- Date published – 14 July 2025
- Certificate of completion - Download here
#mater #smater #adhd #adhdawareness #neurodiversity
To learn more about Mater, visit https://www.mater.org.au/
Hello and welcome to this episode of SMater, a podcast by clinicians for clinicians
brought to you by Mater, an Australian leader in healthcare for more than a century.
My name is Jillian Whiting. And I'm Dr Maria Boulton, GP and former president of the
Australian Medical Association of Queensland. And we're coming to you from Meanjin,
the land on which this podcast is being recorded. Today we're joined by Dr James
McAuliffe, Mater's child and adolescent psychiatrist. - James spent two years in
Central Queensland as a rural general hospital doctor before qualifying as a
paediatrician. He went on to train as a psychiatrist and now specialises in the
mental health of children, adolescents and young adults with a special interest in
ADHD and ASD. - We are matter. - We are Mater. - We are Mater.
- This is SMater.
James, welcome to SMater. Thanks for having me. Today we're tackling the hot topic
of ADHD and we appreciate it can be a complex area to navigate.
Firstly, if we can start with how ADHD presents differently at different stages of
the life span, adults and children. The initial and most obvious presentation is when
children hit school and it's the hyperactive impulsive child who cannot sit still in
the classroom, who cannot contain their excitement, their behaviour, their frustration.
So I think the initial presentation is the sort of presentation that people are very
familiar with. It's the stereotypical ADHD child. So I think that pathway I think is
quite well worn and well trodden over a lot of years. I think the thing that's
shifting as we become more aware of ADHD is the sort of the children and teenagers
who are older, who are not hyperactive or impulsive, but are particularly in a tent
of disorganised and unable to reach their potential. And so I think what's happening
beyond that or more stereotyped classic presentation is that there's an increasing
awareness that just because you're not naughty or just because you're not misbehaved
or just because you're doing well in school doesn't mean you can't have ADHD and I
think what's shifting is that people are becoming increasingly aware of that and
starting to come forth and say look I can't keep my mind on what the teacher's
saying. So I think that's the newer presentation when people are older and in their
later years of school and I'd say something very similar is happening with adults as
well, where there's an increasing awareness and it's those sort of problems in adults
who become aware via social media sort of posts or even the adults becoming aware
via family there's particularly their own children getting assessed, teachers suggesting
things and then in the course of interviews and assessments I'm mentally thinking I
did that I did that or I do that I still have that I've always struggled with
that so I think that's the shift that I'm seeing with ADHD presentations. And people
being more open to seeking support and help? Exactly yeah and it's not sort of
something that, yeah, the sense that this is me, I just have to put up with this.
There's nothing that can be done about this and sort of some pretty negative views
of yourself that have been internalized because that's all you've ever known and you
wouldn't have thought, hang on, this is a diagnosable developmental disorder that can
be treated really quite successfully. James, there's no straightforward diagnostic test
for ADHD but are there some useful diagnostic tools that GPs may be able to use?
You're right. I mean ADHD is a diagnosis that has an enormous amount of subjectivity
involved to it. It is defined by you know state of criteria, a set of criteria
that none of which are measurable.
So I would recommend, there's a number of quite freely available standardised
questionnaires, so they're usually based on the DSM criteria. So the ones that I
would recommend would be something like the SNAP -4, 4 with Roman numerals. There's a
Vanderbilt questionnaire out of the states that's been around for a long time. There
is ASRS, is another one, the ADHT self rating scales, and there's also sort of
various apps that are...
affecting 6 % to 10 % of children and adolescents. It also indicates that the best
estimates of prevalence in Australian adults is between 2 % and 6 % of the
population. A Senate inquiry into ADHD in Australia heard that expert care for
children with ADHD is in such high demand in the public system, and I would add
private system as well, that there are extreme difficulties in getting access. This
is not news to us GPs, with our patients facing long wait lists, both public and
private, and of course it's worse outside metro areas. For GPs who are looking to
refer children for more specialized care, particularly here in Queensland, what are
the options available and how difficult are they to access? And perhaps if you can
also touch on those available for rural areas as well. - So okay, I mean, you just
spot on when you say that there are long lists and there is no easy access to
care for these services as there are for a lot of specialized services or specialist
services in Queensland. So look, I think your local public pediatric services I think
is probably the most common pathway with respect to public. Public child and youth
mental health, as a rough rule, does not see and treat ADHD.
If someone is referred for that specific reason. If they're seeing someone who has
another mental health disorder who also has a diagnosis of ADHD, they will treat and
manage that. If they're seeing someone for severe and complex issues where they
think, "Hang on, I think part of this is ADHD," that will initiate treatment but
largely the the mental health public side of things does not touch ADHD and
Queensland. Privately I think you then obviously have both the psychiatry and
pediatric services. What's emerging more recently are some telehealth options which I
would suggest would be good options for people who are living regionally and
remotely. There are some pediatric services that do fly in, fly out clinics to these
more remote places, which could be an option. And there's also starting to emerge
some new services, both publicly and privately, that are using the...
They're using GPs who have a specific interest and some extra training in ADHD with
close, you know, I'll say supervision and input from either a paediatrician or a
psychiatrist who are then able to see, assess and manage a lot more patients when
it's not all down to one specialist. What are some of the things we need to watch
out for when you have a child with ADHD, transitioning to adolescence and then
adulthood? Yeah, so I think a key part of that going through to childhood,
to adolescence, to adulthood is the medication treatment.
The most effective medication treatment for ADHD remains the stimulant medications. And
the stimulant medications very frequently need to be titrated up as that young person
grows, gets bigger, they need bigger doses to do the same, I'm sorry to have the
same benefit because of that increase in that person's size.
So I think that's a really important thing to be aware of is that titration over
the lifespan is crucial to getting optimal management of ADHD and a dose that used
to work will not take that long to not work, particularly when someone goes through
their growth spurt around that sort of early adolescents. The transitioning to
adulthood, there can certainly be similar issues with needing high doses.
Most females' height tops out at about 16,
males is a year or two later, but what is not necessarily well known is that no
one's weight tops out at that age, and that all human beings of any gender continue
to gain weight up to and beyond their 20th birthday and take on their more adult
shape. And that then often necessitates a change in the dose of their medications
such that you can, you know, receive optimal management from that point of view.
- James, it's really interesting that the six to 12 year olds are used to form the
largest cohort for ADHD patients, but I I think since 2021, 2022,
the age group, their largest population is now the adult population, so people over
18, why is that? So look, I think I've heard this before and look,
my understanding is that historically there wasn't this sense that ADHD was a life
span condition. So there was a lot of children who received the diagnosis and then
it was kind of expected almost. You grow out of it or almost incorrectly. You go
out of it. So that's one part of it. The other part of it is I think that you
know childhood is defined you know roughly by that sort of six to 18 age group.
Sorry it's much younger than that but with respect to ADHD it's only six to 18.
There's 12 years of your life whereas the vast majority of people with ADHD are
treated beyond their 18th birthday and your adult life goes for a lot longer than
within 12 years beyond 2018. So there's just sheer weight of numbers that means that
everyone who's a child then graduates to adulthood and then often remains in need of
treatment for a lot of years and that's why there's more adults with a diagnosis
than children. Is ADHD increasing in prevalence or is it just that there's an
increase in awareness? The research would seem to indicate that the prevalence is
probably steady. I think what is changing is very much an awareness and I think
that's probably predominantly behind the increasing numbers of diagnoses but I think
it's also something to be cautious of. There are countries on this planet who have
have treatment rates exceeding 15%. And I think when that's way out of keeping with
the studies that are done that look at the incidence of ADHD, I think we've got to
be careful as a country that we don't go down that path. I think of treating
anyone who has some features of ADHD as if they do and prescribing the standard
medications when there's probably far more complex things going on that need to be
>> As GPs, you often have a child who's diagnosed with ADHD and then that child is
treated and stable and then the parent comes in and says, "I think I have ADHD."
Is it because it's front of mind or is there a big genetic link? >> I think it's
both. There's a massive genetic link. It really is. When I say genetic, there has
not been a gene identified they say, "Hey, this is the thing that gives you ADHD
"or the causes of it." It's more of that matter of looking at family trees and
family histories and things like twin studies as well that give you that very strong
genetic link, which is in the 90s percentage wise.
So I think it's very much there genetically. And I think you spot on when you say
that, "Hey, look, when someone is diagnosed with and treated with it and then
there's a greater social awareness or public awareness, it gets adults thinking and I
think that is the other significant factor behind those things. Yes. I still remember
one mum saying to me when I diagnosed her child and the, how to put it, the
customary major improvements that occurred. She said you know what I've been
reflecting and she said all my professional life I hide very assertive PAs who are
very good telling me what to do and when and I followed them. Now I've gone out
into consultancy in my own work. I am getting into so much trouble with my clients
because I'm not getting done the things that I say I will do and fully intend to
do. And so I think there's other things that sort of help people go along that I
think intelligent and intuitive people understand that this is how I need to run my
life. They make it happen but things can fall apart when circumstances in life
change and it's important to I think not dismiss them and sort of give those people
the treatment that they deserve and the assistance that they deserve because it is
life -changing.
A federal health department briefing published under freedom of information laws in
2023 illustrated the rise in ADHD prescriptions in Australia. It reported that ADHD
medication levels more than doubled between 2018 and 2022. 1 .4 million ADHD
prescriptions were given to 186 ,000 people in 2018 compared to 3 .2 million
prescriptions to 414 ,000 people in 2022. During the same period,
the cost to taxpayers through the PBS rose accordingly, from $59 .2 million to $151
.96 million.
We've talked about the increase in ADHD and the increase in awareness.
What can we do to address the growing need for ADHD diagnosis and management?
What are the opportunities for GPs? This is, I think, where it gets tough, because
I think a lot of what needs to be addressed is at a much bigger policy level. I
think there are things with respect to, I think, GPs taking their own interest,
potentially getting their own training, everyone is free to join professional
associations, there's one called HADPA, Australian ADHD Professionals Association, GPs
are very welcome to join that, to attend conferences, it's easy to learn through
those sorts of things and get on those networks. So I think there's a lot that GPs
can do with respect to their own learning and then I think not being afraid to be
involved as co -treaters with the involved paediatrician or psychiatrist and looking out
for I think my own anecdotal experience is there's a lot of GPs who will start to
look in their career for opportunities to do something a bit subspecialised and that
might be in an area of musculoskeletal medicine or breast cancer or ADHD treatment
or fertility. So that's a very long list. So I think that's the other avenues for
GPs to become more knowledgeable and more involved. So James,
if a GP wants to co -manage a patient, I mean sometimes we do get a letter from a
psychiatrist saying please police managers patient moving on but but say a GP wants
to be more involved how does that happen look I would suggest to two avenues one
is sort of discussing it directly with the patient and their family saying look I'm
interested in this condition I would like to be involved I would like to learn more
and I'd like to you know help you out more directly because it is not a small
thing to have to go and see a specialist on a regular basis for treatment of
something like ADHD and in my experience families and patients jump at the
opportunity to not have to come and see me every six months you know and I'm happy
to do that because you know for my mind it then it means I can see more see more
people who who need my input and and assessment and care so I think it's
approaching discussing it with the patient and or their
a phone call to the involved specialist, be that a paediatrician or the psychiatrist,
and I think there's very few of any specialists who would not welcome that
assistance and that interest and involvement. That extra support because there's been
no wait times to see a specialist can be sometimes. So how can GPs support their
patient through that time. Whilst waiting for that assessment I think it's the non
-pharmacological aspects of management that are important. So for younger people that
is going to be finding generally an allied health professional with a particular
interest in ADHD. So that is going to be spread across psychologists,
occupational therapists, sometimes speech therapists and senior nurses who might have
been mental health nurses or nurse practitioners who can engage the person or the
young person or others in the sort of cognitive and behavioural strategies that are
useful in managing ADHD.
Because it is a very important part of treatment as an effect size,
like it's not as big as what the medication results in, but I think it's a vital
part of any treatment. So I think it's good to get that started, but those people
also can be able to provide some really good education about ADHD and I think
whatever the significant health condition you have is or even minor ones, people do
better if they know how it works, if they know what it is and they know what it's
about and they can spot things when they're happening and and be aware and start to
sort of Change things themselves before they might then get into the specialist and
and start something such as medication treatment Each state has different legislation
around who can prescribe ADHD medication So can you clarify the legislation in
Queensland and where are GPs getting the guidance on this? Yeah So looking
Queensland, the legislation is that for the under 17 age group,
GPs have no restrictions around prescribing stimulant medications as long as they
stick to the standard dose guidelines. Once someone's turned 18, a person basically
has to continue to see a psychiatrist in order for the GP to be able to prescribe.
So there's a two, three page form that can be found pretty easily on Queensland
Health's website, sort of the Medicines Prescribing Authority for stimulants. So once
someone's 18, if a GP wants to be involved, they need to fill out that form,
submit it. So it's a reasonably quick turnaround and then that GP has permission to
prescribe to that person as long as they stick within the standard lines and and
that adult also has a psychiatrist involved who will see them every two years.
Every two years. That's the magic number is two years. GP will get approval to
prescribe for two years and then they'll have to return to see a psychiatrist to
you know to check that everything's happy everything is as it should be. James in
prescribing the psychostimulant medication what investigations should should we be doing
on children before they start those medications? Yeah depends a bit on the health of
the child in my experience the vast majority of children who walk through my door
are otherwise healthy. So there aren't standard I'll say investigations the thing that
I think is is crucial is is more observations and that's things around height and
weight with weight being more important because weight I think is a more sensitive
indicator of that person's nutritional status and you need to be making sure that
the child is continuing to grow along appropriate percentile lines in order I think
to feel comfortable to continue to prescribe. I think it's okay or appropriate from
time to time to check a pulse and a blood pressure but again in the vast majority
of people who walk through my door they're young people with healthy hearts and no
cardiovascular disease. So I think it's just the the caveats of that is does this
young person have a structurally abnormal heart? History of another cardiac condition
or is there a family history of something concerning? So concerning is not someone
having a heart attack in their 60s when they've been a smoker and had high
cholesterol etc etc. Concerning is when there's a history of some cardiac deaths at
young ages or particularly abnormal rhythms, cardiac rhythms that could have a genetic
component to it. We discussed the need for investigations in healthy children. How
about in adults that are looking to start the medications? Yeah, I think that's
where sort of a more thorough examination or interrogation of more general health
status is important, particularly in the cardiovascular area. So the older a person
is, I'd be far less concerned about a 20 -year -old starting a stimulant medication
as opposed to someone who's in there, let's just say mid to 40s and onwards, which
is happening and which is appropriate, but you've really got to then got to look at
what is this person's cardiovascular risk, what's their cardiovascular status.
You want to make sure that there's not a history of ischemic heart disease or
cerebrovascular disease, I think as increasingly as people leave school,
the, you've got to, I think, be a bit more mindful of potential for misuse and
abuse, and there are, there's more adults who are presenting to alcohol and drug
services, and there are children and adolescents, and so I think That's one factor
that you should have in the back of your mind, not in the front of your mind,
because I think it's, well I can go into that later, but I think it is looking at
general health, particularly cardiovascular, and occasionally also substance use when it
comes to adults. They're the sort of investigations.
ADHD Australia's Senate Inquiry Submission dated in 2023, noted that in Australia,
three in 10 people impacted by ADHD find it hard to get support and one in 10 do
not get any support. Furthermore, people with ADHD and their families view the best
source of support for ADHD to be from doctors and other health professionals followed
by family and friends, Facebook groups, ADHD support groups and website information.
Can a patient outgrow the need for medication? They can. And this is where it gets
a bit uncertain with respect to no one knows specifically what ADHD is and what is
the precise mechanisms of the problems within the CNS. So look, there is evidence
that with time, Heaple's burden of ADHD symptoms declines.
So with that decline, There is going to be a point for some people where they sort
of then fall below a threshold with respect to the burden from their ADHD symptoms.
So there's that natural decline that seems to occur. I think the other thing that
occurs is you grow older and more sensible, more mature, more experienced in life.
Whether you've got ADHD or not, you figure things out and you get better at
remembering things and not being late for work and getting the the washing done and
pay. So that normal process that happens for everyone happens in people with ADHD
and that can then sometimes mean that the person becomes less reliant on the
medication or can do without it. And particularly when you've been doing a job for
15, 20 years, you get pretty good at it and a lot of that is second nature or
you're on autopilot but for young people who are and, you know,
training at university and in apprenticeships, it's often pretty crucial. I'm sure you
and many other specialists have been in that position where parents may come in and
see you and have some concerns about whether their child really needs medication and
questions over whether it's addictive. What do you say, how do you respond in that
case? So look, with specifically with respect to addiction, there's no evidence that
this medication is addictive. You know, it is being given at very sensible calculated
doses that are there to try and switch on the parts of the brain that help you
with your organisation, your planning, etc. It is never given in doses that are
intoxicating, which is a pretty key part of a person becoming addicted to a
substance. And there is, you know, decades worth of experience with respect to the
use of these medications at the doses that they continue to be prescribed at, that
it doesn't result in addiction. And I often then tell concerned parents that there's
actually good evidence that treating ADHD results in a very significant decline in
issues with substance use, both as teenagers and adults. With the theory being that
if you have your ADHD treated, you are just odds on more likely to make better
decisions in your life across a whole range of things, including your use of
substances so that, yeah, so treating ADHD will decrease substance use and addiction
issues and that's been proven across a significant number of studies that have been
born out through even to the level of meta analysis that it is a good thing to
treat ADHD for that purpose. And it's the kind of, you need to be worried about
the opposite almost in not treating ADHD if you've got a concern about substance
use. - We've been hampered by medication shortages and it's a real shame when you
have a patient who's been very stable in a particular medication. Any tips on how
we can navigate that? - Yeah, so, yeah, Listexamphetamine or Vivance was the brand
that was significantly affected in the last, oh God, maybe I'll just put it out of
my mind 'cause it was so terrible. It was 12 to 18 months ago, I think, or across
the, yeah. And that one was a little bit easier in that there were different
strengths available and from those strengths you could get that person their usual
dose of that medication. The current shortages are across long eight or 12 hour
acting methylphenidate, you know, with concerta being the best no brand. And it's
harder one because you can't, every strength has been affected whereas,
and it's on the TGA's website is saying it's gonna be affected until the end of
the year. And it's just tougher to find alternatives to 12 hour acting
methylphenidate because they can't be split. You can't, you can cobble together other
doses, but when every strength is affected, and that's where it's sort of,
I think a lot of that is, you are, the person is needing to go back and see
their specialist to look at, do I switch to the alternative simulant, i .e. do I
switch to vivance, or do I cobble something together from the longer acting Ritalin
capsule, which will cover you for eight hours. So, you know, cobbling together
something with an eight -hour capsule and tablets to try and give you that 12 hours
of benefit that you were receiving from the concerta. We know that management should
be multimodal. So what strategies do you think have been shown to be really
effective and are some more successful than others or better suited to a particular
demographic? Medication treatment should be at the top of the tree,
I think with respect to treatment, but simply because that has been shown pretty
clearly to have the biggest effect on reducing ADHD symptoms. The other forms of
treatment, of the other forms of treatment, there's not a lot of strong evidence for
them. I think it's very sensible to use them and engage with them and recommend
them. But the strength of evidence isn't as great for those methods. So the next
most, I think, evidence -based treatment is the cognitive and behavioural interventions
for ADHD. Then there is a raft of other interventions that are looking at,
they've probably got a significant basis in cognitive and behavioural strategies, but
might be more on the family function and family therapy aspect,
working with teachers, working with exercise physiologists, so there's a whole ADHD
coaches, there's a whole range of people who are involved in managing ADHD.
It's just that we're yet to find the resources, et cetera, to study them in a
manner that would give us that confidence to make those recommendations. And the
other thing that has come from studies is that the non -medication interventions that
are required to make a significant difference are big and are very intensive with
respect to the number of hours that are required, the number of people that need to
be involved and the expertise of the people who deliver them. And so from that
aspect it's just hard I think for families to find the time resources and the
financial resources to really sort of give that its best shot. We're seeing an
increased number of people coming in saying they've googled or they've seen TikTok
and they believe that their child has ADHD or they may have ADHD.
How do you navigate this and make sure that you're not misdiagnosing?
Sure. I think the thing is, well, someone who's not a TikTok user or a subscriber,
I'm never going to be able to sort of specifically question what it is that they
saw. But I start with that simple question of, hey, what was it that you saw or
heard that made you concerned about this? Have you done any further reading? And
usually it's pretty easy to understand what it is that the concern is.
It's rare in my experience that people are off the mark when they've come in with
those concerns. And then I think it's a matter of starting with the specific concern
that came about as of watching something online and then expanding that into the
questioning around the other criteria of ADHD, be it through your own knowledge or
one of those standardized questionnaires. Absolutely, James. Thank you so much for
coming in for what was a really fascinating chat. Thanks for joining us on SMater.
But before you go, we have something we like to call the check -up. So Maria has
five quick questions to ask you. This is just about finding out more about you,
James the person. James, if a genie could grant you one wish, what would it be?
Only one wish.
Okay, it's the first thing that comes into my mind and this is something I
fantasise about and that is there is a a discovery made with respect to the
neurobiology of human beings which makes us far less self -centred,
horrible, paranoid and destructive. I think that's the first time we've heard that
and that is a cracker. James that's fantastic. Who was the last person you face
timed?
It would have been one of my parents. I think my son was trying to face time my
sister last night But it would have been it would have been my mum and dad if you
could impart one piece of knowledge on a medical student What would it be? My
advice would be keep going you'll get there if you want if you are right for the
thing that you want to do You'll get there. I think with respect to advice probably
comes out of my area of work here at the martyr and that is Don't ever assume
that someone with a disability doesn't have the conditions that are going on in all
of us, i .e. the mental health conditions that happen in all of us, because I see
that sort of dismissed on a regular basis and /or health conditions missed because
the time is not taken to really look at that person and find out what might have
gone wrong and address it when there is a major developmental disorder or
intellectual disability present. Very good reminder. And what was your first concert?
Yeah, I got wind of this one. It was either the baby animals at St Paul's Terrace
Hotel. Paul's Tavern? St Paul's Tavern. I don't think it exists anymore. Not sure.
The building's there, but I don't think the pub is. It was either that or the
Cranberries at Festival Hall. How do you want patients to see you?
Good question. Look, I would hope that they see me as someone who is accepting and
helpful but willing to tell them the things that are unnecessary,
which is sometimes tough or unpleasant, and I try and sort of cushion it with
humour. Perfect, James. Thanks again for joining us on SMater. Thanks for having me.
For our listeners at home or in the car are enjoying a well -deserved break, thanks
for tuning in. See you next time on SMater.