Introduction

About ADHD

Attention Deficit/Hyperactivity Disorder (ADHD), is a chronic neurodevelopmental disorder characterized by developmentally inappropriate levels of hyperactivity-impulsivity and/or inattention. ADHD is a clinically and genetically heterogeneous syndrome with multiple possible aetiologies and frequent neuropsychiatric comorbidities.

ADHD is more commonly reported among boys than girls, partly because of an actual gender difference – boys exhibit more disruptive and aggressive behaviour than girls – but also because of the resulting referral bias. The three main presentations of ADHD (predominantly inattentive, predominantly hyperactive-impulsive, and combined) can change over time. While many gender differences decrease by adulthood, functional deficits and in particular executive function deficits are significant challenges, and the gender difference of neuropsychiatric comorbidities persists.

The worldwide prevalence of ADHD is estimated to be around 5-7% of children and adults. While numerous regional studies have been conducted into the prevalence of ADHD in Saudi Arabia, no nationally representative study has been conducted to-date. However, based upon these available data, given that ADHD occurs indiscriminately between diverse populations worldwide, and that when external factors are controlled for the prevalence of ADHD varies very little among different communities, the local prevalence is expected to fall within the worldwide range. ADHD is highly heritable, and while correlations have been found with a variety of prenatal environmental risk factors, as well as premature birth, none of them have a definite causal relationship with ADHD. There is, however, an element of gene-environment interaction (accounting for 10-40% of variance between cases).

ADHD is one of the most well-researched disorders, and our understanding of its epidemiology, pathogenesis, and management is constantly advancing, as evinced by the plethora of studies about ADHD published internationally, including in Saudi Arabia and the Arab World. It is recognized to have a significant burden if under-recognized and untreated.

Internationally, ADHD is managed in various shared-care models between primary and secondary care that best suit each country’s individual resources, culture, and nature of practice. No standardized CPGs for ADHD management exist in Saudi Arabia, and ADHD is diagnosed and treated primarily in tertiary care and the private sector, and managed in many settings with the available resources, often inappropriately or ineffectively. Stimulants are most commonly prescribed. In addition to medication, the term management includes behavioural and psychosocial interventions, which are being implemented at many schools and other settings. Many psychologists in private and public settings offer such treatments, as well as special education programs within some schools. This results in large variability in clinical practice, and suboptimal quality of care. The first step in correcting this imbalance is to give clinicians access to the information and practical tools they need to provide evidence-based care for people with ADHD. The CPG should also aim to elevate treatment of ADHD out of the realm of severe mental disorders in order to reduce stigma. For optimum outcomes, this should include supplements with patient and parent education materials to improve treatment compliance and reduce parenting stress, as well as teacher awareness materials to aid screening and diagnosis.

About Clinical Practice Guidelines

Clinical practice guidelines (CPGs) summarize the best available evidence and provide guidance for healthcare providers during their daily practice. CPGs can support the knowledge-to-action cycle effectively if they were developed using a systematic and rigorous methodology. Published evidence has revealed that CPGs can improve patient outcomes, patient experience, and quality and safety in healthcare.

This adapted CPG is intended for use by healthcare professionals to aid in the management of ADHD in children under 5 years, children and young people (aged 5 to 17 years), and adults aged 18 years or over.