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Adapting evidence-based clinical practice guidelines
for people with attention decit hyperactivity disorder
in Saudi Arabia: process and outputs of a national
initiative
Fahad A. Bashiri
King Saud University College of Medicine
Turki H. Albatti
King Saud University
Muddathir H. Hamad
King Saud University College of Medicine
Haya F. Al-Joudi
King Faisal Specialist Hospital and Research Center
Hadeel F. Daghash
Ministry of Health
Saleh M. Al-Salehi
Princess Nourah bint Abdulrahman University College of Medicine
Jeremy L. Varnham
Saudi ADHD Society
Fatimah Alhaider
King Saud University College of Medicine
Omar Almodayfer
King Abdulaziz Medical City
Abdulkarim Alhossein
King Saud University College of Education
Hesham Aldhalaan
King Faisal Specialist Hospital and Research Center
Yasser A. Aldabbagh
King Khalid Medical City Center for Health Research
Nouf Al Backer
King Saud University College of Medicine
Waleed Altwaijri
King Abdulaziz Medical City
Khalid Alburikan
Saudi Pharmaceutical Society
Maysaa Buraik
John Hopkins Aramco Healthcare
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Mohammad Ghaziuddin
University of Michigan Medical School
Michael J. Nester
Child and Adolescent Services
Hayfaa Wahabi
King Saud University
Samia Alhabib
National Center for Evidence-Based Health Practice Saudi Health Council
Amr A. Jamal
King Saud University College of Medicine
Yasser Sami Amer ( yassersamiamer@gmail.com )
King Saud University https://orcid.org/0000-0003-4097-2317
Research
Keywords: practice guideline, adaptation, evidence-based medicine, ADHD, attention decit hyperactivity
disorder, mental health, Saudi Arabia, Eastern Mediterranean Region
DOI: https://doi.org/10.21203/rs.3.rs-37438/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full
License
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Abstract
Background: We recently adapted the published National institute for Health and Care Excellence (NICE)
Attention decit hyperactivity disorder (ADHD) diagnosis and management guideline to the Saudi Arabian
context. It has been postulated that adaptation of evidence-based clinical practice guidelines to the local
healthcare context rather than de-novo development will improve their adoption and implementation without
imposing a signicant burden on resources. The objective of this paper is to describe the adaptation process
methodology utilized for the generation of the rst national guideline for management of people with ADHD in
Saudi Arabia.
Methods: We used the KSU-Modied-ADAPTE methodology for the guideline adaptation process. We describe
the full process in detail including the three phases of set-up, adaptation, and nalization. The process was
conducted by a multidisciplinary guideline adaptation group in addition to an external review for the clinical
content and methodology.
Results: The group adapted ten main categories of recommendations from one source CPG (NICE). The
recommendations include; (i) service organisation and training, (ii) recognition, identication and referral,
(iii)diagnosis, (iv) support, (v) managing ADHD, (vi) dietary advice, (vii) medication, (viii) maintenance and
monitoring, (ix) adherence to treatment, and (x) review of medication and discontinuation. Several
implementation tools were compiled and developed to enhance implementability including a clinical algorithm,
quality measures, coding system, medication tables, translations, patient information, and online resources.
Conclusions: The nalized clinical practice guideline provides healthcare providers with applicable evidence-
based guidance for the management of people with ADHD in Saudi Arabia. The project also demonstrated the
effectiveness of KSU-Modied-ADAPTE, and emphasized the value of a collaborative clinical and
methodological expert group for adaptation of national guidelines.
Contributions To The Literature
Adaptation of guidelines is a valid alternative to de novo development for generation of evidence-based
guidelines.
The ‘KSU Modied ADAPTE’, as a formal methodology for guideline adaptation, is less resource-intensive
than de-novo development without losing the methodological rigor.
Balanced clinical and methodological expertise in the guideline group is essential for the success of similar
projects.
We describe the process and outputs of a comprehensive national guideline adaptation initiative with
multidisciplinary contributions for management of people with ADHD.
These ndings contribute to the work to enhance adaptation or customization of clinical practice
guidelines and highlight implementability issues for ADHD.
Background
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Attention decit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders that
affects cognitive, emotional, social, academic, and occupational functioning [1]. It is classied into three main
presentations: predominantly inattentive, predominantly hyperactive/impulsive and combined presentation [2].
Although classied as a childhood-onset disorder, it may continue into adolescence and adult life. The
worldwide prevalence of ADHD is estimated to be around 5-7% of children and adults. A number of regional
studies have been conducted into the prevalence of ADHD in Saudi Arabia [3-6], but as yet without denitive
national signicance. It is recognized to have a signicant 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. The diagnosis of ADHD is based on the
diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5) [2] or the
International Statistical Classication of Diseases and Related Health Problems, 10th Revision (ICD-10)
(hyperkinetic disorder) [7]. Although in Saudi Arabia, the ocial coding system that has been adopted is the
Australian revision (ICD-10-AM), whose terminology differs slightly (disturbance of activity and attention,
hyperkinetic conduct disorder, Other hyperkinetic disorders), the term ADHD is widely recognized [7].
There is no standardized clinical guideline for ADHD management in Saudi Arabia. There is, however, a large
volume of internationally published CPGs for ADHD that may create a dilemma for relevant healthcare
providers and clinicians who care for people with ADHD in Saudi Arabia during the processes of sharing
healthcare decisions and care provision. Furthermore, although some initiatives exist about managing ADHD in
primary care, they are in their infancy; ADHD is mainly diagnosed and treated in tertiary care and the private
sector and managed in a variety of settings, sometimes inappropriately or ineffectively. This results in
signicant variability in clinical practice, and suboptimal quality of care.
As part of its strategy to improve access to care for people affected by ADHD in Saudi Arabia, the Saudi ADHD
Society formed a multidisciplinary team to remedy this situation. The resulting clinical practice guideline (CPG)
was adapted from the National institute for Health and Care Excellence (NICE) guideline entitled, Attention
decit hyperactivity disorder: diagnosis and management (NG87) [8], to improve recognition, diagnosis and
quality of care for patients with ADHD.
Clinical Practice Guidelines (CPGs) are dened as ‘statements that include recommendations intended to
optimize patient care, which are informed by a systematic review of evidence and an assessment of the benet
and harm of alternative care options [9]. CPGs have been identied as one of the main tools for improving
evidence-based healthcare quality and safety [9, 10].
Adaptation of CPGs is a valid and ecient alternative to de novo development of CPGs especially in resource-
limited healthcare settings. It was proposed to avoid duplication of efforts, to use the available resources in a
cost-effective manner, and to encourage trans-contextual customization of the CPG prepared for different
economic and healthcare settings reecting the local context and system [9-13].
Given that there are no published CPGs for ADHD management in Saudi Arabia to-date, the presented evidence-
based CPG is proposed as a National CPG using an evidence-based and formal CPG adaptation methodology.
The aim of this study was to adapt the international clinical practice guidelines’ recommendations for people
with ADHD to t the healthcare setting in the Saudi Arabian context including the primary, secondary, and
tertiary care settings.
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Methods
Guideline adaptation methodology
We utilised the ‘KSU Modied ADAPTE’ [9] adaptation methodology, a natural evolution of two earlier formal
adaptation methodologies for CPGs, the original ADAPTE and ‘Adapted ADAPTE’ methods [12-14], which
consists of three phases and 24 steps with modications in the steps and tools to suit the local general
healthcare setting in Saudi Arabia [9, 13]. Figure 1 provides a simplied owchart of our methods [9].
The main two reporting standards for CPGs recommended by the EQUATOR (Enhancing the QUAlity and
Transparency Of health Research) Network are the Appraisal of Guidelines for Research and Evaluation
(AGREE) II reporting checklist and the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement
[15-17]. Despite the fact that these tools were designed more towards de-novo developed CPGs, rather than
adapted CPGs, we will report our adapted CPG for ADHD using the AGREE II reporting checklist after applying
specic explanations to the items of the checklist relevant to our CPG adaptation process in contrast to a CPG
development process (Additional File). Furthermore, there is an ongoing research project for developing an
extension of the RIGHT statement for the reporting of ‘adapted CPGs’ (RIGHT-Ad@pt Checklist) [18].
Phase One (Set Up)
In phase one, Attention decit hyperactivity disorder (ADHD) was identied by the Saudi ADHD Society as the
health topic for this CPG adaptation project. An initial exploratory search regarding ADHD CPGs was conducted
to identify whether there were existing CPGs related to this topic. The guideline adaptation working group (GAG)
was formulated at the outset to include a child psychiatrist, two pediatric neurologists, a developmental
pediatrician, a clinical neuropsychologist, a clinical pharmacist, a general pediatrician and CPG expert
methodologist, a project manager, and a patient advocate. Participation of the patient advocate in the GAG and
all of its meetings was intended to capture the patients’ or publics’ views and preferences in addition to the
support and insight from the networks and resources of the Saudi ADHD Society. The results of the preliminary
search for ADHD Source CPGs encouraged us to proceed and ocially launch this CPG adaptation project with
a national scope. Capacity building sessions were conducted by the CPG methodologist for the rest of the GAG
on concepts of evidence-based healthcare including the CPG adaptation process methodology and its
associated toolkit [9, 11, 14].
The target patient population for the adapted CPG is children and adults suspected of having or diagnosed with
ADHD. The identied target intended users included physicians, clinical psychologists, other behavioral health
clinicians, nurses, occupational therapists, pharmacists, social workers, dieticians, medical students, and health
sciences students.
Phase Two (Adaptation)
In phase two, we identied specic health questions using the PIPOH model, relevant inclusion and exclusion
criteria, and a full search strategy including a list of keywords. The elements of the PIPOH model include the
target patient population (P), intervention(s) (I), professionals and clinical specialties (P), outcomes (O), and
healthcare setting or context (H) that were reported earlier [1,9]. We searched eight bibliographic and CPG
databases in addition to online libraries of relevant professional societies. Eligible Source CPGs for ADHD were
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then critically appraised using the AGREE II Instrument [19]. AGREE II is a valid and reliable instrument with 23
items organized into six domains and is considered the gold standard for quality assessment of CPGs [19]. A
cut-off point of 60% for each AGREE II standardized domain score was agreed upon by the members of the
GAG [1].
Based on the results of the AGREE II appraisal [1] and in-depth content review of the source CPG from NICE,
there was a consensus among the members of the GAG that the recommendations were clear and were based
on the most relevant scientic evidence, applicable to the local context, and acceptable to people with ADHD.
We decided not to conduct further assessment of the certainty of the body of evidence and the strength of
recommendations and relied on the high standardized domain score of domain 3 (rigour of development) of the
AGREE II appraisal and the evidence-base of the NICE source CPG based on its provided Grading of
Recommendations: Assessment, Development, and Evaluation (GRADE) evidence proles [1].
Moreover, the GAG identied, revised, and discussed all the recommendation statements through successive
focus group discussions against the local and national healthcare system in Saudi Arabia. Drafting the rst
version of the adapted CPG was the last step of this phase.
Phase Three (Finalization)
In phase three, the rst draft of the adapted CPG full document was nalized including assessing the
recommendations for acceptability and applicability in the local Saudi Arabian healthcare settings. This
adapted CPG draft was then disseminated to a selected national panel of external reviewers of specialized
healthcare providers, topic experts, and methodologists from relevant healthcare sectors. The feedback of
reviewers was revised and discussed within the GAG and was reected in the nal version of the adapted CPG.
A set of CPG implementation (CPGI) tools was included in the nal CPG full document.
Results
The overall duration of this CPG adaptation project was two years and ve months from 4th of January 2017 till
30th of May 2019. Seven meetings were conducted for planning, reviewing, and focus group discussions
including two training sessions with ongoing hands-on advisory on the CPG appraisal and adaptation tools.
This work marks the rst CPG adaptation project for the management of people with ADHD using the ‘KSU
Modied ADAPTE’.
Phase One (Set Up)
The aforementioned GAG was formulated in January 2017 as a multidisciplinary group with expertise in ADHD
(TA, FB, MH, HA, SA, HD) and evidence-based CPGs (YA). ADHD was selected as a high priority health topic with
clear practice variation and lack of national CPGs for its management. The necessary resources and skills were
identied and allocated. All of the GAG members signed declaration of conicts of interest statements.
The feasibility of the CPG adaptation process was conrmed by conducting a preliminary search for published
CPGs. The working plan was drafted and discussed at the outset using the relevant CPG adaptation working
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plan template from the KSU-Modied-ADAPTE (Appendix Table 3) [9].
Phase Two (Adaptation)
For the rst and second phases, a systematic review for the recently published ADHD Source CPGs was
conducted and published in a separate report, which included the PIPOH model, eligibility criteria, results of the
search and screen for Source CPGs, in addition to the results of the ratings and commentary of the AGREE II
appraisal [1].
Six source ADHD CPGs were reviewed and critically appraised including those developed by the American
Academy of Pediatrics, Canadian ADHD Resource Alliance, National Health and Medical Research Council,
National Institute for Health and Care Excellence (NICE), Singapore Ministry of Health, and University of
Michigan Health System [1] .
The NICE CPG was superior in all of the six standardized domain scores of the AGREE II Instrument and it
addressed all care options for ADHD across the lifespan. The AGREE II ratings of the NICE CPG were 100%
(domain 1: scope and purpose), 96% (domain 2: stakeholder involvement), 93% (domain 3: rigour of
development), 89% (domain 4: clarity and presentation), 92% (domain 5: applicability), 92% (domain 6: editorial
independence), and 100 % (overall assessment 1) [1].
Afterwards, we assessed the currency of the NICE Source CPG to ensure the validity and currency of its
recommendations and their evidence-base using the related assessment of the CPG currency from the KSU-
Modied-ADAPTE (Appendix Table 4) [9].
The GAG reviewed and discussed the AGREE II assessment standardized domain scores and decided to adopt
all of the recommendations of the NICE CPG. Relevant customization of the recommendations was conducted
after several focus group discussions of facilitators and barriers to CPGI especially regarding variable health
systems, medications, or healthcare provider positions.
The GAG decided to adopt the CPGI tools provided by the NICE Source CPG, i.e. baseline assessment tool and
quality standards. Additional CPGI tools were included by the GAG based on and relevant to the adapted ADHD
recommendations including; (i) two medication tables; one for treatment of children and young people and the
other for treatment of adults with ADHD (a merged summary medication has been provided in this article), (ii) a
clinical algorithm for management of ADHD (Figure 2), (iii) the set of related ICD-10-AM codes that were
adopted by the National Health Information Center, Saudi Health Council [7] in addition to the ICD-11 codes [20],
and (iv) links to patient educational information and resources on the Society’s ocial website. A mobile-
friendly web-based version of the CPG was also developed.
Phase Three (Finalization)
Thirteen members participated as the external review panel from the target audience of the CPG based on their
expertise in caring for people with ADHD (FA, OA, AA, HA, YAA, NA, WA, KA, AJ, and MB) and in methodologies
of evidence-based CPGs (HAA and SA) in addition to their representation of multiple relevant healthcare sectors
in Saudi Arabia. Two international experts were invited to contribute to the external review of the clinical content
as well (MG and MJN).
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The external review comments were compiled using a template [9], revised, discussed, and incorporated in the
recommendations and implementation tools of the nalized adapted CPG full document.
The customization or adaptation of recommendations was conducted with regards to the differences in the
health systems and delivery of healthcare services especially for people with ADHD between the United
Kingdom (UK) and the Kingdom of Saudi Arabia. The similarities in the health systems in both countries being
nationalized healthcare systems where the government provides the majority of healthcare services, in addition
to the similarity of income levels facilitated the process of adaptation of recommendations to the local context
[21]. Furthermore, the recommended medications were revised against those currently approved by the Saudi
Food and Drug Authority (Saudi FDA), and those available on a restricted basis through specic hospitals. No
formal cost-analyses or Health Technology Assessment(s) were conducted as part of this project.
Health benets, side effects, and risks were evaluated in the Source CPG (NICE) as part of the AGREE II
assessment [1] and were further revised and discussed during the adaptation or customization of the
recommendations to the local context.
The values and preferences of the target patient population was considered and discussed throughout the CPG
adaptation process through the input of the patient advocate. Moreover, reports from the patient and public
encounters during related services were provided by the society.
As a part of quality assurance, the nalized adapted CPG from the Saudi ADHD Society was then critically
reviewed and endorsed by the Saudi Health Council as well as ve national professional societies – the Saudi
Pediatric Neurology Society, the Saudi Pediatric Association, the Saudi Pharmaceutical Society, the Saudi
Psychiatric Association, and the Saudi Society of Professional Psychology. The adapted CPG included
recommendation statements organized into ten sections including; (i) Service organisation and training, (ii)
Recognition, identication and referral, (iii)Diagnosis, (iv) Support, (v) Managing ADHD, (vi) Dietary advice, (vii)
Medication, (viii) Maintenance and monitoring, (ix) Adherence to treatment, and (x) Review of medication and
discontinuation.
The Saudi ADHD Society contacted NICE, the Source CPG developer, and nalized an ocial end user license
agreement in line with the original NICE terms and conditions and the NICE UK Open Content license.
A summary of the key recommendations is provided in Table 1 and the full CPG document is made available, in
addition to the translation into the Arabic language [22], on a user-friendly and accessible microsite of the
ocial website of the Saudi ADHD Society: https://cpg.adhd.org.sa/
Plan for scheduled review and update
The GAG recommended for the next review of this adapted CPG to be after four years from its publication
(2020) which should be on (2024) after checking for updates in the Source CPG, consultation of expert opinion
on any suggested updates needed 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 of Saudi Arabia. The Checklist for the Reporting of Updated Guidelines (CheckUp) is recommended by
the EQUATOR network to report the updating of CPGs [23].
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Implementation considerations and tools
A full set of CPGI tools was an integral component of the adapted CPG full document (Figure 2, Tables 1-2).
Several CPGI interventions or strategies were highlighted and proposed to promote future CPGI including; (i)
leadership engagement and commitment, (ii) dissemination, (iii) clinical and quality champions, (iv) training
and education, (v) audit and feedback, (vi) networking with existing projects in the organizations (e.g.
performance improvement, accreditation, educational, and scientic activities), and (vi) patients as champions
for change [24,25].
The GAG recommends using this adapted CPG as a core tool within regular Plan-Do-Study-Act (PDSA)
healthcare quality improvement cycles to support and promote quality and safety of healthcare services and
best practice for people with ADHD.
Facilitators and barriers to implementation
Several potential facilitators and barriers to implementation were identied during the CPG adaptation process.
Facilitators include the relevant national strategies, committees, initiatives, and new healthcare services that are
expected as a part of the new model of care, to support implementation. Contribution of representatives of
multiple local healthcare sectors are designed to facilitate early dissemination and implementation.
Identied barriers and challenges that require a pro-active intervention to address them as a part of planning for
implementation include, but are not limited to, the following: (i) medication availability, access, and
sustainability; (ii) dissemination of the adapted CPG; (iii) lack of awareness of the primary care regarding the
updated evidence-based recommendations of ADHD; (iv) lack of seamless integration between different
national healthcare sectors; and (v) poor transition from pediatric to adult healthcare services.
An overall decision support record for the ADHD CPG adaptation group (GAG) using the KSU-Modied-ADAPTE
methodology is provided in Appendix Table 5.
Declarations
The aim of this study was to adapt the international CPGs and their recommendations to the Saudi healthcare
context for the comprehensive management of people with ADHD across all local healthcare sectors.
The iterative process of the ADHD CPG adaptation reveals the nature of intensive work and capacity building
that was an integral component of this project, and the specialized expertise required for such a process
irrespective of the clinical or methodological expertise. The long timeline observed was not unique to this CPG
adaptation project and was reported in other local CPG adaptation projects as well [9].
The GAG did not experience a shorter timeline for this CPG adaptation project compared to the 2–3 year period
often suggested for de-novo development of CPGs [25]. This could be possibly due to the fact that we did not
conduct this CPG adaptation process continuously and the GAG expert team members had other primary
engagements and were not fully dedicated to this project. Indeed, it was obvious that the CPG adaptation
process requires a considerable time commitment.
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Nevertheless, the adaptation of CPG recommendations is a good and valid alternative to de-novo developing a
CPG for people with ADHD, especially given the lack of relevant local high-quality systematic reviews and
randomized controlled trials.
A strength of this study is the use of the ‘KSU Modied ADAPTE’ method because it is clearly structured and
easy to follow with a set of tools to support the process.
Another noted strength was the inclusion of a patient advocate in the GAG with major contributions and input
to the nalized adapted CPG.
Numerous CPGs for ADHD are published and updated regularly by a number of national and international
organizations [1], which may contribute to the noted variability in local practice by providers caring for people
with ADHD [1].
There are increasing initiatives and projects related to knowledge translation in general and CPGs in particular
nationally and regionally [9,27,28]. The World Health Organization of the Regional Oce of the Eastern
Mediterranean is promoting and supporting all advances in the development, adaptation, and implementation
of CPGs at the regional level [28]. Furthermore, ‘National guidelines’ are core components of the ‘Model of Care’
of the new Saudi Arabian National Healthcare Plan [30,31].
From the experience of the GAG, which coincides with published evidence, it is an essential pre-requirement of
such a CPG adaptation project to practically determine the expected workload, resources, expertise, and the
need for dedicated leadership and project management. This needs assessment is by default part of the set-up
phase of adaptation.
Conclusions
The ‘KSU Modied ADAPTE’ methodology for CPG adaptation is a rigorous, practical, and intensive tool that –
along with the AGREE II instrument as a major component of the adaptation process – has been demonstrated
to be particularly feasible for national CPG projects.
Our experience with this adaptation methodology provides useful insight into its utilization on a national level
in Saudi Arabia, and further demonstrates its potential suitability for the Eastern Mediterranean region.
Additional modications to the adaptation process and tools as per the context are recommended and
accepted [9, 14].
Participation of a large number of healthcare sectors through multi-disciplinary groups in the CPG adaptation
process aims at increasing the future uptake of the recommendations of this CPG. We anticipate an increase in
the level of collaboration and integration of ADHD-related healthcare services as a result of the adoption of this
adapted CPG.
Implications for practice
Availability of a national CPG is essential but not sucient to guarantee ultimate standardization of patient
healthcare. The degree of positive impact on people with ADHD will highly depend on the effectiveness of
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dissemination and implementation strategies in addition to other quality improvement and safety
interventions.
Future research
A formal cost-analysis is suggested to decide whether the process of CPG adaptation is cost-effective.
Research evidence is required as well to determine the effectiveness of CPGI tools and strategies for ADHD, as
well as effectiveness of the adapted CPG in the following areas: (i) early identication and referral of children
and adults with ADHD, (ii) appropriate transition of care from child to adult healthcare services for ADHD, (iii)
parent training programs, (iv) initiation of drug treatment with dose adjustment as indicated, (v) regular
assessment of the response to medication, and (vi) annual review of drug treatment.
Abbreviations
ADHD: Attention Decit Hyperactivity Disorder, AGREE: Appraisal of Guidelines for Research and Evaluation,
CPG: Clinical Practice Guideline, CPGI: Clinical Practice Guideline Implementation, GRADE: Grading of
Recommendations: Assessment, Development, and Evaluation, KSU: King Saud University, NICE: National
institute for Health and Care Excellence.
Declarations
Ethics approval and consent to participate
Not applicable
Consent for publication
Consent for publication was obtained from all participants.
Availability of data and materials
The data that support the ndings of this study has been made available in the tables, gures and appendices
of this article in addition to reference [1]. Further details could be made available from the authors upon
reasonable request to the corresponding author and the Saudi ADHD Society.
Competing interests
The authors declare that they have no competing interests. Conict of interest declaration documents can be
made available from the Saudi ADHD Society upon request.
Funding
The process of CPG adaptation was funded by The Saudi ADHD Society, Saudi Arabia and was not related by
any means to any pharmaceutical or industrial company. The Saudi ADHD Society did not inuence the
selection of the Source CPG or the nal adapted CPG’s recommendations. Hayfaa Wahabi, Amr Jamal, and
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Yasser Amer were supported by the Research Chair for Evidence-Based Health Care and Knowledge Translation,
Deanship of Scientic Research, King Saud University, Riyadh, Saudi Arabia.
Authors’ contributions
YSA, FAB, and MHH have conceptualized and written the rst draft of the manuscript, and had the responsibility
for the decision to submit it for publishing. YSA, FAB, MHH conceptualized the design. THA, FAB, MHH, HFA,
JLV, SMA, HFD, and YSA were members of the CPG adaptation working group (or the scientic committee)
where THA was the project lead and YSA was the CPG methodologist. FA, OA, AA, HA, YAA, NA, WA, KA, MG,
AAJ, and MJN were members of the external review group for the clinical content of the adapted CPG. HAA and
SA were members of the external review group for the CPG adaptation process methodology. All authors
participated in interpretation of the data and critically reviewed the manuscript. YSA revised the paper in
consideration of feedback from co-authors. All authors read and approved the nal manuscript.
Acknowledgments
The authors wish to thank the Saudi ADHD Society for its initiative in supporting this CPG adaptation project as
a part of the Unied ADHD Clinical Practice Guidelines Project. Yasser S. Amer and Hayfaa A. Wahabi were
supported by the Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of
Scientic Research, King Saud University, Riyadh, Saudi Arabia.
Furthermore, we would like to thank the Research Support and Services Unit (RSSU), Deanship of Scientic
Research, King Saud University for their technical support.
Appendix Table 3. Guideline adaptation working plan
Appendix Table 4. Assessment of the currency of the NICE ADHD Guidance
Appendix Table 5. Guideline adaptation decision support process
References
1. Amer YS, Al-Joudi HF, Varnham JL, Bashiri FA, Hamad MH, Al Salehi SM, et al. Appraisal of clinical practice
guidelines for the management of attention decit hyperactivity disorder (ADHD) using the AGREE II
Instrument: A systematic review. PLoS One. 2019;14(7):e0219239.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®):
American Psychiatric Pub; 2013.
3. Alqahtani M. Attention-decit hyperactive disorder in school-aged children in Saudi Arabia. European
Journal of Pediatrics. 2010;169(9):1113-1117. doi: 10.1007/s00431-010-1190-y
4. Albatti TH, Alhedyan Z, Alnaeim N, Almuhareb A, Alabdulkarim J, Albadia R, et al. Prevalence of attention
decit hyperactivity disorder among primary school-children in Riyadh, Saudi Arabia; 2015-2016. Int J
Pediatr Adolesc Med. 2017;4(3):91-4.
5. AlZaben FN, Sehlo MG, Alghamdi WA, Tayeb HO, Khalifa DA, Mira AT, et al. Prevalence of attention decit
hyperactivity disorder and comorbid psychiatric and behavioral problems among primary school students
in western Saudi Arabia. Saudi Med J. 2018;39(1):52-8.
Page 13/30
6. Jenahi E, Khalil MS, Bella H. Prevalence of attention decit hyperactivity symptoms in female
schoolchildren in Saudi Arabia. Ann Saudi Med. 2012;32(5):462-8.
7. Alharbi M, Isouard G, Tolchard B. The Development of ICD Adaptations and Modications as Background
to a Potential Saudi Arabia's National Version. Global Journal of Health Science. 2019;11(11):158.
8. National institute for Health and Care Excellence. Attention decit hyperactivity disorder: diagnosis and
management. NICE guideline [NG87]. Available from: https://www.nice.org.uk/guidance/NG87.
9. Amer YS, Wahabi HA, Abou Elkheir MM, Bawazeer GA, Iqbal SM, Titi MA, et al. Adapting evidence-based
clinical practice guidelines at university teaching hospitals: A model for the Eastern Mediterranean Region.
J Eval Clin Pract. 2019;25(4):550-60.
10. Glasziou P, Ogrinc G, Goodman S. Can evidence-based medicine and clinical quality improvement learn
from each other? BMJ quality & safety. 2011;20(Suppl 1):i13-i7.
11. Fervers B, Burgers JS, Haugh MC, Latreille J, Mlika-Cabanne N, Paquet L, et al. Adaptation of clinical
guidelines: literature review and proposition for a framework and procedure. Int J Qual Health Care.
2006;18(3):167-76.
12. Wang Z, Norris SL, Bero L. The advantages and limitations of guideline adaptation frameworks. Implement
Sci. 2018;13(1):72.
13. Fervers B, Burgers JS, Voellinger R, Brouwers M, Browman GP, Graham ID, et al. Guideline adaptation: an
approach to enhance eciency in guideline development and improve utilisation. BMJ Qual Saf.
2011;20(3):228-36.
14. Amer YS, Elzalabany MM, Omar TI, Ibrahim AG, Dowidar NL. The 'Adapted ADAPTE': an approach to
improve utilization of the ADAPTE guideline adaptation resource toolkit in the Alexandria Center for
Evidence-Based Clinical Practice Guidelines. J Eval Clin Pract. 2015;21(6):1095-106.
15. Equator-network.org. 2020.The EQUATOR Network | Enhancing The Quality And Transparency Of Health
Research. [online] Available at: <https://www.equator-network.org/> [Accessed 29 June 2020].
16. Chen Y, Yang K, Marušić A, Qaseem A, Meerpohl JJ, Flottorp S, Akl EA, Schünemann HJ, Chan ESY, Falck-
Ytter Y, Ahmed F, Barber S, Chen C, Zhang M, Xu B, Tian J, Song F, Shang H, Tang K, Wang Q, Norris SL; for
the RIGHT (Reporting Items for Practice Guidelines in Healthcare) Working Group. A Reporting Tool for
Practice Guidelines in Health Care: The RIGHT Statement. Ann Intern Med. 2017;166(2):128-132.
17. Brouwers MC, Kerkvliet K, Spithoff K, AGREE Next Steps Consortium. The AGREE Reporting Checklist: a tool
to improve reporting of clinical practice guidelines. BMJ. 2016;352:i1152
18. Song Y, Darzi A, Ballesteros M, et al. Extending the RIGHT statement for reporting adapted practice
guidelines in healthcare: the RIGHT-Ad@pt Checklist protocolBMJ Open 2019;9:e031767. doi:
10.1136/bmjopen-2019-031767
19. Brouwers MC, Florez ID, McNair SA, Vella ET, Yao X. Clinical Practice Guidelines: Tools to Support High
Quality Patient Care. Semin Nucl Med. 2019;49(2):145-52.
20. World Health Organization, International Classication of Diseases 11th Revision, ICD-11, [Internet]. [cited
29 April 2020]. Available from: https://icd.who.int/en.
21. World Bank Country and Lending Groups—World Bank Data Help Desk [Available from:
https://datahelpdesk.worldbank.org/knowledgebase/articles/906519‐world‐bank‐country‐and‐lending‐
groups Accessed 22 February 2020.
Page 14/30
22. Al-daleel al-irshadi as-sareeri li idtirab fart alharakah wa tashatut alintibah al-mamlakah al-arabiah al-
saudiah [Evidence-Based Clinical Practice Guideline for Management of Attention Decit Hyperactivity
Disorder (ADHD) in Saudi Arabia]. Riyadh: Saudi ADHD Society; 2020. [Arabic]
23. Vernooij RWM, Alonso-Coello P, Brouwers M, Martínez García L, CheckUp Panel. Reporting Items for
Updated Clinical Guidelines: Checklist for the Reporting of Updated Guidelines (CheckUp). PLOS Medicine.
2017;14(1): e1002207.
24. Harrison MB, Legare F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context and
assessing barriers to their use. Cmaj. 2010;182(2):E78-84.
25. Dizon JM, Machingaidze S, Grimmer K. To adopt, to adapt, or to contextualise? The big question in clinical
practice guideline development. BMC Res Notes. 2016;9(1):442.
26. Harrison MB, Graham ID, van den Hoek J, Dogherty EJ, Carley ME, Angus V. Guideline adaptation and
implementation planning: a prospective observational study. Implement Sci. 2013;8:49.
27. Koornneef E, Robben P, Hajat C, Ali A. The development, implementation and evaluation of clinical practice
guidelines in G ulf C ooperation C ouncil (GCC) countries: a systematic review of literature. Journal of
evaluation in clinical practice. 2015 Dec;21(6):1006-13.
28. El-Jardali F, Mandil A, Jamal D, BouKarroum L, El-Feky S, Nour M, Al-Abbar M. Engagement of health
research institutions in knowledge translation in the Eastern Mediterranean Region. Eastern Mediterranean
Health Journal. 2018 Jul 1;24(7).
29. Developing/adapting evidence-based guidelines in the Eastern Mediterranean Region. Eastern
Mediterranean Health Journal. 2016;22(4):286-287.
30. Alharbi MF. An analysis of the Saudi health-care system's readiness to change in the context of the Saudi
National Health-care Plan in Vision 2030. Int J Health Sci (Qassim). 2018 May-Jun;12(3):83-87.
31. National Transformation Program | Saudi Vision 2030 [Internet]. Vision2030.gov.sa. 2020 [cited 20 June
2020]. Available from: https://vision2030.gov.sa/en/programs/NTP
Tables
Table 1. Summary of the Key recommendations in the Adapted clinical practice guideline for the management
of children and adults with ADHD*
Page 15/30
Recognition
There are certain groups may have increased prevalence of ADHD compared to the general population like:
· People born preterm
· Looked-after children (e.g. those living in care homes such as orphanages or juvenile detention
facilities)
· People with oppositional, conduct disorders or mood disorders
· People with neurodevelopmental disorders (for example autistic spectrum disorders, tics, intellectual
disability, and specic learning diculties)
· People with a close family member diagnosed with ADHD
· People with epilepsy
· Adults with a mental health condition
· People with a history of substance misuse
· People with acquired brain injury
Identication and referral
We recommend that universal screening for ADHD should not be undertaken in nursery, primary and
secondary schools. When a child or young person with disordered conduct and suspected ADHD is referred
to a school’s special education teacher or consulting teacher, in addition to helping the child with its
behavior, he/she should inform the parents about local specialized programmes (e.g. General Pediatric
clinics, Developmental and Behavioral Clinics, etc.).
Diagnosis
The diagnosis of ADHD is based on the diagnostic criteria in the Diagnostic and Statistical Manual of
Mental Disorders – 5th Edition (DSM-5) [2] or the International Statistical Classication of Diseases and
Related Health Problems, 10th Revision (ICD-10) (hyperkinetic disorder) [8]. It should be made by a
specialist psychiatrist, specialized pediatrician, an appropriately trained family physician or other
appropriately qualied healthcare professional with training and expertise in the diagnosis of ADHD after a
full clinical, psychosocial, developmental and psychiatric assessment and use of standard rating scales like
Conners' rating and Vanderbilt scales.
Note: Currently, the national adopted system is ICD-10-AM.
Management
Proper management of patients with ADHD includes early recognition and referral to specialized service and
a comprehensive shared treatment plan with the patients and their families. It requires a multidisciplinary
approach that involves behavioral therapy, school intervention, parents’ education, and pharmacotherapy.
The goals of treatment are to reduce the severity of symptoms and functional impairment and to improve
the quality of life.
Children under 5 years.
ADHD-focused group parent-training programme is the rst-line treatment for children under 5 years of age.
Medications should not be offered for any child under 5 years without a second opinion from an ADHD
service with expertise in managing ADHD in young children.
Children aged 5 years and over and young people
A group-based education and information on the causes and impact of ADHD should be given to parents
and carers of all children aged 5 years and over and young people with ADHD. A course of Cognitive
Behavioral Therapy (CBT) should be considered for those who have beneted from medication but still
having a signicant impairment in at least one domain.
Page 16/30
Medications should be offered for patients with a persistent signicant impairment.
The diagnosis should be conrmed before offering any medications and the patient should have full
assessment for the presence of coexisting medical, mental or neurodevelopmental conditions.
First-line therapy
Methylphenidate (either short or long-acting) should be offered as the rst-line pharmacological treatment
for children aged 5 years and over and young people with ADHD.
Second-line therapy
Switching to Lisdexamfetamine should be considered for children who have had a 6-week trial of
Methylphenidate.
Dexamphetamine should be considered for children aged 5 years and over and young people whose ADHD
symptoms are responding to Lisdexamfetamine but who cannot tolerate the longer effect prole.
Third-line therapy
Atomoxetine or Guanfacine should be offered to children aged 5 years and over and young people if they
cannot tolerate methylphenidate or Lisdexamfetamine or their symptoms have not responded to separate 6-
week trials of Lisdexamfetamine and Methylphenidate, having considered alternative preparations and
adequate doses.
Adults
Medications to adults with ADHD should be offered if their ADHD symptoms are still causing signicant
impairment in at least one domain after environmental modications have been implemented and reviewed.
Non-pharmacological treatment should be considered for adults who have diculty adhering to
medications or those who found medication to be ineffective or cannot tolerate it.
A structured, supportive psychological intervention should be offered for adults with ADHD. Treatment may
involve elements of or a full course of CBT.
First-line therapy
Lisdexamfetamine or Methylphenidates should be offered as rst-line pharmacological treatment.
Switching to Methylphenidate or Lisdexamfetamine should be considered for adults who have had a 6-week
trial of Lisdexamfetamine or methylphenidates at an adequate dose but have not derived enough benet.
Second-line therapy
Dexamfetamine should be considered for adults whose ADHD symptoms are responding to
Lisdexamfetamine but who cannot tolerate the longer effect prole.
Atomoxetine should be offered to adults if they cannot tolerate Lisdexamfetamine or Methylphenidate or
their symptoms have not responded to separate 6-week trials of Lisdexamfetamine and Methylphenidate,
having considered alternative preparations and adequate doses.
Further medication choices
The following medications should not be offered without advice from a tertiary ADHD service: (i)
Guanfacine for adults, (ii) Clonidine for children with ADHD and sleep disturbance, rages or tics and (iii)
atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression,
rages or irritability.
We recommend offering the same medication choices to people with ADHD and anxiety disorder, tic
disorder or autism spectrum disorder as other people with ADHD. We also recommend stopping any
medication for children aged 5 years and over, young people and adults with ADHD experiencing an acute
psychotic or manic episode. Restarting or starting new ADHD medication after the episode has resolved
should be considered.
Page 17/30
Maintenance and monitoring
We recommend the followings:
· Monitor effectiveness of medication and adverse effects.
· Regular measurement of weight, height and BMI for people taking medication for ADHD.
· Monitor heart rate and blood pressure and compare with the normal range for age before and after
each dose change and every 6 months.
· Do not offer routine blood tests or ECGs to people taking medication for ADHD unless there is a
clinical indication.
· If a person taking guanfacine has sustained orthostatic hypotension or fainting episodes, reduce their
dose or switch to another ADHD medication.
· If a person taking stimulants develops tics, think about whether: the tics are related to the stimulant
(tics naturally wax and wane) and the impairment associated with the tics outweighs the benets of ADHD
treatment. If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in
children aged 5 years and over and young people only), Atomoxetine, Clonidine or stopping medication.
· Monitor young people and adults with ADHD for sexual dysfunction (that is, erectile and ejaculatory
dysfunction) as potential adverse effects of Atomoxetine.
· If a person with ADHD develops new seizures or a worsening of existing seizures, review their ADHD
medication and stop any medication that might be contributing to the seizures. After investigation,
cautiously reintroduce ADHD medication if it is unlikely to be the cause of the seizures.
· Monitor the behavioral response to medication, and if behavior worsens adjust medication and review
the diagnosis.
Dietary advice
A balanced diet, good nutrition and regular exercise for patients with ADHD is advised. Elimination of
articial coloring and additives from the diet should not be advised. A referral to dietitian should be offered
if a relationship was found between behaviors and specic food or drinks.
*For the complete set of recommendations of the adapted guideline, please refer to the ocial website:
https://cpg.adhd.org.sa/recommendations/
Table 2. Summary of medications prescribed for the management of children and adults with ADHD*
Page 18/30
Medications Dose Comments
Methylphenidate
Immediate-release
(RITALIN)
Modied-release
CONCERTA ® XL
Child 4–5 years:
Starting dose: 2.5 mg twice
daily, increased in steps of 2.5
mg daily if required, at weekly
intervals.
Maximum dose: 1.4 mg/kg
daily in 2–3 divided doses.
Child 6–17 years:
Starting dose: 5 mg 1–2 times
a day, increased in steps of 5–
10 mg daily if required, at
weekly intervals increased if
necessary up to 60 mg daily in
2–3 divided doses, increased if
necessary up to 2.1 mg/kg
daily in 2–3 divided doses
Maximum dose: 60 mg daily
in 2–3 doses, higher dose (up
to a maximum of 90 mg daily)
under the direction of a
specialist.
Starting dose: 18 mg once
daily to be taken in the
morning, increased in steps of
18 mg every week adjusted
according to response
increased if necessary up to
2.1 mg/kg daily.
Maximum dose: 54 mg once
daily.
Dose equivalence and
conversion
Total daily dose of 15 mg of
standard-release formulation is
considered equivalent to
Concerta ® XL 18 mg once
daily.
Cautions:
Agitation, anxiety, drug dependence, epilepsy
(discontinue if increased seizure frequency),
family history of Tourette syndrome, susceptibility
to angle-closure glaucoma, and tics.
Contraindications:
Anorexia nervosa, arrhythmia, cardiomyopathy,
cardiovascular disease, cerebrovascular disorders,
heart failure, hyperthyroidism,
phaeochromocytoma, psychosis, severe
depression, severe hypertension, structural cardiac
abnormalities, suicidal ideation, uncontrolled
bipolar disorde, and vasculitis.
Common side effects:
Alopecia, anxiety, decreased appetite, arrhythmias.
Arthralgia, Abnormal behaviour, cough, depression,
diarrhoea, dizziness, drowsiness, dry mouth, fever,
gastrointestinal discomfort, growth retardation,
headaches, hypertension, laryngeal pain, altered
mood, movement disorders, nasopharyngitis,
nausea, palpitations, sleep disorders, vomiting,
and decreased weight.
Lisdexamfetamine
Child 6–17 years:
Starting dose: 30 mg once
daily, alternatively initially 20
mg once daily, increased in
steps of 10–20 mg every week
if required, dose to be taken in
the morning, discontinue if
response insucient after 1
month;
Maximum dose: 70 mg per
day.
Cautions:
Bipolar disorder, history of cardiovascular disease,
history of substance abuse, may lower seizure
threshold (discontinue if seizures occur), psychotic
disorders, susceptibility to angle-closure
glaucoma, tics, and Tourette syndrome
Contraindications:
Advanced arteriosclerosis, agitated states,
hyperthyroidism, moderate to severe hypertension,
and symptomatic cardiovascular disease.
Page 19/30
Common side effects:
Upper abdominal pain, anxiety, decreased appetite,
abnormal behaviour, constipation, depression,
diarrhoea, dizziness, drowsiness, dry mouth,
dyspnoea, fatigue, feeling jittery, fever, headache,
insomnia, mood altered, nausea, palpitations,
psychiatric disorders, skin reactions, tachycardia,
tremor, vomiting, and decreased weight.
Dexamfetamine Child 6–17 years:
Starting dose: 2.5 mg 2–3
times a day, increased in steps
of 5 mg once weekly if
required.
Maximum dose: 1 mg/kg daily,
up to 20 mg daily (40 mg daily
has been required in some
children). maintenance dose
to be given in 2–4 divided
doses
Cautions:
Anorexia, bipolar disorder, history of epilepsy
(discontinue if seizures occur), mild hypertension,
psychosis, susceptibility to angle-closure
glaucoma, tics, and Tourette syndrome.
Contraindications :
Agitated states, cardiovascular disease, history of
drug abuse, hyperexcitability, hyperthyroidism,
moderate hypertension, severe hypertension, and
structural cardiac abnormalities.
Common side effects:
Abdominal pain, anxiety, decreased appetite,
arrhythmias, arthralgia, abnormal behaviour,
depression, dry mouth, headache, altered mood,
movement disorders, muscle cramps, nausea,
palpitations, poor weight gain, sleep disorders,
vertigo, vomiting, and decreased weight.
Atomoxetine
Child 6–17 years (body-weight
up to 70 kg):
Starting dose:
0.5 mg/kg daily for 7 days,
dose is increased according to
response; maintenance 1.2
mg/kg daily, total daily dose
may be given either as a single
dose in the morning or in 2
divided doses with last dose no
later than early evening,
Maximum dose: 1.8
mg/kg/day or
120 mg per day (high daily
doses to be given under the
direction of a specialist).
Child 6–17 years (body-weight
70 kg and above):
Starting dose: 40 mg daily for
7 days, dose is increased
according to response;
maintenance 80 mg daily, total
daily dose
Cautions:
Aggressive behaviour, cardiovascular disease,
cerebrovascular disease, emotional lability, history
of seizures , hostility, hypertension, mania,
psychosis, QT interval prolongation, structural
cardiac abnormalities, susceptibility to angle-
closure glaucoma and tachycardia.
Contraindications
Phaeochromocytoma, severe cardiovascular
disease. Severe cerebrovascular disease
Common side effects:
Anxiety, decreased appetite, asthenia, chest pain,
constipation, depression, dizziness, drowsiness,
gastrointestinal discomfort, headaches, insomnia,
altered mood, mydriasis, nausea, skin reactions,
tic, vomiting and decreased weight.
Page 20/30
may be given either as a single
dose in the morning or in 2
divided doses with last dose no
later than early evening, high
daily doses to be given under
the direction of a specialist.
Maximum dose: 120 mg per
day.
Guanfacine
Child 6–12 years (body-weight
25 kg and above):
Starting dose: 1 mg once daily;
adjusted in steps of 1 mg every
week if necessary and if
tolerated; maintenance 0.05–
0.12 mg/kg once daily
Maximum dose: 4 mg per day.
Child 13-17 (body weight 41.5-
49.4): maximum dose 5 mg,
Child 13-17 (body weight 49.5-
58.4): maximum dose 6 mg
Child 13-17 (body weight 58.4
and above): maximum dose 7
mg
Cautions:
Bradycardia (risk of torsade de pointes), heart
block (risk of torsade de pointes), history of
cardiovascular disease, history of QT-interval
prolongation, and hypokalaemia (risk of torsade
de pointes).
Common side effects:
Anxiety, decreased appetite, arrhythmias, asthenia,
constipation, depression, diarrhoea, dizziness,
drowsiness, dry mouth, gastrointestinal
discomfort, headache, hypotension, mood altered,
nausea, skin reactions, sleep disorders, urinary
disorders, vomiting, and increased weight.
Clonidine Child ≥6 yr and adolescent):
Immediate-release product
(PO):
Starting dose: 0.05 mg HS
QHS; if needed, increase by
0.05 mg every 3–7 days
Maximum dose: 0.4 mg/24 hr
in 3-4 divided doses.
Extended-release product (PO):
Starting dose: 0.1 mg QHS; if
needed increase by 0.1 mg
every 7 days BID
Maximum dose: 0.4 mg/24 hr.
Cautions:
Cerebrovascular disease, constipation, heart
failure, history of depression, mild to moderate
bradyarrhythmia, polyneuropathy, Raynaud’s
syndrome or other occlusive peripheral vascular
disease, sleep disturbance, rages or tics.
Contraindications
Severe bradyarrhythmia secondary to second - or
third-degree AV block or sick sinus syndrome
Common side effects:
Constipation, depression, dizziness, dry mouth,
fatigue , headache, nausea, postural hypotension,
salivary gland pain, sedation, sexual dysfunction,
sleep disorders, and vomiting.
*For the complete Medication tables, please refer to the ocial link: https://cpg.adhd.org.sa/implementation-
tools-considerations/medication-tables/
Appendix Table 3. Guideline Adaptation Working Plan
Page 21/30
Timeline Corresponding
Modules Assigned to Tasks CPG Phase
January
2017 Preparation
Module
CPG
Adaptation
Group (GAG)
Prepare for the
Adaptation Process
· Decide on health
topic area
· Assess feasibility
of adaptation
· Identify needed
resources
· Establish
multidisciplinary
panel (adaptation
working group)
· Write/ submit
protocol
· Identify
endorsing body
· Discuss
authorship and
accountability
· Discuss
dissemination
and implementation
Meeting 1 Set Up Phase
February
2017
Preparation
Module
GAG
· Decide on terms
of
reference/consensus
process
· Establish CPG
inclusion/exclusion
criteria
· Help identify key
search terms
· Help identify key
documents/ sources
· Capacity building
for CPG adaptation
methodology (KSU-
Modied-ADAPTE)
Meeting
2
Adaptation
Phase
Scope and
Purpose
Module
GAG
Dene Health
Questions
Rene topic area
Page 22/30
Timeline Corresponding
Modules Assigned to Tasks CPG Phase
March
2017
April
2017
April
2017
Search and
Screen
Module
Assessment
Module
GAG
Search & Screen
CPGs
· Complete CPG
Search
· Narrow list of
CPGs (if needed) by
inclusion/ exclusion
criteria
Assess CPGs
· Complete AGREE
II appraisal
· Assess CPG
currency
· Complete
evaluations
(literature search
and evidence,
consistency of
evidence and
conclusions,
conclusions and
recommendations)
for all
recommendations
(optional)
· Prepare
recommendations
matrix
· Assess
acceptability
Meetings3-5
July 2017 Decision and
Selection
Module
GAG
Decide & Select
· Review all data
· Decide on
recommendations
for adapted CPG
Meeting 6
Page 23/30
Timeline Corresponding
Modules Assigned to Tasks CPG Phase
March
2018
Customization
Module
GA
Draft CPG Report
Write rst draft of
CPG
and/or report on
process
Online
communication Finalization
Phase
July 2018
GAG
Approve rst draft by
CGC-s (Clinical
content and
Methodology)
Online
Communication
December
2018 –
February
2019
External
Review
Module
External
Review
Panel for
clinical
content and
methodology
External Review
· Send for external
review and
consultation
(Clinical content and
Methodology)
· Get formal
endorsement
April-May
2019
December
2019
Aftercare
planning
Module
GAG Discuss feedback
Review and
consultation
Meetings 7-10
GAG Plan for Future
review & update
Decide on update
process
Final
Production
Module
GAG
Produce Final CPG
Create nal adapted
CPG
Including
Implementation
tool(s) and
Performance
Measures
Meeting 11
Page 24/30
Timeline Corresponding
Modules Assigned to Tasks CPG Phase
July 2020 GAG
Consider
implementation
issues and
strategies based on
the Implementation
tools and
performance
measures.
Online
communication Implementation
Phase
Appendix Table 4. Assessment of Currency of the Selected Source CPG
Currency Survey of the CPG Developer
Source CPG: Attention decit hyperactivity disorder: diagnosis and management. NICE guideline [NG87].
Published date: 14th of March 2018
1. Are you aware of any new evidence relevant to this CPG statement? No
2. Is there any new evidence to invalidate any of the recommendations comprising the CPG? No
3. Are there any plans to update the CPG in the near future? No
4. When the CPG was last updated? 13th of September 2019
What is the citation for the latest version? https://www.nice.org.uk/guidance/ng87
Appendix Table 5. Decision support record for the ADHD CPG adaptation group (GAG) using the KSU-Modied-
ADAPTE methodology
Page 25/30
PHASE MODULE STEP TOOL DECISION REASON
(if not utilized)
Utilized Not
utilized
ONE: SET-UP 1.1.
Preparation 1 1 √
2√
2 √
3 √
4 √
5 3 √
4√
1√
6 5 √
TWO:
ADAPTATION 2.1. Scope and
Purpose 7 6 √
2.2. Search and
Screen 8 2 √
7√
9 8 √
10 9 √Not utilized. The GAG
decided to rely on
inclusion/ exclusion
criteria and PIPOH
compatibility
10 √
2.3. Assessment 11 9 √
10 √
12 11 √
13 12 √Not utilized. The GAG
decided to select and
adopt all the
recommendations from
one Source CPG: NICE
NG87
14 13 √The GAG decided to rely
on Domain 3 scores of the
AGREE II appraisal
14 √
15 15 √The GAG decided to rely
on Domains 2 and 5
scores of the AGREE II
appraisal
2.4. Decision and
Selection 16 √
Page 26/30
17 √Decision making and
selection (5 options). The
GAG adopted the
recommendations with
their evidence.
2.5. Customization 18 16 √
THRE:
FINALIZATION 3.1. External Review
and
Acknowledgment
Module
19 17 √
20 √
21 √
22 √
3.2. Aftercare
Planning 23 18 √
3.3. Final
Production 24 √
Figures
Figure 1
Summary of the ‘KSU Modied ADAPTE’ process for CPG adaptation
Page 27/30
Figure 1
Summary of the ‘KSU Modied ADAPTE’ process for CPG adaptation
Figure 1
Summary of the ‘KSU Modied ADAPTE’ process for CPG adaptation
Page 28/30
Figure 2
Clinical algorithm for management of ADHD
Page 29/30
Figure 2
Clinical algorithm for management of ADHD
