Recognising and treating ADHD in adults in public mental health services: A scoping review of key concepts

Abstract

Objectives

To summarise service models, facilitators and barriers relevant to recognising and treating attention deficit/hyperactivity disorder (ADHD) within adult public mental health services.

Methods

A scoping review following PRISMA-ScR guidelines examined international literature describing adult ADHD care delivered within public mental health systems. Data were charted on models of care, implementation facilitators and barriers, and evidence gaps were identified.

Results

Thirteen sources met inclusion criteria. The literature was limited and largely conceptual, consisting predominantly of editorials, commentaries and clinical guidance, with minimal empirical evaluation of implementation or outcomes. Three broad approaches to service delivery were described: embedding ADHD assessment and treatment within existing adult mental health teams; establishing specialist adult ADHD or neurodevelopmental services; and shared-care and primary-care–led models supported by specialist input. Facilitators included targeted workforce training and collaboration with primary care services. Barriers related to diagnostic complexity, clinician confidence, service capacity and concerns regarding prioritisation within public systems.

Conclusions

The literature consistently supports embedding ADHD care within routine adult public mental health teams, supported by targeted registrar and psychiatrist training and structured collaboration with general practitioners. Empirical evaluation of service models is needed to inform sustainable and equitable implementation within publicly funded mental health services.

Keywords

ADHD adult public mental health models of care service reform

Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterised by persistent patterns of inattention and/or hyperactivity–impulsivity that frequently continue across the lifespan and are associated with substantial functional impairment.¹ Findings from the Multimodal Treatment Study of ADHD (MTA) longitudinal study highlight the variable course of ADHD from childhood to young adulthood. Approximately one-third of participants experienced periods of full remission; however, these were often temporary. Only 9.1% demonstrated sustained remission by the study endpoint (mean age 25 years).² Consistent with this, an umbrella review of global evidence reported that approximately 30–60% of individuals with ADHD in childhood continue to meet diagnostic criteria in adulthood and that predominantly inattentive presentations are the most common form of ADHD observed in adults.³

ADHD frequently co-occurs with other psychiatric disorders, and a substantial proportion of adults receiving care in public mental health services are estimated to have underlying ADHD with prevalence estimates between 15% and 21%.⁴ Despite this, routine identification and treatment within Australian public adult mental health services remain uncommon. Failure to recognise ADHD in these settings may contribute to misdiagnosis, suboptimal treatment and poorer outcomes.⁵

In Australia, adult ADHD assessment and treatment have largely developed within the private sector. Australia’s mental health system is characterised by a division between public and private care. The public system provides essential acute, in-patient, and community-based services and is chronically stretched. The private sector, subsidised by the federal government, offers faster and more specialised treatment in areas such as ADHD, but primarily to those who can afford insurance or out-of-pocket fees, raising concerns about equitable access to care.⁶ Consequently, private psychiatric care absorbs a substantial proportion of ADHD-related demand and plays a critical role in community care. Both the Royal Australian and New Zealand College of Psychiatrists and the 2023 Australian Government Senate Inquiry into services for people with ADHD have called for improved access to ADHD care within public mental health services, alongside enhanced workforce training.^7,8 For most adult public mental health services, introducing ADHD care presents a substantial workforce and service redesign challenge.

This review aims to map available literature relevant to clinicians, clinical leaders and service planners seeking to integrate ADHD care into adult public mental health services, and to identify gaps in the literature.

Methods

This review followed Joanna Briggs Institute methodology and PRISMA-ScR reporting standards and the review protocol was registered on the Open Science Framework (OSF).^9,10 The review was guided by the following research questions (RQ):

RQ1

What models of care or service reforms are described to support the introduction of ADHD care into adult public mental health services?

RQ2

What facilitators are reported to support implementation of ADHD care in adult public mental health settings?

RQ3

What barriers are identified that may hinder implementation of ADHD care in these services?

Information sources and search strategy

A systematic literature search was undertaken in March 2025 in MEDLINE, PsycINFO, Embase, CINAHL and ProQuest Central. Search terms related to adult attention deficit/hyperactivity disorder (ADHD), public or government-funded mental health services, and models of care were used. No date limits were applied. A full breakdown of the search strategy and results is provided in Supplemental Material, Appendix 1.

Eligibility criteria

Sources were eligible for inclusion if they addressed identification, assessment, treatment or service models for adult ADHD within public mental health services. Given the emerging nature of the evidence base, editorials, commentaries, guidelines, descriptive studies and reviews were included to capture service-level and policy-relevant evidence. Records were excluded if they focused solely on children or adolescents, addressed only the clinical diagnosis or treatment of adult ADHD without reference to service models or public mental health systems, were not available in English, or were books or conference abstracts.

Selection of sources and data charting

Titles and abstracts of search results were independently screened by two reviewers. Full texts of potentially relevant sources were retrieved and independently assessed against the inclusion and exclusion criteria. Data were charted using a standardised extraction form and findings were synthesised narratively to inform service planning.

Results

Selection of sources of evidence

The database search identified a total of 1,616 records. After removal of duplicates and screening of titles and abstracts, 105 full-text records were assessed for eligibility, of which 13 were selected for inclusion. Characteristics of included records are provided in Supplemental Material, Appendix 2.

The study selection process is summarised in Figure 1. Included records mapped to the review questions as follows: six addressed models of care or service reform (RQ1), four described facilitators (RQ2) and three discussed barriers (RQ3).

Figure 1.

PRISMA flow diagram.

Models of care and service reform (RQ1)

Three broad models of care were identified: embedding ADHD assessment and treatment within existing adult mental health teams, establishing specialist adult ADHD services and developing multidisciplinary neurodevelopmental teams that assess ADHD alongside autism spectrum disorder.^11–14

Only one publication described ADHD care embedded within routine adult mental health practice with the remaining literature largely advocating for integration without reporting implementation processes or outcomes.¹²

Establishing specialist adult ADHD teams was recommended in guidelines from the United Kingdom and Ireland.^15,16 Importantly, in both countries these specialist ADHD teams are expected to accept direct referrals from general practitioners (GPs) and, in parallel, general adult teams are expected to embed ADHD assessment and treatment into routine care.

The Royal College of Psychiatrists highlights the high co-occurrence of ADHD and autism and recommends establishing adult neurodevelopmental teams to reduce missed diagnoses, improve care, and use resources more efficiently.¹⁴ The advantages and disadvantages of different models or reforms referred to in the literature are tabulated in Table 1.

Table 1.

Advantages and disadvantages of approaches to integrating adult ADHD care into public mental health services.

Model	Advantages	Disadvantages
Specialist adult ADHD team (or neurodevelopmental team)	• Enables development of specialist expertise • Multidisciplinary staffing • Supports research • Efficient when combined with autism services.	• May marginalise ADHD from general services • Risk of deskilling general psychiatrists • Costly/resource intensive • Risk of overwhelming referrals.
Embedded ADHD services	• Integrates ADHD into routine public mental health care • Builds clinician capability • Supports trainees • Uses existing links with primary care.	• Requires significant training • Clinician resistance possible • Needs strict referral protocols
Shared-care model	• Reduces burden on public services • GPs skilled in monitoring physical comorbidities • Supports continuity of care.	• GPs may lack ADHD assessment training • Requires strong protocols • Limited access to multidisciplinary supports.
Primary-care–led model	• Greatly expands access • Reduces pressure on specialists • Supports early intervention.	• Requires specialist GP training • Risk of inconsistent diagnostic quality • Limited multidisciplinary input.

Facilitators to implementation (RQ2)

Two key facilitators were identified: collaboration with primary care and the use of emerging technologies.

A spectrum of approaches to GP involvement in ADHD care and shared-care arrangements with GPs is described, ranging from GP-led follow-up following diagnosis by a psychiatrist to GP-led diagnosis and medication management following targeted training.^12,17 Some evidence in Australian literature suggests that many GPs are willing and able to expand their role in ADHD management.¹⁸ Emerging technologies, including digital assessment tools and remote monitoring, were discussed as potential supports for service expansion, although evidence for routine use in ADHD assessment and care remains limited.^19,20

Barriers to implementation (RQ3)

Two recurring themes were identified: limited clinician training, including mixed clinician attitudes towards adult ADHD and diagnostic complexity, particularly related to comorbidity.

Several sources noted that adult ADHD assessment has not historically been a focus of psychiatric training, contributing to low clinician confidence.²¹ Diagnostic complexity was highlighted across multiple records, particularly in distinguishing ADHD symptoms from comorbid mood, anxiety, substance use and personality disorders.²² Attitudinal barriers included concerns regarding stimulant prescribing, workload implications and prioritisation within public services.²³

Discussion

This scoping review synthesises international guidance and emerging literature relevant to clinicians and service leaders considering how adult ADHD care might be incorporated into public mental health services rather than relying on the gradual diffusion of ADHD care through individual clinician initiative. The findings are directly relevant to clinical leaders responding to growing demand for adult ADHD care within public service systems. Experiences from the United Kingdom and Ireland are instructive for Australian service planning. In the UK, the Independent ADHD Taskforce concluded that public models reliant solely on specialist, single-diagnosis services, where diagnosis is restricted to psychiatrists or paediatricians, are unlikely to be sustainable.²⁴

Significant structural differences in service design between the United Kingdom, Ireland and Australia mean that the overseas models described cannot be directly transplanted into the Australian context.

Irrespective of the approach taken to introducing ADHD recognition and care into adult services, service leaders must consider established change management issues including risks, costs and stakeholder consultation. Given that clinical, educational and administrative resources are limited, implementation is likely to draw resource from other clinical programs unless there is parallel investment in workforce and infrastructure.²⁵

Implications for policy and service planning

Recent legislative reforms across multiple Australian jurisdictions, as well as in New Zealand, enable specially trained GPs to play an expanded role in ADHD diagnosis and treatment. These reforms signal a major shift in how ADHD care is likely to be delivered to the community.^26,27 While New Zealand faces similar workforce and access challenges and recognises adult ADHD in public health pathways, differences in service organisation may require different implementation approaches.

Public mental health teams in Australia generally only accept individuals for treatment who present with acute symptoms or significant risk, including referrals from GPs. As a result, access is largely limited to patients with ADHD who have acute comorbid psychiatric illness or are in crisis, whether previously diagnosed or not. Currently, public services are only likely to prescribe ADHD psychopharmacological treatment for acutely ill patients following a confirmed diagnosis. In contrast, private psychiatric practitioners facilitate assessment in less acute contexts, including for individuals with subthreshold but functionally impairing symptoms, and may prescribe psychostimulant treatment. Reforms expanding the roles of GPs are likely to increase the number of adults with diagnosed ADHD presenting to public services. As GPs play an expanding role in ADHD diagnosis and management, there will be an increasing expectation that public services recognise ADHD and establish effective partnerships with primary care and private practitioners to support patients presenting with acute, complex comorbidity.²⁸

Workforce capability

Workforce capability emerges as a central theme in the literature. Diagnostic complexity and clinician attitudes towards adult ADHD require targeted training. Responsibility for building this capability rests with professional colleges, training bodies and public services themselves. Delays in embedding adult ADHD competencies within training curricula are inconsistent with professional position statements and emerging service demands.⁷ Furthermore, where adult public services do not recognise or treat ADHD, trainees have little opportunity to gain clinical experience with this population.

Many psychiatrists working in public settings currently have had little or no training in identifying, diagnosing or treating ADHD. It is therefore understandable that some will be apprehensive about the prospect of upskilling. Resistance to service change is likely and should be recognised and addressed respectfully and with appropriate support. High-quality educational resources are increasingly available, including the Australian Evidence-based Clinical Practice Guidelines for ADHD and the ADHD Prescribing Guide produced by the Australian ADHD Professionals Association (AADPA).^29,30 Engagement of experienced private-sector psychiatrists as external contractors to provide teaching and supervision may also support workforce development.

A possible model for Australian public services

Within the context described above, an internal-referral model, where specialist adult ADHD or neurodevelopmental teams accept referrals from within their parent service and co-manage care with general teams, may be both feasible and protect against the service pressures observed internationally. Such an approach mirrors the integration of specialist alcohol and other drug services within public mental health systems in Victoria, as recommended by the Royal Commission into Victoria’s Mental Health System.³¹ This model could support the challenging task of embedding ADHD care within routine public service practice, provide essential training opportunities for psychiatry registrars and other clinicians and facilitate research, which is currently constrained by Australia’s reliance on private ADHD services.

Limitations

The relevant literature found in this review was limited in volume, with little empirical implementation or outcomes research, particularly within public-sector systems, and was largely drawn from the United Kingdom, Ireland and Australia. Consequently, conclusions regarding feasibility and impact must be interpreted cautiously.

Conclusion

This scoping review suggests that, despite increasing clinical and policy interest, the evidence base guiding the integration of adult ADHD care into public mental health services is limited. Nevertheless, the available literature offers practical direction for service leaders, professional colleges and educators responding to rising demand and is consistent with embedding ADHD care within routine adult public mental health teams.

Future research must move beyond descriptive accounts to evaluate the implementation, safety and outcomes of adult ADHD service models within public mental health systems. In particular, studies examining workforce capability, models of shared care with primary care and private practitioners and outcomes for individuals with complex comorbidity are needed to inform sustainable service development and support equitable access to care for adults with ADHD.

Supplemental material

Supplemental material - Recognising and treating ADHD in adults in public mental health services: key concepts: A scoping review

Supplemental material for Recognising and treating ADHD in adults in public mental health services: key concepts: A scoping review by Tom Callaly, Hatem Elshazly, Robert Lundin, Melissa Mulraney, Merryl Whyte and Scott Hall in Australasian Psychiatry

Footnotes

ORCID iDs

Tom Callaly

Robert Lundin

Merryl Whyte

Ethical considerations

Ethics review was not sought or required for this study as it involved analysis of published literature and did not include human participants, identifiable data or unpublished patient information.

Author contributions

TC: conceptualisation; formal analysis; investigation; Methodology; writing – original draft; and project administration.

HE: conceptualisation, investigation; methodology; and writing – review and editing.

RL: supervision, investigation; methodology; and writing – review and editing.

MM: supervision, investigation; methodology; and writing – review and editing.

MW: Writing – methodology and review and editing.

SH: Writing – methodology and review and editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data generated or analysed during this study are included in this published article and its supplementary materials.*

Supplemental material

Supplemental material is available online.

References

American Psychiatric Association; American Psychiatric Association DSM Task Force . Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Arlington (VA): American Psychiatric Association, 2013.

Sibley

Arnold

Swanson

, et al. Variable patterns of remission from ADHD in the multimodal treatment study of ADHD. The American journal of psychiatry 2022; 179: 142–151. https://doi.org/10.1176/appi.ajp.2021.21010032

Ayano

Tsegay

Gizachew

, et al. Prevalence of attention deficit hyperactivity disorder in adults: umbrella review of evidence generated across the globe. Psychiatry Res 2023; 328: 115449. https://doi.org/10.1016/j.psychres.2023.115449

Johnson

Lim

Jacoby

, et al. Prevalence of attention deficit hyperactivity disorder/hyperkinetic disorder in paediatric and adult populations in clinical settings: a systematic review, meta-analysis and meta-regression. Mol Psychiatry 2026; 31(1): 576–586. https://doi.org/10.1038/s41380-025-03178-8

Ginsberg

Quintero

Anand

, et al. Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. Prim Care Companion CNS Disord 2014; 16(3): 13r01600. https://doi.org/10.4088/PCC.13r01600

Bradlow

RCJ

Armstrong

Ogden

. Adult attention deficit hyperactivity disorder in Australia: how its current commercial model for diagnosis and treatment is encouraging misdiagnosis. Med J Aust 2025; 223(8): 384–386. https://doi.org/10.5694/mja2.70049

Royal Australian and New Zealand College of Psychiatrists . ADHD across the lifespan. Position statement no. 55. Melbourne (VIC): RANZCP 2023, Available from: https://www.ranzcp.org/clinical-guidelines-records/clinical-guidelines-records-library/adhd-across-the-lifespan (Accessed 18 June 2025).

Commonwealth of Australia . Assessment and support services for people with ADHD. Canberra (ACT): Senate printing unit. Available from: https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ADHD/Report (2023), Accessed 3 September 2025.

Peters

MDJ

Godfrey

McInerney

, et al. Scoping reviews. In: Aromataris

Munn

(eds). JBI Manual for Evidence Synthesis. Adelaide (AU): Joanna Briggs Institute, 2020. Available from: https://synthesismanual.jbi.global (Accessed 15 November 2025).

10.

Tricco

Lillie

Zarin

, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018; 169(7): 467–473. https://doi.org/10.7326/M18-0850

11.

Coghill

. Organisation of services for managing ADHD. Epidemiol Psychiatr Sci 2017; 26(5): 453–458. https://doi.org/10.1017/S2045796016000937

12.

Crimlisk

. Developing integrated mental health services for adults with ADHD. Adv Psychiatr Treat 2011; 17(6): 461–469. https://doi.org/10.1192/apt.bp.109.006924

13.

Bolea-Alamañac

Nutt

Adamou

, et al. Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: update on recommendations from the British association for psychopharmacology. J Psychopharmacol 2014; 28(3): 179–203. https://doi.org/10.1177/0269881113519509

14.

National Autism Implementation Team; Royal College of Psychiatrists . National clinical ADHD pathway feasibility study. London (UK): Royal College of Psychiatrists, 2021. Available from: https://www.thirdspace.scot/wp-content/uploads/2021/09/NAIT-Feasbility-Study-Report-2021-National-ADHD-Pathway.pdf (Accessed 24 October 2025).

15.

National Institute for Health and Care Excellence . Attention deficit hyperactivity disorder: diagnosis and management (NG87). London (UK): NICE, 2019. Available from: https://www.nice.org.uk/guidance/ng87 (Accessed 18 June 2025).

16.

Raaj

Wrigley

Farrelly

. Adult ADHD in the Republic of Ireland: the evolving response. BJPsych Bull 2024; 48(3): 173–176. https://doi.org/10.1192/bjb.2023.77

17.

Asherson

Leaver

Adamou

, et al. Mainstreaming adult ADHD into primary care in the UK: guidance, practice, and best practice recommendations. BMC Psychiatry 2022; 22(1): 640. https://doi.org/10.1186/s12888-022-04290-7

18.

Kwon

Bhurawala

Munoz

, et al. General practitioners’ attitudes and knowledge about attention-deficit hyperactivity disorder (ADHD): insights from a survey. Australas Psychiatry 2024; 32(1): 18–22. https://doi.org/10.1177/10398562231211156

19.

Chen

Yang

Odisho

, et al.

Can biomarkers be used to diagnose attention deficit hyperactivity disorder?

Front Psychiatr 2023; 14: 1026616. https://doi.org/10.3389/fpsyt.2023.1026616

20.

Chen

Tachmazidis

Batsakis

, et al. Diagnosing attention-deficit hyperactivity disorder (ADHD) using artificial intelligence: a clinical study in the UK. Front Psychiatr 2023; 14: 1164433. https://doi.org/10.3389/fpsyt.2023.1164433

21.

Suetani

Giam

Jagadheesan

. Adult attention deficit and hyperactivity disorder: how can we put the cart behind the horse? Aust N Z J Psychiatr 2023; 57(8): 1089–1090. https://doi.org/10.1177/00048674231170558

22.

Choi

W-S

Woo

Wang

S-M

, et al. The prevalence of psychiatric comorbidities in adult ADHD compared with non-ADHD populations: a systematic literature review. PLoS One 2022; 17(11): e0277175. https://doi.org/10.1371/journal.pone.0277175

23.

Cao

Deakin

Gill

. Attitudes of South Australian psychiatrists towards attention deficit hyperactivity disorder in adults. Australas Psychiatry 2024; 32(1): 11–17. https://doi.org/10.1177/10398562231211132

24.

NHS England . Report of the independent ADHD taskforce: part 1. London (UK): NHS England, 2025. Available from: https://www.england.nhs.uk/long-read/report-of-the-independent-adhd-taskforce-part-1/ (Accessed 2 July 2025).

25.

Bahraini

Maisonneuve

, et al. Barriers and facilitators to implementing a Canadian shared-care ADHD program in pediatric settings in shanghai: a consolidated framework for implementation research approach. BMC Health Serv Res 2024; 24: 564. https://doi.org/10.1186/s12913-024-10910-7

26.

Kramer

APJ

. The changing landscape of ADHD in Australia. RACGP GP News, 2025. Available from: https://www1.racgp.org.au/newsgp/gp-opinion/the-changing-landscape-of-adhd-in-australia (Accessed 27 September 2025).

27.

PHARMAC.

Decision to change the regulatory and funding restrictions for stimulant medicines for ADHD. Wellington (NZ): pharmac, 2025. Available from: https://www.pharmac.govt.nz/news-and-resources/consultations-and-decisions/2025-06-decision-to-change-the-regulatory-and-funding-restrictions-for-stimulant-medicines-for-adhd. (Accessed 6 September 2025).

28.

Carrington

McAloon

. Why shared-care arrangements for prescribing in attention deficit hyperactivity disorder may not be accepted. Eur J Hosp Pharm Sci Pract 2018; 25(4): 222–224. https://doi.org/10.1136/ejhpharm-2015-000743

29.

Australasian ADHD Professionals Association . Australian evidence based clinical practice guideline for attention deficit hyperactivity disorder (ADHD). Melbourne: Australasian ADHD Professionals Association, 2022.

30.

Australasian ADHD Professionals Association . ADHD prescribing guide for Australian healthcare professionals. 1st ed. Melbourne: Australasian ADHD Professionals Association, 2024.

31.

Royal Commission into Victoria’s Mental Health System . Final report: summary and recommendations. Melbourne (VIC): Victorian Government, 2021. Available from: https://www.vic.gov.au/royal-commission-victorias-mental-health-system-final-report (Accessed 15 November 2025).

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.28 MB