The Saudi ADHD CPG Project decided to utilize the Modified ADAPTE framework for trans-contextual adaptation of CPGs (rather than de novo development) that was published by the King Saud University CPG Program. The rationale for this decision was the lack of high quality randomized controlled trials and systematic reviews with meta-analyses from the local patient population with ADHD that could support formulation of new recommendations. Additionally, the existence of a large number of evidence-based CPGs with a variable degree of quality as per the definition of the current international standards for trustworthy or high-quality CPGs that imposes a degree of confusion for clinicians during their selection and utilization of evidence-based CPGs for their daily practice and patient care.
Scope and Purpose
Attention-deficit hyperactivity disorder (ADHD) and related diagnoses*
*The three ADHD presentations (formally “sub-types”) as defined in the International Classification of Diseases, 11th revision [ICD-11], and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [DSM-V].
Clinical Practice Guideline Category
Counselling, Diagnosis, Evaluation, Management, and Treatment
Clinical Practice Guideline Objective(s)
- To provide recommendations on the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in children, young people, and adults
- To assist clinicians, people with ADHD, and their carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists
- Specifically, the guideline aims to:
- Examine the validity of the diagnostic construct of ADHD
- Evaluate the role of specific pharmacological agents and non-pharmacological, psychological, and psychosocial interventions in the treatment and management of ADHD
- Evaluate the role of specific services and systems for providing those services in the treatment and management of ADHD
- Integrate the above to provide best-practice advice on the care of people with a diagnosis of ADHD through the different phases and manifestations of the disorder, including the initiation and maintenance of treatment for the chronic condition, the treatment of acute episodes and the promotion of well-being
- Consider economic aspects of various interventions for ADHD.
- Evaluate the clinical effectiveness and cost-effectiveness of elimination and restriction diets and of dietary supplementation with polyunsaturated fatty acids (PUFAs) on children and young people with ADHD
Health / Clinical Question (PIPOH)
The health questions (clinical/key questions) were formulated by utilizing the ADAPTE tool 6 the PIPOH model (Population – Intervention – Professionals – Outcome – Healthcare settings) as the following:
P: Patient (Target Population)
Children under 5 years, children and young people (aged 5 to 17 years), and adults aged 18 years or over who are suspected to have ADHD or have a diagnosis of ADHD.
I: Interventions and Practices Considered / CPG Category
- Service organisation and training
- Recognition, identification and referral
- Information and support
- Managing ADHD
- Dietary advice
- Maintenance and monitoring
- Adherence to treatment
- Review of medication and discontinuation
- Terms used in this guideline
P: Professionals (Intended/Target Users or Stakeholders)
- Occupational Therapists
- Physician Assistants
- Psychologists/Non-physician Behavioural Health Clinicians
- Social Workers
- Family Practice/General Practice
- Clinical Nutrition
- Neurology/Paediatric Neurology
- General Paediatrics/Behavioural and Developmental Paediatrics
- General Psychiatry/Child and Adolescent Psychiatry
- Clinical Psychology/Educational Psychology
O: Major Outcomes Considered
- Sensitivity and specificity of diagnostic measures
- Clinical effectiveness
- ADHD symptoms and severity
- Comorbidities (e.g. conduct problems, anxiety)
- Social skills
- Academic (e.g. reading & mathematics) and occupational performance
- Emotional outcomes and self-efficacy
- Response to treatment
- Adverse effects of treatment
- Quality of life
H: Healthcare Settings
Primary, secondary and tertiary care settings dealing with assessment, treatment and management of ADHD in Saudi Arabia.
Recommendations for research
The guideline committee has made the following recommendations for research.
- National Prevalence. An investigation of the prevalence of ADHD on a national level with consideration of differing regional and societal factors
- Acceptance among educators. Attitudes of teachers and educators towards ADHD in general, towards having children aged 5-18 years with ADHD (as a primary diagnosis) in their classrooms, and towards providing educational accommodations for children with ADHD
- School environment. What is the impact of school environment on the academic performance of children aged 5-18 years with ADHD compared to their peers?
- Scholastic achievement: What is the impact of ADHD management on the academic achievement of persons with ADHD?
- Children and young people aged 5 to 18 years – brief, group-based, ADHD focused, parent-training intervention: What is the clinical and cost effectiveness, and optimum length?
- Medication choice in people with coexisting conditions: What is the clinical and cost effectiveness of ADHD medications in people with ADHD and tic disorders, a history of psychosis or mania, or personality disorder?
- Medication choice in people with no previous exposure to medication for ADHD: What is the clinical and cost effectiveness of ADHD medications in this population?
- Prescribing beyond monotherapy: What is the clinical and cost effectiveness of various ADHD prescribing strategies when monotherapy has failed?
- Diversion and misuse of stimulants: What is the actual national prevalence of, and risk factors for this phenomenon?
- Stigma: What are the various perceptions of children of all ages, adults, parents and other carers related to both ADHD and its medications?
- Road traffic accidents (RTAs): What proportion of RTAs nationally, and what proportion of resulting morbidity and mortality, may be attributable to untreated or under-treated ADHD?
- Substance use: What is the prevalence of ADHD among individuals with substance use disorders (SUDs), and what is the impact on the risk for SUDs of adequate management of ADHD?
- Genetic environment: What are the unique genetic risk factors, if any, for the development of ADHD in Saudi Arabia?
- Service availability in primary care: What is the clinical, functional, and economic impact of enabling access to ADHD management in primary care settings?
- Basic science research and clinical research, clinical trials for therapies and new medication, use of fMRI, PET, MEG scan
- Financial and economic studies 
Implementation Considerations and Tools
The Saudi ADHD CPG Adaptation Group decided to adopt the implementation interventions and tools provided by the NICE CG72 in addition to an ADHD Medication Table and a Clinical algorithm that were developed by the group based on the adapted ADHD recommendations.
The panel decided to adopt the following implementation tools developed by NICE including:
Implementation interventions or strategies
1. Leadership engagement and commitment:
Ensure the involvement of the leadership and senior staff at the outset of the pilot implementation.
Raise awareness through routine communication channels (e.g. email or newsletters, regular meetings, internal staff briefings and other communications with all relevant partner organisations). Identify things staff can directly include in their own practice.
3. Clinical and Quality Champions:
Identify a lead with an interest in ADHD to champion the CPG and motivate others to support its use and make service changes, and to explore any significant issues locally.
4. Training and education:
Regular training and education sessions on the recommendations and evidence-base of this CPG for all relevant healthcare providers.
5. Patients as champions for change:
Similar plans of health education for patients, parents, and the public should be considered to improve the public awareness about the condition.
6. Audit and feedback:
Conduct a baseline assessment (pre-implementation) against the recommendations to find out whether there are gaps in current provision of care of ADHD.
Plan ahead and think about what data is needed to measure improvement and plan how it will be collected. Collaborate with other health and social care organisations and specialist groups to compare current practices with the CPG recommendations. This may also help identify local issues that will slow or prevent implementation.
Conduct a post-implementation audit and compare to identify any gaps or barriers.
Develop an action plan, with the steps needed to put the CPG into practice, and make sure it is ready as soon as possible. Big, complex changes may take longer to implement, but some may be quick and easy to do. For very big changes include milestones and a business case, which will set out additional costs, savings and possible areas for disinvestment. A small project group could develop the action plan. The group might include the CPG champion, a senior organisational sponsor, staff involved in the associated services, finance and information professionals. Implement the action plan with oversight from the lead and the project group. Big projects may also need project management support.
Regular PDCA (Plan – Do – Check – Act) quality improvement cycles should be conducted regularly and monitored by the quality measures.
Networking with existing relevant projects in the organization (e.g. scientific activities, performance improvement, accreditation, etc.)
Adaptation Process Methodology
The description of the methodology for the production of this CPG can be fulfilled by utilizing the King Saud University-Modified ADAPTE method (42), as this method was approved by the Saudi ADHD CPG Project at the Saudi ADHD Society to be the method of CPG synthesis. This CPG adaptation method includes three phases (setup, adaptation, and finalization), nine modules, and 24 steps with modifications in the steps and tools to suit the local general healthcare setting in Saudi Arabia.
Overall, the steps include selection of the health topic, formulation of the CPG adaptation working group, identification of health questions using the PIPOH model, searching and selecting Source CPGs with clear inclusion and exclusion criteria, quality assessment of included Source CPGs by using the Appraisal of guidelines for research and evaluation (AGREE II) Instrument, assessment of the currency of the selected Source CPG, drafting of the Adapted CPG, external review and consultation process, finalization of the Adapted CPG with a set of implementation tools, declaration of conflicts of interests, and finally a plan for review and update. For further details on the specific modifications in steps and tools, refer to the article by Amer et al. 2018 (42).
CPG Title: Evidence-Based Clinical Practice Guidelines for Management of Attention Deficit Hyperactive Disorder
CPG Release Date: 2018 (First Edition)
Status: Adopted using the Modified ADAPTE Method, based on the original ADAPTE Manual & Resource Toolkit-Version 2.0 for trans-contextual adaptation of CPGs released by the Guidelines International Network Adaptation Working Group (The former ADAPTE collaboration).
Adaptation Working Group
Members of the Saudi ADHD Society’s working group on the development of Saudi unified clinical practice guidelines for ADHD. All members of the panel have filled the “Declaration of Conflict of Interest” (ADAPTE Tool 3).
Source CPG Developers
- National Institute of Health and Care Excellence (NICE)
- National Collaborating Centre for Mental Health (NCCMH)
Searching & Selection of CPGs
The protocol for the systematic review of ADHD CPGs for the purpose of this project was published in PROSPERO, CRD42017078712 (43).
List of the Main CPG Database websites we searched:
- Guidelines international Network (G-I-N)
- National Guidelines Clearinghouse (NGC)
- National Institute of Health and Clinical Excellence (NICE)
- Google Scholar
Key words used included “attention-deficit/hyperactivity disorder” or “ADHD,” and “guideline,” “practice guideline,” “clinical practice guideline,” “practice parameter,” “guidance,” or “recommendations”.
Eligibility Criteria for Source CPGs
- Methods of Development: Evidence-Based CPGs: (Detailed Methodology of Development Documented; link Recommendations with Evidence; link to Systematic Reviews) rather than Consensus-based CPGs (Expert opinion)
- Author(s): Group authorship (CPG development group) from CPG developer organizations and Specialized Society (clinical specialty) rather than single author CPGs.
- Country: International and National CPGs.
- Date of Publication: Range of year of publications (2012 – 2017). An updated search was conducted in 2018.
- Language: English CPGs only (also ARABIC if any; but can be excluded as they are not Evidence-Based simply they are adopted from other source CPGs)
- Status: Only original source CPG (de novo developed) rather than adapted CPGs
List of Retrieved Source CPGs
Six recent ADHD CPGs complying with the identified PIPOH and eligibility criteria were included. These CPGs were developed by the following organizations:-
- American Academy of Paediatrics (AAP) in 2012,
- University of Michigan Health System (UMHS) ADHD Guideline Team in 2012,
- National Institute of Health and Care Excellence (NICE) 2016 (and updated in 2018),
- National Health Medical Research Centre (NHMRC) in 2013,
- the Canadian ADHD Resource Alliance (CADDRA) in 2011/ 2014, and
- Singapore Ministry of Health (SMOH) in 2014 Subcommittee on Attention-Deficit/Hyperactivity Disorder
The organizing committee has decided on group authorship and stated the order of authorship
Name of the Working Group (Panel):
‘CPG Adaptation for Management of ADHD’
Name of the Project Lead:
Dr Turki Albatti
Assessment of the Quality of the Source CPGs using the AGREE II Instrument
The Appraisal of Guidelines for Research & Evaluation II (AGREE II) Instrument (www.agreetrust.org)
Table (1): Tool No. 9. AGREE II Standardized Domain Scores for critical appraisal of ADHD CPGs
|D1: Scope & Purpose||80%||74%||100%||72%||37%||91%|
|D2: Stakeholder Involvement||67%||50%||96%||76%||59%||43%|
|D3: Rigour of Development||66%||35%||93%||53%||47%||60%|
|D4: Clarity & Presentation||76%||63%||89%||65%||83%||81%|
|D6: Editorial Independence||75%||78%||92%||67%||28%||69%|
|Recommendation for use||Yes-1, Yes with modifications-2, No-0||Yes-1, Yes with modifications-2, No-0||Yes-1, Yes with modifications-2, No-0||Yes-0, Yes with modifications-3, No-0||Yes-0, Yes with modifications-2, No-1||Yes-2, Yes with modifications-1, No-0|
The AGREE II Domain Score Colour Coding (< 40% red > 41 – 70% yellow > 71 % green)
Therefore, The Overall Assessment and decision of the panel was to adapt the NICE NG87 and to exclude the other five CPGs due to higher AGREE domain scores of NICE NG87
Table (2) Decision Support for CPG Adaptation Group for Management of ADHD
|PHASE||MODULE||STEP||TOOL||DECISION||REASON (if not utilized)|
2.1. Scope and Purpose
2.2. Search and Screen
Decided not to utilize this step in order not to delay the process
Decided to rely on inclusion/exclusion criteria (filters) & PIPOH compatibility
Decided to select all (Rs) of NICE NG87
Decided to rely on D3 Scores of AGREE II
Decided to rely on D5, D2 Scores of AGREE II
2.4. Decision and Selection
Decision making and selection
The panel modified the options to be two
(Accept or Reject) rather than five according to recommendation of KSU-Modified-ADAPTE (42)
3.1. External Review and Acknowledgment Module
3.2. Aftercare Planning
3.3. Final Production
Assessment of Currency of the Selected Source CPG
Table (3): Tool No. 11. Sample Currency Survey of the CPG Developer
|NICE CG59 2016 Update|
|Are you aware of any new evidence relevant to this CPG statement?||No|
|Is there any new evidence to invalidate any of the recommendations comprising the CPG?||No|
|Are there any plans to update the CPG in the near future?||No (after 4 years)|
|When the CPG was last updated?||The updated CPG was issued: May 2018|
|What is the citation for the latest version?||https://www.nice.org.uk/guidance/ng87|
External Review and Consultation Process
Reviewers for the Clinical Content
Who was asked to review the clinical content of the CPG?
Reviewers for the Adaptation Methodology
Plan for Scheduled Review and Update
The group has decided for the next review of this adapted CPG to be after four years from the publication date (July 2020) which should be on (July 2024) after checking for updates in the Source CPG, consultation of expert opinion on the changes needed for updating according to the newest evidence and recommendations published in this area in addition to the implementation and evaluation results at relevant healthcare organizations in the Kingdom.
List of Funding Sources
This work was completely funded by the Saudi ADHD Society and was not related by any means to any pharmaceutical or industrial company. The Saudi ADHD Society did not influence the selection of the Source CPG or the final adapted recommendations.
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