With more Australians than ever being diagnosed with ADHD, how do the treatments on offer stack up?
Everyone is talking about attention deficit hyperactivity disorder these days. And as the term "ADHD" entrenched itself in modern parlance it felt like everyone was eager to "diagnose" me with it, too.
They were everywhere: People I loved — my sister, my best mate, other close friends. People I barely knew — acquaintances from picnics and parties whose energy and brio drew me to them instantly.
Invariably, after an hour of fast-paced, wildly meandering conversation, these new friends revealed their own ADHD diagnosis and then informed me I was "almost definitely" one of them.
Such interactions made me suspicious: None of them was qualified to make the diagnosis; yet as well as freely diagnosing me, some had even diagnosed themselves.
Nevertheless, I was curious. Could all of these unqualified observers be right about me?
ADHD is found in about 8 per cent of children and adolescents with boys twice as likely to be diagnosed. Up to 6.7 per cent of adults show symptoms with rising rates of women being diagnosed as awareness improves.
ADHD diagnoses have been skyrocketing in Australia over the past decade. The number of Australians prescribed ADHD medication grew by almost 300 per cent in a decade, rising to 470,000 people in 2022-2023. While this figure doesn't precisely reflect the growth in cases because one patient may be issued with more than one prescription, there are now about one million Australians diagnosed with ADHD.
By some estimates, it is the most common mental health condition on Earth, affecting more than 360 million symptomatic adults worldwide.
Research by Deloitte Access Economics estimates the condition costs Australia more than $20 billion per year.
I decided to seek out a proper assessment by a psychiatrist and in August 2023, my ADHD journey began.
An 'equivocal' case
I waited six months for an appointment with a Sydney-based psychiatrist who specialises in ADHD. The assessment cost $530 for a 90 minute consultation with a Medicare rebate of $237.45.
I was lucky. Diagnosing and treating ADHD has become big business in Australia. Some clinics charge $2,000 for an assessment and others who are facing long wait lists have been told they'll be pushed to the front of the queue if they pay $3,000.
It's no surprise that some choose to bypass formal diagnosis altogether and, like those I met at parties, self-diagnose to save both time and money. And there's no shortage of celebrities and TikTok reels supposedly laying out the symptoms.
Melissa Webster, CEO of ADHD Australia, warns against self-diagnosis. "It's important individuals get diagnosed accurately by trained psychiatrists or psychologists," she says.
My psychiatrist explained there are three main subtypes of ADHD.
The impulsive/hyperactive subtype fits all the stereotypes of the condition such as inability to sit still and regulate emotions or, paradoxically, a tendency to hyper-focus on specific topics. Hyper-focus behaviour leads some to call ADHD a superpower. But more on that later.
Two other recognised ADHD subtypes are known as inattentive/distractible, typically featuring a calmer demeanour but great difficulty focusing on tasks and keeping organised, and a combined type with symptoms of both inattentive and impulsive.
My psych administered a questionnaire, digging into my behaviour. I was asked questions like, "How often do you have problems remembering appointments or obligations?" (not too often) and "How often do you find yourself talking too much when you are in social situations?" (often), and "How often do you lose things?" (occasionally).
In Australia ADHD is identified by nine inattentive and nine hyperactive-impulsive behaviours listed in the Diagnostic and Statistical Manual version five — the "bible" of mental health conditions used by psychologists and psychiatrists. For children, six of the nine symptoms must be observed. For adults, five of the nine are required.
The questionnaire took me about 75 minutes to complete verbally with the psych and when it was over the psychiatrist told me I had "an equivocal case", mostly of the first ADHD subtype, hyperactive/impulsive.
"Gary presents with an interesting confluence of problems," my psychiatrist wrote in his summary report. "He seems to be describing a longstanding combined subtype of ADHD" which, he says, is characterised by "hyperactivity and impulsivity, and some level of inattention."
What that means is that while I did show symptoms of ADHD my scores were borderline: it was hard to say with certainty whether I definitively do or don't have the condition. Unlike many other health conditions there's no blood test that can identify ADHD. Brain imaging also shows conflicting results.
Yet even as a borderline case, my psychiatrist immediately offered medication. It was suggested that I take a tablet of Vyvanse, a stimulant medication, once a day.
As an equivocal case my diagnosis felt to me like a judgement call. I couldn't shake the feeling that another assessment may draw a different conclusion. I was left with a dilemma: Should I take the medication?
Medication can be life-changing
Many with ADHD report that medication — typically a stimulant but treatment can also include non-stimulants and antidepressants — allows their true selves to flourish. Some even call it life-saving because the chaos of their lives with ADHD was so unmanageable.
Kealey Nutt, 38, tried everything to manage her ADHD symptoms from cognitive behaviour therapy to apps, vitamin supplements, journalling, calendars, diaries, lists and executive coaching until starting medication 18 months ago.
"It's definitely not a 'cure' — I still experience symptoms — but the medication definitely helps," she says. "It calms me."
For journalist and author Ginger Gorman, 48, ADHD medication has overturned her paralysing depression and anxiety that left her "barely able to get out of bed" — a consequence, she says, of perimenopause combined with ADHD.
Gorman believes accepting a prescription for the stimulant medication Ritalin changed everything for her: "Within 20 minutes, I no longer felt depressed or anxious. I could finally think calmly and clearly. If I'd have known how life-changing it would be, I'd have done it long ago," she says.
ADHD medications work by adjusting the levels of specific neurotransmitters in the brain, such as dopamine and norepinephrine (also known as noradrenaline), and in turn influence behaviour.
Yet for me, as a borderline case, going on daily medication that altered my brain and possibly even my personality did not feel like the right step. My frustration at being unable to focus has been linked to smartphone addiction, as well as my natural impulsivity, energy and hyperactivity. While having their downsides, these are often the traits people say they like in me.
It's established that the way medication helps those with ADHD to focus can also sometimes cause what's known as "emotional blunting" — a clinical term describing reduced emotional responses. In the case of ADHD it means dulling some of the energetic spikes that typify the condition, and personality, of those with neurodivergence.
I worried about whether I was being caught up in a "diagnosis culture" where many place themselves on a spectrum of disorder and medicate away difficult personality traits.
I decided to decline medication. Instead, with my psychiatrist's support and advice, I began to investigate alternatives to managing my equivocal ADHD diagnosis.
The rise of the ADHD coach
With medication ruled out for me, my psychiatrist recommended an ADHD coach, a profession on the rise in Australia. Coaches aren't trained clinical mental health professionals, cannot diagnose or prescribe medication and there's no regulator for this rapidly-growing new industry which one coach describes as the "Wild West". This means anyone can call themselves an ADHD coach.
The question is: are ADHD coaches actually effective?
In 2009, Perth-based Dr Michele Toner became the first ADHD coach in Australia qualified by the International Coaching Federation (ICF). She has since mentored 50 others.
Toner says there are ways to help ensure a coach has expert training. Accreditation by the ICF is key. There are five approved institutions in Australia. Toner has created a directory of qualified coaches "in response to requests from doctors who routinely refer their patients and value ADHD coaching as a modality".
One coach on Toner's list is Liz Welshman, who first heard about ADHD coaching in 2020 when her son, then five, was diagnosed. His paediatrician recommended an ADHD coach in addition to medication, but she couldn't find one with availability. So, Welshman took a course herself, completing nine months of lectures and study with a US provider.
"I fell in love with it," she says. "That trajectory is common for ADHD coaches — some sort of lived experience, they get obsessed, then find themselves working in the field."
Research by the Australasian ADHD Professionals Association, which has guidelines on the diagnosis and treatment of ADHD, found coaching "could" be beneficial and recommended further investigation.
Welshman does no marketing to recruit clients and has a two-month waiting list. Many clients are referred by psychiatrists. She also sees clients who, like me, have declined medication in favour of coaching. About 80 per cent of her clients are adults.
"Some have been prescribed medication and didn't like the side effects; others didn't find it helpful, and some clients want to manage ADHD themselves," she says.
However Welshman urges her clients to also receive a clinical evaluation. "ADHD symptoms can be similar to those of other health conditions and we're not clinicians, we're coaches, we can't diagnose," she says. "Having said that, if clients are feeling symptoms of distraction and procrastination to the point of impairment, coaching can help with those challenges."
Lauren Chesher, 39, opted for coaching and medication to help manage ADHD symptoms. "I could never be on time. I'd lose all my stuff" and was often left feeling "hopeless and helpless", she says.
After struggling to find an appointment with a psychologist or psychiatrist Chesher "gave coaching a try". Coaching has helped her understand her brain "in a really affirmative way" after she struggled with burnout from her corporate job.
"Coaching has taught me I need to rest after coming out of a hyper-focused state and made me feel proud of the things I can do due to the hyper-focus," she says.
The epiphany came from a metaphor. "My coach said, 'Some are sprinters, others are marathon runners. You're sprinting, and sprinters can't maintain that pace consistently — you need to build in breaks to rest and recover'."
It was a mindset shift that Chesher says changed her life: "I realised I'd been running a marathon at a sprinter's pace. Hence the burn-out."
Chesher's coach also helped structure her day differently, building in flexibility to rest and attending group ADHD coaching sessions, where she learns from others like her.
Dextroamphetamine, one of several chemicals used in drugs that treat ADHD, helps Lauren "stop the noise" that distracted her pre-diagnosis, she says.
How affordability impacts treatment
Everyone's ADHD presents differently, Welshman says.
"Some have the incredible ability to hyper-focus on an area of interest and make connections between seemingly disparate concepts. Fantastic. That's their superpower," she says.
Ginger Gorman agrees: "I also love that it allows you to put ideas together that others don't. ADHD comes with a lot of gifts: high creativity, high energy, a unique way of telling stories with detail and side-quests, which I've always found intriguing and exciting."
But ADHD as a superpower can be a fraught concept.
Welshman says the claim that ADHD should be viewed as a superpower can be "a really invalidating narrative" for those who find the condition "incredibly impairing".
Common problems Welshman's clients bring to coaching sessions include emotional dysregulation, impulsive spending and inability to control clutter. While ADHD coaching can assist with managing these behaviours when they cause difficulties, Welshman points out a flaw in the current system of coaching is that it places responsibility for making and attending appointments on the person juggling the condition.
"I see the people who have the resources to book themselves in for coaching, so I'm probably not seeing those most impaired by ADHD, who may struggle to self-advocate," she says.
Every individual will seek the treatment that’s right for them — whether that’s medication, coaching or other coping strategies.
Nevertheless, there is another reason why medication is often the go-to treatment for ADHD.
While medication subsidised by the Pharmaceutical Benefits Scheme still costs money, in most cases it is far less expensive than coaching. It is also harder to guarantee how an individual will respond to coaching.
ADHD Australia advocates for support from the NDIS — which doesn't currently include ADHD — and for medication to fall under the PBS, which subsidises several ADHD medications. The organisation also offers workplace training to help leaders better understand ADHD. ADHD coaching doesn't attract rebates either from Medicare or health funds.
A one-hour session with Welshman costs $190. A box of 100 tablets of Ritalin, for example, costs less than $20 including the PBS discount. It's one important reason Kealey Nutt chose medication over coaching.
"I have investigated ADHD coaches several times in the past year but the cost is really prohibitive," she says.
Coaching felt like a "financial risk" she says, questioning whether practitioners were sufficiently experienced or the possibility she may not respond to treatment. Medication felt like a safer bet.
For some clients, coaching ends when goals are achieved but Welshman admits for others it's "when the money runs out".
ADHD Australia's chief executive Melissa Webster says "many individuals within our ADHD community speak very, very highly of the success and outcomes from coaches, provided they've received the appropriate training".
One pilot study found "potential positive outcomes" for those using ADHD coaches, but noted that "further robust research is needed" to inform its broad application to those with the condition.
From client to coach
Like Welshman, personal experience with ADHD sparked Gareth Minife's interest in working as an ADHD coach. At school, three labels were slapped on Minife, who is 38: gifted, anxious, depressed.
"I was hyperactive, over-achieving, and would sometimes work 24 hours straight in my job selling and repairing bicycles," he says.
It was unsustainable. Minife booked an ADHD assessment two years ago, which confirmed he had the condition.
"I was a jack rabbit right up until diagnosis," he says.
Therapy with a psychiatrist, and medication, followed.
"My initial sessions with a counsellor didn't work out so well for me, and medication alone didn't solve all my issues," he says.
Instead, Minife went to see an ADHD coach and found that relationship more trusting and beneficial.
"They would help me out of mental spirals and suggest strategies to better organise myself," he says.
After eight months, he found he could manage his symptoms alone and stopped coaching. His experience was so positive Minife is on track to be accredited as a coach with the ICF.
Demand for his work is already clear: Without any marketing Minife has clients referred to him, the "ADHD Fairy", by word of mouth. Now after his shift from client to coach, he sits on the opposite side of the couch.
"Usually if coaches sit, listen and ask the right questions, the person eventually comes up with an idea to solve the issue themselves," he says. "Our job is to filter the positive from the negative, but it's totally led by them."
'I don't need to change. The system does'
Christine Sully, 55, says she suspected she had ADHD after several family members, including her sister and her 15-year-old daughter, were diagnosed.
Medical research has not yet confirmed what causes ADHD — a range of factors are suspected from variations in multiple genes and environmental risks such as heavy metal exposure and pregnancy complications that impact brain development.
But it's clear ADHD runs in families. Research suggests first-degree relatives are up to nine times more likely than average to be diagnosed with an up to a 91 per cent likelihood that a parent with ADHD will pass it on to a child.
Sully says it became impossible to ignore her own similar, symptoms. Against wisdom, Sully is one of the self-diagnosed and now addresses her symptoms using mindfulness and movement breaks.
"I struggled all through school and was expelled at 15 because of my inability to concentrate," she says. "I had jobs and would get the sack after a couple of months."
Sully saw similar struggles in her daughter, who was burning out, sleeping lots, felt she wasn't coping and stopped wanting to attend school. Medication followed her daughter's formal diagnosis. "She tried several, including Ritalin, but it made her moody, flat or exhausted, so she stopped taking it," Sully says.
Her daughter's school psychologist insisted that if she was to stay enrolled, she had to take prescribed meds, Sully says. "All her bubbly creativity just stopped."
Finally, Sully put her foot down and her daughter stopped the medication. They didn't tell the school. "We told them we'd experiment with different meds and options," Sully says. "We didn't mention one of those options was no meds at all."
Now her daughter has a different school experience. She skips subjects or shortens her school day to avoid burnout, says Sully who is a believer that medication should be tried only after self-regulation strategies have been attempted and failed.
Sully is an advocate of the ADHD as a superpower philosophy. She argues that treatments attempting to shave off the non-neurotypical edges of a person with ADHD contributes to low self-esteem. Her views tap into the highly emotional nature of ADHD diagnosis and treatment and point to the need for individualised responses.
"Medication should be a final, not a first, point of call. My daughter was prescribed it at diagnosis," she says. "People's neurodiverse personalities are wonderful just as they are. Medication, to me, is neurotypical people saying, 'You need to fit into our world'."
But she believes such views are hard to assert in the healthcare system: "It's hard to self-advocate to a psychiatrist offering medication by saying, 'I'm not the one that needs to change. The system does'.'"
Yet clinical psychologist Emily Hanlon emphasises that untreated ADHD can increase the likelihood of risk-taking behaviour, particularly substance abuse, which can be used to self-medicate. She believes properly prescribed ADHD medications reduce these risks. While psychological therapies are also effective, Hanson argues in the short term few interventions are as impactful as medication.
"When combined with therapy, lifestyle adjustments, and skill-building strategies, treatment empowers individuals to thrive with ADHD, dramatically improving their quality of life," Hanlon says.
The risk of over-diagnosis
Critics of the system include the Critical Psychiatry Network Australasia, a group of mental health professionals who believe ADHD is over-diagnosed and over-medicated.
The reasons for rising ADHD diagnoses are complex and include increased awareness and recognition of the condition by both individuals juggling symptoms and frontline medical staff.
Some research also suggests cultural difference in the perception of ADHD symptoms — which are rated according to how often a patient or parent perceives the behaviour — contributes to differences in diagnosis rates between countries.
Another study showed lower mean ADHD scores in Norway and Sweden compared with Australia and the US, concluding four factors explained the difference: genuinely more cases in the US and Australia, a tendency to over-report in Australia and the US, and under-reporting in Scandinavia.
The research also argued that children starting school earlier in Australia and the US "indicated a context difference" that meant behaviour considered disruptive was more likely to be labelled ADHD.
Yet another explanation may be the benchmark for diagnosis. While the DSM-5 is commonly used in Australia and the US, in Europe the International Classification of Diseases (ICD), which uses a different set of diagnostic criteria, is the go-to.
The ICD standards only diagnose children with ADHD when their behavioural symptoms are considered severe, while the DSM-5 criteria includes mild or moderate behaviour shifts as symptomatic of ADHD.
Whether the different figures reflect better diagnosis and treatment in Australia or over-diagnosis and over-treatment continues to be researched.
Clinical psychologist Mariane Power says Australia's ADHD rates likely reflect greater awareness and access to diagnosis rather than over-diagnosis.
"Diagnosis remains inaccessible for many, especially women and people of colour, due to systemic barriers and longstanding biases in research and healthcare," Power says. "Continued awareness and improved diagnosis are critical to unlocking the potential those with ADHD have to maximise their out-the-box thinking, creativity, problem-solving, and justice sensitivity — qualities essential for driving innovation in our rapidly changing world."
A rapidly expanding, unregulated industry
Wherever a patient and their doctor land on the subject of medication, growing numbers of psychiatrists are recommending ADHD coaching as a complement to drug treatment.
Psychiatrist Dr Albert Veloso says that such coaches form "an important part of the support system for people with ADHD".
The strength of coaching can also be its weakness.
Coaching is more action oriented and, in an unregulated industry, individual coaches have more freedom in the way they deliver help to those with ADHD. Yet psychologists and psychiatrists are eager to emphasise the difference between clinical mental health practice rooted in science, and coaching, a more flexible treatment. Veloso notes his concern about the quality of training and experience different coaches offer.
It's a concern shared by Emily Hanlon, a clinical psychologist who specialises in ADHD assessment and intervention.
She praises ADHD coaching for providing "practical strategies for organisation and goal-setting" but says it's important to understand its limitations.
"Unlike psychologists, ADHD coaches aren't regulated by a governing body, meaning their qualifications and approaches can vary significantly," she says. "This can pose risks for individuals needing support beyond skill-building, as deeper emotional and cognitive challenges may go unaddressed."
This is important because, she says, "many ADHD'ers have comorbid conditions like anxiety that require the expertise of trained mental health professionals".
In November, a Senate inquiry into ADHD reported that barriers of access to treatment (waiting times, costs) have significant flow-on effects. Those with ADHD face shorter life expectancy and higher rates of incarceration, sleep disorders, anxiety, depression, substance abuse and suicide.
The experience of someone like Lauren Chesher suggests people diagnosed with ADHD receive huge benefits from coaching, medication or both.
But how to respond to my diagnosis leaves me in a Catch-22: I'm not keen on taking medication yet I'm unable to afford an ongoing ADHD coach. When it comes to "equivocal" cases like mine, the costs can feel harder to justify for this expensive and increasingly ubiquitous condition.
Credits
Words: Gary Nunn
Editing and production: Catherine Taylor
Illustrations: Dylan Goolagong
