South Africa’s New ADHD Guidelines
A comprehensive, parent-friendly analysis of the 2025 SASOP/PsychMg child and adolescent ADHD guidelines — what they say about diagnosis, investigations, medication, and everything in between.
DOI: 10.4102/sajpsychiatry.v31i0.2357 · Published 25 February 2025. Updates the Flischer & Hawkridge guidelines from 2013 — a 12-year gap.
In February 2025, the South African Society of Psychiatrists (SASOP) and PsychMg published the first update to South Africa’s child and adolescent ADHD guidelines in over a decade. Endorsed by SASOP’s ADHD Special Interest Group, the Child & Adolescent Psychiatry Special Interest Group (CAPSIG), and the Paediatric Neurology and Development Association of Southern Africa (PANDA-SA), these guidelines represent the most authoritative South African guidance on ADHD assessment and treatment currently available.
This article walks through every major section of those guidelines in plain language — explaining what they recommend, what has changed, and what it means for your child’s care.
1 Who Should Diagnose ADHD?
The guidelines are clear: the diagnosis should ideally be made by a specialist healthcare professional with appropriate expertise — a child psychiatrist, a paediatric neurologist, or a neurodevelopmental paediatrician. This matters because ADHD overlaps significantly with other conditions, and getting the diagnosis right is the foundation for everything that follows.
No blood test, brain scan, or computerised assessment can diagnose ADHD. The diagnosis rests on a comprehensive clinical history from parents/caregivers, the child themselves, and crucially, collateral information from schools — report cards, rating scales, and teacher observations. Therapist reports (educational psychologists, occupational therapists, speech therapists, optometrists) should also be reviewed.
2 Screening: Rating Scales in South Africa
The guidelines endorse four screening instruments commonly used in South Africa:
Conners’ Rating Scales
High sensitivity (83.5%) but poor specificity (35.7%). Widely used in private practice.
SNAP-IV
Very sensitive but poor specificity (4–38%). Picks up symptoms well but cannot confirm they are specific to ADHD.
Vanderbilt (VADPRS/VADTRS)
Reliable (Cronbach’s alpha 0.93–0.95). Highlighted as the accessible option for the SA context. A local study confirmed acceptable reliability.
Copeland Symptom Checklist
Used alongside other measures as part of a broader assessment battery.
Rating scales are valuable screening tools, but they cannot diagnose ADHD on their own. A positive screen should prompt a full clinical evaluation — not lead directly to a prescription. The guidelines also emphasise that a single reporter (parent or teacher alone) is insufficient. Both perspectives are needed. Teachers are particularly poor at detecting inattentive symptoms — the quiet, dreamy child who never disrupts the class is often missed.
3 Medical Examination & Special Investigations
This section is critically important because it clarifies what is — and what is not — necessary in the diagnostic workup.
What IS Required
- ✓Full medical history and physical examination — to exclude causative or confounding medical conditions.
- ✓Baseline vitals — blood pressure, pulse rate, height, and weight. These must be documented before treatment and monitored at every follow-up.
- ✓Visual and auditory screening — with referral to optometrists or audiologists when indicated. A child who cannot see the board or hear the teacher may present like ADHD.
- ⚠Laboratory tests — only when clinically indicated. Iron deficiency should be excluded if suspected. Liver function tests are required when atomoxetine is prescribed. Routine blood tests are not needed for every ADHD patient.
- ⚠ECG — only if there is a history or family history of significant cardiac pathology (congenital defects, cardiac surgery). Not routine.
What Is NOT Recommended
- ✗Routine EEG — not part of the diagnostic workup. Only if epilepsy is specifically suspected.
- ✗NEBA (theta/beta wave) testing — despite FDA approval in the US, the guidelines state EEG biomarkers for diagnostic purposes are not supported.
- ✗Neuroimaging — MRI, brain mapping, and event-related potentials have detected differences in research but have no indication in clinical practice. Costly and inaccessible.
- ✗Computerised assessments (TOVA, MOXO, QbTest) — have not been established as useful in children and adolescents.
If a clinic recommends an expensive brain scan, EEG, or computerised attention test as part of an ADHD diagnosis, question it. The guidelines are explicit: these investigations are not necessary for diagnosing ADHD and should not be marketed as diagnostic tools. The clinical interview — a thorough history from parents, teachers, and the child — remains the gold standard. Save the money for treatment.
4 Psychometric Evaluation
The guidelines take a clear position: there are no neuropsychological tests with sufficient sensitivity and specificity to diagnose ADHD on their own. Psychometric testing — including IQ testing, attention batteries, and educational assessments — should be interpreted within the broader clinical picture and is not diagnostic in isolation.
That said, psychometric evaluations are valuable in specific situations:
- ✓Where diagnostic uncertainty exists — for example, differentiating ADHD from a specific learning disability or intellectual disability.
- ✓Where comorbidity is suspected — identifying co-occurring learning disorders, processing speed difficulties, or working memory deficits.
- ✓To individualise interventions — understanding a child’s cognitive profile helps tailor school accommodations and therapy.
There is increasing interest in using genetic testing to guide medication choice. The guidelines note that the CYP2D6 gene (relevant to amphetamines and atomoxetine) and the CES1 gene (the sole enzyme in methylphenidate metabolism) are potentially useful for predicting tolerability and metabolism. However, effect sizes have been small and few consistent findings reported. Pharmacogenetic testing is not yet recommended as routine practice — a thorough clinical assessment remains the best guide to medication choice.
5 Comorbidities: ADHD Rarely Travels Alone
This is arguably the most clinically significant section of the entire guideline. The message is unmistakable: ADHD rarely exists in isolation. Fifty to ninety per cent of children have at least one comorbid condition, and fifty per cent have two or more. Missing a comorbidity means missing a treatment target.
Oppositional Defiant Disorder / Conduct Disorder
The most common externalising comorbidity. Associated with greater impairment, learning problems, aggression, and later substance use. Requires multimodal treatment including parent management training.
Anxiety Disorders
Generalised anxiety, social anxiety, OCD. The most impairing condition should be treated first. Atomoxetine has potential anxiolytic benefits, particularly for social anxiety.
Mood Disorders (Depression)
The guidelines distinguish between demoralisation from living with ADHD and true depressive disorder with an independent course. Both conditions usually require treatment.
Bipolar Disorder
When both co-occur, functioning is poorer than for either alone. Stabilise the mood first, then treat the ADHD.
Autism Spectrum Disorder (ASD)
Since DSM-5, both can now be co-diagnosed. Children with combined ADHD+ASD have more severe symptoms including sleep disturbance. Start medications lower and titrate carefully — side effects may be more prevalent.
Tic Disorders / Tourette Syndrome
Tics are NOT a contraindication to stimulants — a significant change from older practice. Monitor carefully; switch to atomoxetine only if stimulants worsen tics in that individual.
Specific Learning Disorders
Reading, written expression, auditory processing, visual processing, processing speed. Screen for both if either is present — outcomes improve significantly when both receive intervention.
Sleep Disturbance
Most commonly initial insomnia. Growing evidence of circadian rhythm disruption. Methylphenidate may delay sleep onset. Behavioural sleep interventions and melatonin are effective.
Epilepsy
ADHD symptoms often present before the first seizure. No strong evidence that stimulants increase seizure frequency in stable epilepsy. Choose anticonvulsants that minimise cognitive side effects.
Eating Disorders & Obesity
Bidirectional relationship. Mechanisms include impulsive eating, shared dopaminergic genetics, and sleep-disordered breathing. Screen for ADHD in eating disorders and vice versa.
Foetal Alcohol Syndrome
Can be particularly difficult to manage. Requires close monitoring for side effects when medication is used.
Excessive Digital Media Use
The relationship is bidirectional: EDMU worsens ADHD symptoms, and ADHD predisposes to EDMU. They mutually aggravate each other over time.
6 Choosing ADHD Medication: Factors to Consider
The guidelines emphasise that medication choice should be individualised, not algorithmic. Several factors influence the decision:
Previous medication trials: An individual child may respond differently to a medication at different developmental stages. A failed trial at age six does not rule out success at age ten.
Age: Children under five are more vulnerable to side effects. Environmental modifications and parent management training should come first in this group. Very young children may tolerate shorter-acting preparations better.
Duration of impairment: A child impaired primarily at school may need medication only during school hours. A child severely impaired at home and school needs longer coverage. Duration of action is a critical consideration.
Comorbidities: The more severe condition is generally treated first. ADHD with comorbidity should be managed at specialist level.
Access and affordability: Most South Africans rely on public healthcare and may not have access to the full medication range. ADHD is not a prescribed minimum benefit — medical schemes are not required to fund it. Stock shortages periodically impact choice even in the private sector.
Family context: Multiple family members may be on treatment. Affordability for the whole family matters.
7 Medications Available in South Africa
The guidelines provide the most comprehensive table of ADHD medications available in South Africa to date. Here is the complete picture:
Stimulants (First-Line Treatment)
Stimulants are the best-studied treatment for ADHD. Methylphenidate and amphetamines have an average response rate of 70%. In addition to reducing core symptoms, they improve defiance, academic performance, social functioning, and motor coordination. These effects are dose-dependent and evident across multiple settings.
| Medication | Brand Names (SA) | Duration | Starting Dose | Max Daily Dose | Notes |
|---|---|---|---|---|---|
| METHYLPHENIDATE — IMMEDIATE RELEASE (4 hours) | |||||
| MPH IR 10mg tablet | Ritalin®, Douglas MPH®, Biotech MPH® | 4 h | 5 mg at breakfast | 60 mg | 2–3 times daily, 4h apart |
| METHYLPHENIDATE — EXTENDED RELEASE (6–8 hours) | |||||
| MPH SODAS | Ritalin LA® | 6–8 h | 10 mg at breakfast | 60 mg | 60% immediate : 40% extended. 10/20/30/40mg capsules |
| MPH 50:50 | Medikinet MR® | 6–8 h | 10 mg at breakfast | 60 mg | 50% immediate : 50% extended. 5/10/20/30/40mg capsules |
| METHYLPHENIDATE — EXTENDED RELEASE (10–12 hours) | |||||
| MPH OROS | Concerta®, Neucon®, Unicorn MPH®, Mefedinel® | 10–12 h | 18 mg at breakfast | 54 mg (child) 72 mg (13–18) | 22% immediate : 78% extended. Must swallow whole |
| MPH MUPS | Contramyl XR® | 10–12 h | 18 mg | 54–72 mg | Multi-unit particulate system |
| MPH Matrix | Radd® | 10–12 h | 18 mg | 54–72 mg | Hydrophilic matrix release |
| MPH Film-coat | Acerta® | 10–12 h | 18 mg | 54–72 mg | Extended-release film-coated tablets |
| AMPHETAMINES | |||||
| Dexamfetamine sulphate | Amfexa® | 6–7 h | 5 mg at breakfast | 20 mg (up to 40 rarely) | Breakable 5mg and 10mg tablets. Once or twice daily |
| Lisdexamfetamine | Vyvanse® | 14 h | 30 mg with breakfast | 70 mg | Pro-drug. 30/50/70mg capsules. Not registered under 13 years |
Weight does not determine dose. There is very little correlation between body weight and stimulant dosage. Titrate against clinical response and side effects.
Try both stimulant classes. MPH and amphetamines have similar population-level efficacy, but individual children may respond to one and not the other. An adequate trial of both classes should be given before moving to non-stimulants.
Long-acting is usually preferred for better adherence, smoother coverage, less rebound, and reduced diversion risk. But shorter-acting may suit younger or treatment-naïve children.
Combinations are sometimes appropriate — for example, a long-acting preparation during the day plus a short-acting “top-up” for evening homework at boarding school.
Above-maximum doses may sometimes be clinically appropriate under specialist care with close monitoring.
Non-Stimulant Medications
| Medication | Brand (SA) | Dose | Key Indications | Notes |
|---|---|---|---|---|
| Atomoxetine | Strattera® | 1.2–1.8 mg/kg/day | Stimulant side effects; suboptimal stimulant response; comorbid anxiety (especially social anxiety); tic disorders; high misuse risk | Slightly lower effect size than stimulants. Must be given continuously (no weekends off). Monitor liver function. Can be combined with stimulants under specialist care |
| Clonidine | Menograine® | Off-label | Adjunctive use | Lower efficacy. More severe side effects. Used off-label |
| Imipramine | Tofranil® | Off-label | Adjunctive/alternative | Tricyclic antidepressant. Lower efficacy profile. Side effect considerations |
Guanfacine — non-stimulant used internationally but not available in South Africa.
Bupropion — no evidence for use in children and adolescents with ADHD.
Modafinil — no evidence for use in children and adolescents with ADHD.
8 Monitoring Treatment
- ✓First follow-up within 4–6 weeks of starting medication.
- ✓Maximum 4–6-month intervals between follow-ups (legally required — methylphenidate is Schedule 6 in SA, meaning 30-day dispensing limits and monthly prescriptions).
- ✓Monitor height, weight, blood pressure, and pulse at every visit.
- ✓Multi-source feedback — from the child, parents, teacher, and any involved therapists.
- ⚠Treatment interruption is NOT recommended. Atomoxetine must be continuous. Stimulants should generally be continuous too. Drug holidays are only justified for catch-up growth/weight, and should never coincide with transitions (new school year) or vulnerable periods (exams).
9 Non-Pharmacological Interventions: What Works and What Doesn’t
This section matters enormously because parents are frequently told — or sold — interventions with little or no evidence. The guidelines are helpfully direct.
What IS Supported
Psychoeducation
Described as a “vital component” of ongoing management. For parents, children (if developmentally appropriate), teachers, tutors, and caregivers. Covers symptoms, treatment options, side effects, compliance, lifestyle factors, discipline strategies.
Behavioural Therapy & Parent Training
Medium to large effects on organisational skills. Strong effect on broader well-being. Includes parent counselling, social skills training, problem-solving, cognitive restructuring. Recommended as complementary to medication, not as a replacement.
Behavioural Sleep Interventions & Melatonin
Considered effective for the sleep disturbances that affect approximately 50% of ADHD children.
What Has Limited Evidence
Exercise
Improves attention, motor skills, and executive function. Does not significantly improve hyperactivity, depression, aggression, or social problems. Broader health benefits are clear, but insufficient data to recommend a specific type, intensity, or frequency for ADHD. Physical activity is not a substitute for medication.
Dietary Interventions
Eliminating artificial food colouring and the DASH diet show some evidence. No blinded RCTs exist. General recommendation: follow a healthy, Mediterranean-type diet. More research needed before firm recommendations.
Omega-3 Supplementation
Small to moderate improvement across three meta-analyses. May allow stimulant dose reduction when used as augmentation. No effect on emotional lability or oppositional symptoms. The only supplement with any meaningful evidence.
Mindfulness
Some improvement in ADHD symptoms at 6-month follow-up versus no treatment. Other studies showed benefit for emotional regulation but not ADHD core symptoms. More evidence needed before recommending ahead of medication and behavioural therapy.
Vitamin D (if deficient)
Some benefit when supplementing a confirmed deficiency. No evidence for zinc, B12, iron, or folate supplementation for ADHD symptoms.
What Is NOT Supported
Cognitive Training & Neurofeedback
This is a critical finding. When only blinded studies are considered, no effect of cognitive training or neurofeedback on ADHD symptoms is seen. High costs and low efficacy do not support this as an intervention, even in game-like form. The unblinded studies that show positive effects likely reflect placebo and expectation effects rather than genuine therapeutic benefit.
Computer-Based Cognitive Training (CBCT)
Effects were stronger for unblinded measures. Controlled trials with blinded measures could not support any significant effect. Despite marketing claims, the evidence does not back this as an ADHD treatment.
Brain Stimulation (TNS & TMS)
Trigeminal nerve stimulation and transcranial magnetic stimulation have been advocated for children with ADHD but cannot be recommended because of insufficient evidence.
Food Supplements (Beyond Omega-3)
No consistent evidence from randomised controlled trials for bacopa, zinc, L-carnitine, B6, magnesium, ginkgo biloba, ginseng, phosphatidylserine, curcumin, or any other “brainsmart” supplement. Should not be recommended in children.
Parents frequently encounter clinics, therapists, and online programmes promoting neurofeedback, brain training apps, or supplement protocols as ADHD treatments. The guidelines are unambiguous: when properly blinded research is examined, these interventions show no meaningful effect on ADHD symptoms. They may be expensive, time-consuming, and give a false sense that treatment is happening when it is not. If your child has ADHD, the evidence supports medication combined with behavioural therapy and psychoeducation — not brain games or supplement stacks.
10 What Has Changed: The Ten Most Significant Updates
- Tics are no longer a contraindication to stimulants. Monitor carefully, but do not withhold effective treatment because of tics. Switch only if stimulants worsen tics in that specific child.
- ADHD and ASD can now be co-diagnosed. The old mutual exclusion is gone. This has major implications for assessment — both conditions should be actively screened for when either is present.
- No routine EEG, neuroimaging, or computerised testing. Explicitly rejected as diagnostic tools. This pushes back against clinics marketing expensive but unvalidated assessments.
- Lisdexamfetamine (Vyvanse) now available in SA — a 14-hour pro-drug amphetamine with lower misuse potential. Registered for 13+ only.
- Multiple generic long-acting MPH options now listed (Contramyl XR, Radd, Acerta, Neucon, Unicorn MPH, Mefedinel) — improving access and affordability alongside brand-name Concerta.
- Digital media use formally addressed as a bidirectional risk factor — the first time screen time has been included in SA ADHD guidelines.
- Eating disorders, obesity, and elimination disorders formally included as comorbidities, broadening what clinicians should actively screen for.
- Neurofeedback and cognitive training explicitly rejected based on blinded evidence — a clear signal to parents and funders.
- Treatment interruption is not recommended — a firmer stance than previous guidelines. Continuous treatment is the default.
- Pharmacogenetic testing acknowledged but not yet recommended for routine use — recognising the direction of travel while maintaining evidence-based caution.
These guidelines reinforce what 25 years of clinical practice has shown me: ADHD is a real, neurological condition that responds well to evidence-based treatment. The clinical interview remains the foundation of diagnosis. Medication — particularly stimulants — remains the cornerstone of treatment, supported by behavioural therapy, psychoeducation, and a structured home and school environment.
What the guidelines do not support — and what parents should be cautious about — are expensive investigations that add nothing to the diagnosis, and alternative treatments that sound appealing but lack evidence when properly tested.
Your child’s brain is not broken. It is wired differently. And when you combine genuine understanding with evidence-based treatment, the trajectory changes. That is what these guidelines are about — and that is what our courses are designed to help you achieve.
— Dr John Flett
Mpondo S, Vogel W, Michaelis IA. Management and co-morbidities in children and adolescents with ADHD: A clinical audit in the Eastern Cape. S Afr J Psychiat. 2026;32(0), a2585. Full text (open access)