Child development and ADHD in general practice: Queensland GPs can diagnose, DevPed Connect, and why Intuniv still needs a paediatrician

Kate Johnston

Medical director of GP Partnerships Engagement, which includes the HealthPathways team and the GP liaison team. Opened the morning: a taster, not a full curriculum, tied to HealthPathways and PHN support.

Dr Angela Owens

Developmental and general paediatrician, Child Development Service. Built DevPed Connect. Almost all of the teaching below is hers. Otter garbles the program as Deaf D Connect, Deadpy, Deputy Connect, Death Pinect, and FT Connect.

Pete

Housekeeping only — exits, bathrooms, silent phones, a 25- and 30-minute bell. Not a content speaker.

The morning, HealthPathways, and why this is a taster

Kate Johnston opened a packed Gold Coast education morning. Child development and ADHD, with a touch on adult ADHD. Highest attendance they had ever had. Bags off chairs so latecomers could squeeze in.

She was clear about the limits. They cannot teach everything you want to know in one morning. Pre-submitted questions, questions from the floor, faces to names, how to get in contact, how the services work. A starter. A taster. HealthPathways running through the slides, because part of why GP Partnerships does these events is to link topics that matter to GPs to the pathways written “by GPs for GPs.”

Practical HealthPathways change: individual login is now the only way in. The back of the system logs your touch points and produces a report you can attach to annual CPD hours. Flyer in the pack, QR on the screen. Kim from the PHN was in the room. Kate named the GP liaison team — Karen, Rhee, and Pete — and Siobhan from the GP clinical editors.

Pete did housekeeping (exits, bathrooms, phones, parking vouchers, no food in the room, a bell at 25 minutes). Then Kate introduced Angela Owens, paediatrician, who had led development and implementation of DevPed Connect.

Queensland GPs can diagnose — since 2019

The old mechanism: you see a child in clinic, then wait 12 to 18 months for a paediatrician. What she wants you to shift to: regular touch points and coaching, so families get something useful in days to weeks, not a dead wait list.

The other advantage GPs have, which she kept coming back to: you can treat the whole family unit. It is never “just ADHD.” Layers of family and social issues. Paediatricians can only treat the child in front of them.

Common misconception, especially if you work the border: in New South Wales you need a specific course. In Queensland you do not. Anyone with GP registration can diagnose and manage. That does not mean you should if you are not comfortable. That is what the morning, the resource pack, and DevPed Connect are for.

She cannot teach everything in one sitting. Heaps of links on the slides. Next time you see a child, open Angela’s slide, click the link, or text her through DevPed Connect.

Child Development Service referral rates have gone up over 200% in the last few years. There are not enough paediatricians. “We need you to help these families… We can’t do it all.” That is not the same as “everything is ADHD.” It is a balance.

The one medicine you cannot start: Intuniv

The only thing Queensland GPs cannot do, in her framing, is prescribe Intuniv (guanfacine; Otter: Intune) as an initiation. You can do ongoing prescriptions with paediatrician support, but you need paediatrician oversight to meet PBS criteria.

That is one of the jobs of DevPed Connect. It is mostly a text-message system, with a platform behind it. She can provide that paediatrician oversight without the family waiting 12 to 18 months to sit in her clinic. They will still see some children. The point is to turn the wait into an active care pathway.

There are Queensland Health guidelines on getting used to prescribing psychostimulants — most GPs are used to repeats, not to starting and titrating. She flagged those as a resource, not as a protocol she read aloud.

QScript, ongoing scripts, and the new GP

Everyone in Queensland needs to check QScript. You already do this in adults, looking for drug diversion. Same tool, paediatric ADHD.

Common scenario: the family has gone to a new GP. “I just needed a recent contact. My kid’s had ADHD medication.” They bring nothing. Look the patient up on QScript, see what they were last on, and you can feel more confident about the ongoing script. Child Development Service gets calls asking them to re-prescribe because “you prescribed it last.” Every one of those calls is a child they cannot see who actually needs them.

If the child is stable, ongoing script may be fine. If they are escalating, contact DevPed Connect for coaching — or change it yourself if you are comfortable.

Why undiagnosed ADHD is not a small problem

In severely dysregulated children who cannot attend school, education is getting harder for teachers. Otter first captured “92 kids”; later Angela described a classroom of 22, at least half with some sort of diagnosis, less support, higher curriculum burden. Kids slip through: not going to school, reduced hours, home schooling that parents cannot actually manage on top of siblings.

It is not only education. These children often want friendships and blow them up when they get angry. In the teenage years, untreated, higher rates of depression, anxiety, reduced self-esteem. They start to realise they are different. “My brain did that. I didn’t mean to. My brain was out of control.” Increased risk of substance abuse in adulthood.

How it looks at different ages — including the quiet child

ADHD symptoms look different by age. You are mostly not diagnosing the four- and five-year-olds — please refer the bouncing-off-the-wall preschoolers to Child Development Service. Under that age it looks like lots of motor activity and impulsivity, and they will not sit still. The range of normal in that age group is huge. Differentiating busy-but-typical from true disorder is their job.

In primary school, inattention becomes the story. There is still a cohort of hyperactive children who cannot stay in the classroom. There is also a quiet inattentive cohort who fail quietly. They will not come into your room looking hyperactive. They may be slipping a year or two behind because they cannot focus. Do not dismiss ADHD because they do not look half-acting.

She has seen the other failure mode: a psychologist who has known the child for a year, school reports, questionnaires that fulfil criteria — and a GP who will not hear ADHD.

In adolescence, many can control the hyperactivity, or it comes out as risk-taking or drug-taking. It becomes more internal: anxiety, depression, self-esteem. Less overt than the six-year-old. Adults compensate — calendar alerts, mechanisms — so do not dismiss ADHD because someone’s life is not completely dishevelled. High functioning and still needing support can coexist. (She added, dryly, that she is probably one of them.)

Who is more likely: family, preterm, epilepsy, learning, care

When these things sit on the history, think a little harder:

• First-degree relative with ADHD. Biologically likely. Also useful: which medicine fitted Mum or Dad better. That is probably the category she would try first in the child. Same for a sibling. If Ritalin LA failed and Vyvanse was “the magic drug,” do not start Ritalin LA in this one — try Vyvanse first. Two stimulant families: dexamfetamine / Vyvanse versus the methylphenidate (Ritalin) family. Not always, but take the family signal.
• Preterm. Developmental delays are common; ADHD is one of the most prominent. Language disorders often go unmissed — low threshold for a language assessment. Low birth weight similar.
• Epilepsy or acquired brain injury. Frontal brain. Same sort of presentation as ADHD.
• Learning disorders. You cannot always fix the learning bit. You can sometimes help them attend and focus enough to use other strategies. If you treat ADHD in a child with learning difficulties, monitor learning over the next one to two years. Some catch up. Some do not — and that is when you need extra learning assessments. High crossover with dyslexia, dysgraphia, specific learning disorders. If learning is still really tricky a year or two on, reach out via DevPed Connect.
• Out-of-home care. Hard lives, often parents with executive-function challenges, carers who change. You cannot fix all the trauma. Slightly better attention can still change trajectory a bit.
• In-utero substance, especially amphetamines. Those “dizzy alert” babies. (Otter’s phrasing; she said there was a bad photo of her on the slide.)

Executive functions: the conductor, not just school

Until she started developmental work, she thought ADHD was attention, focus, hyperactivity — the observable behaviour in clinic. Underneath is executive function. The frontal brain is the conductor. ADHD is the disordered end of that spectrum.

• Inhibition — the brake. Cannot sit still; something out the window, they go. Big feeling, they get angry. Failure of the brake in more than schoolwork. Socially: they interrupt because they thought of something great from the weekend. This affects whole life, not just treating school.
• Shifting. Hyper-fixed and cannot switch, or shifting all the time and cannot hold one thing.
• Emotional control. A two-out-of-ten problem feels like a ten. The thermometer is broken.
• Initiation. Big ideas for a story, no idea where to start. Oral presentations and simple maths may be fine; a long essay derails them.
• Working memory. Hold information, manipulate it, spit it out. One plus six written down may be fine; a word problem about Jimmy’s apples is not. Visual scaffolds: underline the important bits, write them down. This really shows up after year three. Until then the curriculum is multimodal — writing, blocks in front of them. From year three we assume everyone can cope with language. We learn to read to year three; we read to learn after. If they have not learned to read properly by then, it is really tricky. Videos, exploring, more than one way in.
• Planning and organising. Five-step recipe; they fall down at step two. Parents say “get dressed for dinner” and have forgotten that is put shoes here, bag here, find shower stuff, get clothes. “They never listen” is often “that was eight steps.” Visual schedules, checklists, stars if it has to be a game. Empower the child to remind themselves.
• Materials. Maths book, pencils, the other room. Not simple for these children.
• Monitor. Checking whether the paragraph makes sense. Checking whether this big emotion is appropriate for this room. You can coach: your monitor is a bit broken, so you have to check each time.

All of this hits social relationships, emotional life, learning, and self-care. Classroom is only one room.

Three pillars: symptoms, two settings, impairment

How do you decide average-range versus criteria? Three things.

1. DSM-5 symptom count. Six symptoms of inattention plus six of hyperactivity, or a bit of both — hyperactive subtype, inattentive, or combined. The tick-boxes are not the hard bit. Parents have pre-ChatGPT’d the list.
2. Two environments. Most of the advice she gets through DevPed Connect is parents coming with this. She needs collateral. School letter, or some sort of school collateral, showing dysfunction. Home and school (or work, in an adult). Dump that collateral to her before you put a case through. Homeschooling is hard: you cannot reliably get a second setting, so those children are often the ones you refer to a psychologist for a standardised assessment.
3. Impairment, judged against age. A six-year-old’s attention is not a 17-year-old’s. If a 17-year-old cannot sit still for five minutes, that is one thing. If a six-year-old is being asked to sit for an hour lecture, of course they will not. Otter captured an example of a child who had “moved from Japan last year” and did not speak English — of course they will not attend. Put a clinical lens on it. Straight As and trouble focusing: they probably do not have ADHD causing dysfunction right now. They might later. Thriving is not a script.

Vanderbilt, SNAP-IV, CADDRA, Conners, Novopsych

Vanderbilt is not her favourite, but it is the one that is free. It is a tick-and-flick of DSM criteria. What it does not have, on the paper form, is age norms. Attention at six is not attention at 17. You have to put that lens on yourself — unless you use Novopsych.

Novopsych (Otter: Novosyke, and later “no oversight” / “oversight”) is a paid platform that has the tools, auto-scores, and prints reports. She would recommend it if you do this work regularly. Not that much per month compared with scoring by hand. On Novopsych, Vanderbilt does have age standardisation from one attempt to give normative ranges — that is the one benefit. It will tell you inattentive, hyperactive, or combined. She hates using it for oppositional defiant disorder in a clinical service: please don’t. Anxiety and depression are flags. She wanted scores above 65 across a teacher and a parent form to meet criteria across two settings, plus it has to match your history.

ADHD rarely travels alone. Do not panic. You do not need the whole picture in one consult. Every three months, every six months, you piece it together. She is happy for you to dump her all the reports parents bring, and she will synthesise a rough formulation. There is a whole ADHD guideline; “Christy” is their go-to GP guru if you want more support. Conners for the messy cases; dump the collateral; she will find the gaps.

Pillars again at the end of this block: symptom count, long-term duration, across settings, actually causing impairment — not just being annoying.

History, sleep, growth, ECG, bloods, lookalikes

Comprehensive history, as you already do. Sleep is one of the biggest. Teenagers who were fine until now and are declining: check sleep and night gaming. A child who will not sleep cannot concentrate. She had been up since 3 am because her own children were awake — attention harder today, and we all know that in ourselves. Improve sleep, see what is left, then if there is still dysfunction, maybe mix (treat).

She wants height, weight, blood pressure (Otter: “high weight blood pressure”) so she can help with medicines, and a trajectory over time. Growth is probably the main side-effect of stimulants. Baseline so you can see impact.

Differentials: it is not never just ADHD, and it is not always just ADHD. Even helping the ADHD a little can clarify the other diagnoses over time. ADHD versus autism is often muddy. Social relationships horrible because of impulsivity — she does not know yet. Treat for a year, see if it improved; if it did not, take those children seriously and assess. There is no one moment in a child’s life when you assess development. It is a continuum. You do not have to have all the answers at once. Put therapies in, treat ADHD a bit, see what is left, work on whatever is rearing its head at this appointment.

Pervasiveness: inattentive their whole life — probably ADHD. Fine until two months ago — probably something else. Biological mimickers: she herself presented for an ADHD diagnosis and had Graves’ disease (Otter: Gray’s). Screen for anaemia, nutrition. Those will not magically fix everything; every 1% of function helps. Other medicines that might be impacting. Baseline bloods in some of these children. CADDRA history guide if you want a checklist.

DevPed Connect: text advice versus case conference

DevPed Connect is the program she made. Website as a platform. Two doors:

• Advice — left side. Almost every GP who used it in the last year started here. Opens like a text-message platform. Respond when you are next at work. Cases can stay open for weeks. Call button if she is there, or book a chat. Drag and drop old reports, previous growth charts.
• Multidisciplinary case conference — right side. For complex children: you want a social worker, you want her, you want a paediatrician. She or another paediatrician plus two internal therapists. That meets the requirements for you to charge Medicare for a case conference. Pre-book a week or two out, block 20 minutes, hash it out, written plan afterwards. Autism level 3 who have deteriorated in adolescence and have not had an active paediatrician: you will probably still wait-list them, but you can get a plan and get paid for the time. Getting three people in a room is usually the hard bit; they hold the other two.

Open for any child with developmental disorders, not just ADHD, across the Gold Coast region. They have to live here. They do not have to be currently owned by Child Development Service — discharged years ago is fine. Caveat: they do not do children actively owned by private paediatricians. Go back to the people who know them. If they saw a private paediatrician three or four years ago, have not seen anyone, and the family cannot afford to pay, she will try to help, and she will tell you when the answer is actually “they need to see a paediatrician.”

Trying to stop “just in case” referrals. “Is it ADHD or autism? I’ll send a referral now because it will be 18 months.” Ask for advice first. If you treat for ADHD and she coaches you, you can come back as many times as you want on that child’s journey. If a year later it finally meets threshold for something else, she back-dates to the original date of advice. They do not miss their place. If it converts to a referral she can do that internally — you do not have to do a second Smart Referral. Trade-off: through Smart Referrals you can see they are category 3 from this date and a rough wait. She cannot offer that tracking. She would still rather you ask for coaching first. Otherwise you start receiving wait-list audits and messages: this case might need DevPed Connect support first — not because they will not see them, because there is something you can do now.

Smart Referrals request-for-advice, in her view, is one question, one response, case closed. Not much of behavioural developmental paediatrics shuts in one ping. DevPed Connect is an open platform, a to-and-fro conversation.

Gold Coast region only, New South Wales, lunchboxes

Question from the floor: can you still connect if the patient lives in New South Wales? Technically not, as patients. Same problem with Logan. When you go in you have to put patient details — you can put xx if you want to talk about a case in general, without specifics, or you just want ADHD education. She will talk to you. She cannot, medico-legally, take them on, and she cannot help their wait list. She can help you in general.

Other option: lunchbox education sessions. Virtual with her — she lives in North Brisbane (Otter: North Rubin) — or Lisa, their nurse, can come out to your practice, including New South Wales. Twenty-minute sessions, pre-booked, with your team or just you. Topic-based rather than case-based.

Someone in the room said New South Wales has a similar “connect to the paediatrician and ask questions” service. Angela’s distinction: Smart Referrals-style advice closes after one reply. Developmental behaviour needs a conversation.

Floor: questionnaires are not a diagnosis

A specialist in the room (not named; they said they were not a GP) asked her to clarify screening tools, Novopsych, questionnaires, symptom checklists, and cognitive testing. In their training, screening checks whether ADHD is in the picture; questionnaires quantify which symptoms and impairment; current Australian guidelines say cognitive testing should not be relied on for diagnosis. They see GPs and teachers and patients arrive with Novopsych saying “I’ve got my diagnosis.”

Angela: yes and no. You cannot diagnose based on a questionnaire alone. You need context and clinical judgement. Pervasive over a long time? Across contexts? Is ADHD the most predominant thing? Anxiety versus ADHD is a common muddle. You can get a positive screener from parent and teacher and it is anxiety overwhelming the picture.

According to the ADHD guidelines you can now use diagnostic tools. A certain cohort still needs cognitive assessment — not everyone. The specialist pressed: heading said “diagnostic toolkits”; screening is screening; questionnaires complement diagnosis and cannot be called a diagnostic kit by themselves. Angela agreed it is a misconception that a score is a diagnosis. The questionnaire only helps the “light blue bubble.” The rest is you. If you are not sure what normal is, ask her. She responds within one business day (Otter: “one business”).

Caveat: a small proportion get executive-function screeners with a psychologist — usually the children who do not have a second environment, who come in for a functional assessment. Not everyone. Dump her everything; she will find the gaps.

Another floor question: straightforward diagnosis as a young child, then adolescence, symptoms change, do you change medicines or has it resolved? Is there a tool? Sometimes a repeat screener; paper Vanderbilts do not give you function well, so she would probably do a Conners at that stage for functional pervasiveness. When do you know you need to change meds? “Let’s see how the management one [goes]… It’s so taste dependent.” The recording ends as the next speaker is being queued. This morning was diagnosis and access, not a titration clinic.

Take-home messages for clinic

1. Queensland, since 2019: any GP with registration can diagnose and manage childhood ADHD. No extra course (unlike NSW). Comfortable is a different question. Adult changes in December made the topic louder; the child rule is older.
2. Do not sit on a 12–18 month wait. Coaching in days to weeks. You can treat the whole family; she cannot.
3. Intuniv (guanfacine) cannot be initiated by a GP without paediatrician oversight / PBS. Ongoing scripts with support, yes. DevPed Connect can supply that oversight. This lecture did not give milligrams.
4. QScript every time, including the child who switched GP and brought no paperwork.
5. Untreated ADHD is school exclusion, broken friendships, teen mood, and later street amphetamines. Treating in childhood is not the substance-abuse pathway parents fear.
6. Quiet inattentive primary-school children fail quietly. Preschool bounce: refer. Adolescents go internal. High-functioning adults still count.
7. Family stimulant response, preterm (plus language), epilepsy / ABI, learning disorders, out-of-home care, in-utero amphetamines — lower threshold. After treating ADHD with learning problems, watch learning for one to two years.
8. Executive function is the whole life, not a school target: brake, shift, emotion, start, working memory (after year three), plan, materials, monitor.
9. Three pillars: DSM-5 count, two settings with collateral, impairment versus age. Straight As are not a script. Homeschool: often need a psychologist for a second setting.
10. Vanderbilt is free and has no age norms unless Novopsych. T-score above 65 parent and teacher was her Novopsych bar. SNAP-IV, CADDRA, Weiss, CDS school form. Conners has the best diagnostic-accuracy evidence; she will run the comprehensive one via DevPed Connect. No questionnaire is a diagnosis.
11. Sleep first in the newly declining teenager. Height, weight, BP baseline. ECG only if cardiac history. Graves’, anaemia, nutrition, other medicines. Muddy ADHD versus autism: treat a bit, see what is left. You do not need every answer today.
12. DevPed Connect: Gold Coast region; not active private-paediatrician patients; dump collateral; advice text first; case conference (peed + two therapists, Medicare, ~20 minutes) for the messy ones; wait-list back-dated to first advice. NSW / Logan: put xx and talk in general, or book a lunchbox session (virtual, or Lisa to the practice).

Dr Kotha · Gold Coast · child-development.drkotha.com