Adapting evidence-based clinical practice guidelines for people with attention deficit hyperactivity disorder in Saudi Arabia: process and outputs of a national initiative

Abstract

Background
We recently adapted the published National Institute for Health and Care Excellence (NICE) Attention deficit 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 significant burden on resources. The objective of this paper is to describe the adaptation process methodology utilized for the generation of the first national guideline for management of people with ADHD in Saudi Arabia.

Methods
We used the KSU-Modified-ADAPTE methodology for the guideline adaptation process. We describe the full process in detail including the three phases of set-up, adaptation, and finalization. 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, identification 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 finalized 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-Modified-ADAPTE, and emphasized the value of a collaborative clinical and methodological expert group for adaptation of national guidelines.

Full text

Bashirietal.
Child Adolesc Psychiatry Ment Health (2021) 15:6
https://doi.org/10.1186/s13034-020-00351-5
RESEARCH ARTICLE
Adapting evidence-based clinical practice
guidelines forpeople withattention decit
hyperactivity disorder inSaudi Arabia: process
andoutputs ofanational initiative
Fahad A. Bashiri1,2 , Turki H. Albatti3,4,5, Muddathir H. Hamad1, Haya F. Al‑Joudi6 , Hadeel F. Daghash7 ,
Saleh M. Al‑Salehi8, Jeremy L. Varnham4* , Fatimah Alhaidar3, Omar Almodayfer9, Abdulkarim Alhossein10 ,
Hesham Aldhalaan11, Yasser A. Ad‑Dab’bagh12,13, Nouf Al Backer14, Waleed Altwaijri9, Khalid Alburikan15,
Maysaa W. Buraik16, Mohammad Ghaziuddin17 , Michael J. Nester18, Hayfaa A. Wahabi19 , Samia Alhabib20,
Amr A. Jamal19,20,21,22 and Yasser S. Amer19,23,24,25*
Abstract
Background: We recently adapted the published National Institute for Health and Care Excellence (NICE) Attention
deficit 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 significant burden on
resources. The objective of this paper is to describe the adaptation process methodology utilized for the generation of
the first national guideline for management of people with ADHD in Saudi Arabia.
Methods: We used the KSU‑Modified‑ADAPTE methodology for the guideline adaptation process. We describe the
full process in detail including the three phases of set‑up, adaptation, and finalization. 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 recom‑
mendations include: (i) service organisation and training, (ii) recognition, identification 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 devel‑
oped to enhance implementability including a clinical algorithm, quality measures, coding system, medication tables,
translations, patient information, and online resources.
Conclusions: The finalized 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
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Open Access
Child and Adolescent Psychiatry
and Mental Health
*Correspondence: jeremy@adhd.org.sa; yamer@ksu.edu.sa;
yassersamiamer@gmail.com
4 Saudi ADHD Society, Riyadh, Saudi Arabia
19 Research Chair for Evidence‑Based Health Care and Knowledge
Translation, King Saud University, Riyadh, Saudi Arabia
Full list of author information is available at the end of the article
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Bashirietal. Child Adolesc Psychiatry Ment Health (2021) 15:6
Contributions totheliterature
• Adaptation of guidelines is a valid alternative to de
novo development for generation of evidence-based
guidelines.
• e ‘King Saud University (KSU)-Modified-
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 compre-
hensive national guideline adaptation initiative with
multidisciplinary contributions for management of
people with ADHD.
• ese findings contribute to the work to enhance
adaptation or customization of clinical practice
guidelines and highlight implementability issues for
ADHD.
Background
Attention deficit hyperactivity disorder (ADHD) is one
of the most common neurodevelopmental disorders that
affects cognitive, emotional, social, academic, and occu-
pational functioning [1]. It is classified into three main
presentations: predominantly inattentive, predominantly
hyperactive/impulsive and combined presentation [2].
Although classified as a childhood-onset disorder, it may
continue into adolescence and adult life. e 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 definitive national sig-
nificance. It is recognized to have a significant burden if
under-recognized and untreated. Internationally, ADHD
is managed in various shared-care models between pri-
mary and secondary care that best suit each country’s
individual resources, culture, and nature of practice.
e diagnosis of ADHD is based on the diagnostic cri-
teria in the Diagnostic and Statistical Manual of Mental
Disorders – 5th Edition (DSM-5) [2] or the International
Statistical Classification of Diseases and Related Health
Problems, 10th Revision (ICD-10) (hyperkinetic disor-
der) [7]. Although in Saudi Arabia, the official coding
system that has been adopted is the Australian revision
(ICD-10-AM), whose terminology differs slightly (distur-
bance of activity and attention, hyperkinetic conduct dis-
order, other hyperkinetic disorders), the term ADHD is
widely recognized [7].
ere were no standardized clinical guidelines for
ADHD management in Saudi Arabia. ere 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 health-
care decisions and care provision. Furthermore, although
some initiatives have targeted the management of 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. is results in significant
variability in clinical practice, and suboptimal quality of
care [8–10].
As part of its strategy to improve access to care for peo-
ple affected by ADHD in Saudi Arabia, the Saudi ADHD
Society formed a multidisciplinary team to remedy this
situation. e resulting clinical practice guideline (CPG)
was adapted from the National institute for Health and
Care Excellence (NICE) guideline entitled, Attention
deficit hyperactivity disorder: diagnosis and management
(NG87) [11], to improve recognition, diagnosis and qual-
ity of care for patients with ADHD.
Clinical Practice Guidelines (CPGs) are defined as
‘statements that include recommendations intended to
optimize patient care, which are informed by a system-
atic review of evidence and an assessment of the benefit
and harm of alternative care options [12]. CPGs have
been identified as one of the main tools for improving
evidence-based healthcare quality and safety [12, 13].
Adaptation of CPGs is a valid and efficient 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 reflecting the local context and system [12–16].
Given that there were no published CPGs for
ADHD management in Saudi Arabia, the presented
of KSU‑Modified‑ADAPTE, and emphasized the value of a collaborative clinical and methodological expert group for
adaptation of national guidelines.
Keywords: Practice guideline, Adaptation, Evidence‑based medicine, ADHD, Attention deficit hyperactivity disorder,
Mental health, Saudi Arabia, Eastern mediterranean region
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Bashirietal. Child Adolesc Psychiatry Ment Health (2021) 15:6
evidence-based CPG is proposed as a National CPG
using an evidence-based and formal CPG adaptation
methodology. e aim of this study was to adapt the
international clinical practice guidelines’ recommenda-
tions for people with ADHD to fit the healthcare setting
in the Saudi Arabian context including primary, second-
ary, and tertiary care settings.
Methods
Guideline adaptation methodology
We utilised the ‘King Saud University (KSU)-Modified-
ADAPTE’ [12] adaptation methodology, a natural evolu-
tion of two earlier formal adaptation methodologies for
CPGs, the original ADAPTE and ‘Adapted ADAPTE’
methods [15–17], which consists of three phases and 24
steps with modifications in the steps and tools to suit the
local general healthcare setting in Saudi Arabia [12, 16].
Figure1 provides a simplified flowchart of our methods
[12].
e two main reporting standards for CPGs recom-
mended 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 Healcare (RIGHT) statement
[18–20]. Despite the fact that these tools were designed
for de-novo developed CPGs, rather than adapted CPGs,
we will report our adapted CPG for ADHD using the
AGREE II reporting checklist after applying specific
explanations to the items of the checklist relevant to our
CPG adaptation process in contrast to a CPG develop-
ment process (Additional file1). 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) [21].
Phase one (set up)
In phase one, Attention deficit hyperactivity disorder
(ADHD) was identified 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. e guideline adaptation working
group (GAG) was formulated at the outset to include a
child psychiatrist, two pediatric neurologists, a develop-
mental pediatrician, a clinical neuropsychologist, a clini-
cal 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
public’s views and preferences in addition to the support
and insight from the networks and resources of the Saudi
ADHD Society. e results of the preliminary search for
ADHD Source CPGs encouraged us to proceed and offi-
cially 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 adapta-
tion process methodology and its associated toolkit [12,
14, 17].
e target patient population for the adapted CPG is
children and adults suspected of having or diagnosed
with ADHD. e identified target intended users include
physicians, clinical psychologists, other behavioral health
clinicians, nurses, occupational therapists, pharmacists,
AGREE: Appraisal of Guidelines for Research and Evaluaon; CPG: clinical pracce guideline; CPGI: clinical pracce guideline
implementaon; KSU: King Saud University; PDSA: Plan-Do-Study-Act; PIPOH: paent populaon, intervenon, professionals,
outcomes, healthcare sengs.
Set Up
Phase One
• Topic selection.
• Feasibility for CPG
adaptation
• Team formation.
• Adaptation Working
Plan.
Adaptation
Phase Two
• Health questions
(PIPOH model).
• Eligibility criteria.
• Search & Screen
Source CPGs.
• AGREE II Instrument:
quality assessment.
• Decide & select
• Draft Adapted CPG.
Finalization
Phase Three
• External review.
• Plan for future review &
update.
• Finalized adapted CPG
with CPGI tools &
proposed CPGI
strategies.
• Future baseline
assessment of current
practice (Pre-
implementation).
'Living CPG'
Concept
• Future audit & feedback
(Post-implementation).
• Planned review &
update.
• Recommended PDSA
cycles.
Fig. 1 Summary of the ‘KSU Modified ADAPTE’ process for CPG adaptation
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Bashirietal. Child Adolesc Psychiatry Ment Health (2021) 15:6
social workers, dieticians, medical students, and health
sciences students.
e healthcare settings include primary, secondary
and tertiary care dealing with assessment, treatment and
management of ADHD in Saudi Arabia.
Phase two (adaptation)
In phase two, we identified specific health questions
using the PIPOH model, relevant inclusion and exclu-
sion criteria, and a full search strategy including a list of
keywords. e elements of the PIPOH model include the
target patient population (P), intervention(s) (I), profes-
sionals and clinical specialties (P), outcomes (O), and
healthcare setting or context (H) that were reported ear-
lier [4, 12]. We searched eight bibliographic and CPG
databases in addition to online libraries of relevant pro-
fessional societies. Eligible Source CPGs for ADHD were
then critically appraised using the AGREE II Instrument
[22]. 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 [22]. 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 scientific 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 Recom-
mendations: Assessment, Development, and Evaluation
(GRADE) evidence profiles [1].
Moreover, the GAG identified, revised, and discussed
all the recommendation statements through successive
focus group discussions against the local and national
healthcare system in Saudi Arabia. Drafting the first ver-
sion of the adapted CPG was the last step of this phase.
Phase three (nalization)
In phase three, the first draft of the adapted CPG full doc-
ument was finalized including assessing the recommenda-
tions for acceptability and applicability in the local Saudi
Arabian healthcare settings. is adapted CPG draft was
then disseminated to a selected national panel of exter-
nal reviewers of specialized healthcare providers, topic
experts, and methodologists from relevant healthcare sec-
tors. e feedback of reviewers was revised and discussed
within the GAG and was reflected in the final version of
the adapted CPG. A set of CPG implementation (CPGI)
tools was included in the final CPG full document.
Results
e overall duration of this CPG adaptation project was
two years and five months from 4th of January 2017 till
30th of May 2019. Seven meetings were conducted for
planning, reviewing, and focus group discussions includ-
ing two training sessions with ongoing hands-on advisory
on the CPG appraisal and adaptation tools.
is work marks the first national CPG adaptation pro-
ject for the management of people with ADHD using the
‘KSU-Modified-ADAPTE’.
Phase one (set up)
e aforementioned GAG was formulated in Janu-
ary 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. e necessary resources and
skills were identified and allocated. All of the GAG mem-
bers signed declaration of conflicts of interest statements.
e feasibility of the CPG adaptation process was confirmed
by conducting a preliminary search for published CPGs. e
working plan was drafted and discussed at the outset using
the relevant CPG adaptation working plan template from the
KSU-Modified-ADAPTE (Appendix, Table3) [12].
Phase two (adaptation)
For the first 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 Alli-
ance, National Health and Medical Research Coun-
cil, National Institute for Health and Care Excellence
(NICE), Singapore Ministry of Health, and University of
Michigan Health System [1].
e NICE CPG was superior in all of the six stand-
ardized domain scores of the AGREE II Instrument and
it addressed all care options for ADHD across the lifes-
pan. e AGREE II ratings of the NICE CPG were 100%
(domain 1: scope and purpose), 96% (domain 2: stake-
holder involvement), 93% (domain 3: rigour of develop-
ment), 89% (domain 4: clarity and presentation), 92%
(domain 5: applicability), 92% (domain 6: editorial inde-
pendence), and 100% (overall assessment 1) [1].
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Bashirietal. Child Adolesc Psychiatry Ment Health (2021) 15:6
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-
Modified-ADAPTE (Appendix, Table4) [11, 12].
e GAG reviewed and discussed the AGREE II assess-
ment 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 sys-
tems, medications, or healthcare provider positions.
We have followed the same format or presentation of
recommendation statements developed by NICE that
relied on the ‘wording’ of each recommendation rather
than highlighting a quality of evidence and grade of rec-
ommendation like other CPG developers may opt for.
e rationale for this format has been clearly stated in
the NICE website: https ://www.nice.org.uk/about /what-
we-do/our-progr ammes /nice-guida nce/nice-guide lines
/makin g-decis ions-using -nice-guide lines in addition to
further explanation in, Chapter9: writing the guideline
of, ‘Developing NICE guidelines: the manual’: https ://
www.nice.org.uk/proce ss/pmg20 /chapt er/writi ng-the-
guide line
e 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 recommenda-
tions including: (i) two medication tables; one for treatment
of children and young people and the other for treatment of
adults with ADHD (a summary medication table has been
provided in this article), (ii) a clinical algorithm for manage-
ment of ADHD (Fig.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 [23], and (iv) links to patient educational information
and resources on the Society’s official website. A mobile-
friendly web-based version of the CPG was also developed.
Phase three (nalization)
irteen 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 methodolo-
gies of evidence-based CPGs (HAA and SA) in addition to
their representation of multiple relevant healthcare sectors
in Saudi Arabia. Two international experts with local expe-
rience were invited to contribute to the external review of
the clinical content as well (MG and MJN).
Fig. 2 Clinical algorithm for management of ADHD
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e external review comments were compiled using
a template [12], revised, discussed, and incorporated in
the recommendations and implementation tools of the
finalized adapted CPG full document.
e 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. e 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 recommen-
dations to the local context [24]. Furthermore, the recom-
mended medications were revised against those currently
approved by the Saudi Food and Drug Authority (Saudi
FDA), and those available on a restricted basis through spe-
cific hospitals. No formal cost-analyses or Health Technol-
ogy Assessment(s) were conducted as part of this project.
Health benefits, side effects, and risks were evaluated in
the Source CPG (NICE) as part of the AGREE II assess-
ment [1] and were further revised and discussed during the
adaptation or customization of the recommendations to
the local context.
e values and preferences of the target patient popu-
lation 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 finalized adapted
CPG from the Saudi ADHD Society was then critically
reviewed and endorsed by the Saudi Health Council as well
as five national professional societies: the Saudi Pediatric
Neurology Society, the Saudi Pediatric Association, the
Saudi Pharmaceutical Society, the Saudi Psychiatric Asso-
ciation, and the Saudi Society of Professional Psychology.
e adapted CPG included recommendation statements
organized into ten sections including: (i) Service organisa-
tion and training, (ii) Recognition, identification and refer-
ral, (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.
e Saudi ADHD Society contacted NICE, the Source
CPG developer, and finalized an official end user license
agreement in line with the original NICE terms and con-
ditions 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 [25], on
a user-friendly and accessible microsite of the official web-
site of the Saudi ADHD Society: https ://cpg.adhd.org.sa/.
Plan forscheduled review andupdate
e GAG recommended for the next review of this
adapted CPG to be after four years from its publica-
tion (2020) which should be on (2024) after checking for
updates in the Source CPG, consultation of expert opin-
ion on any suggested updates needed according to the
Table 1 Summary oftheKey recommendations intheadapted clinical practice guideline forthemanagement ofchildren
andadults withADHD
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 specific learning difficulties)
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
Identification 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) or the Interna‑
tional Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD‑10) (hyperkinetic disorder). It should be made by a specialist
psychiatrist, specialized pediatrician, an appropriately trained family physician or other appropriately qualified 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 Con‑
ners’ rating and Vanderbilt scales. Note: Currently, the national adopted system is ICD-10-AM
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Bashirietal. Child Adolesc Psychiatry Ment Health (2021) 15:6
Table 1 (continued)
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 functional impairment and to improve the quality of life
Children under 5 years
ADHD‑focused group parent‑training programme is the first‑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
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 benefited from medication but
still having a significant impairment in at least one domain
Medications should be offered for patients with a persistent significant impairment
The diagnosis should be confirmed 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 first‑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 Lisdexamfeta‑
mine but who cannot tolerate the longer effect profile
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 significant impairment in at least one domain after environ‑
mental modifications have been implemented and reviewed
Non‑pharmacological treatment should be considered for adults who have difficulty adhering to medications or those who found medication to be inef‑
fective 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 first‑line pharmacological treatment
Switching to Methylphenidate or Lisdexamfetamine should be considered for adults who have had a 6‑week trial of Lisdexamfetamine or methylpheni‑
dates at an adequate dose but have not derived enough benefit
Second-line therapy
Dexamfetamine should be considered for adults whose ADHD symptoms are responding to Lisdexamfetamine but who cannot tolerate the longer effect profile
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
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 benefits of ADHD treatment. If tics are stimulant related, reduce the stimulant dose, or consider changing to guan‑
facine (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 artificial 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 specific food or drinks
For the complete set of recommendations of the adapted guideline, please refer to the ocial website: https ://cpg.adhd.org.sa/recom menda tions /
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Bashirietal. Child Adolesc Psychiatry Ment Health (2021) 15:6
newest evidence and recommendations published in this
area in addition to the implementation and evaluation
results at relevant healthcare organizations in the King-
dom of Saudi Arabia. e Checklist for the Reporting of
Updated Guidelines (CheckUp) is recommended by the
EQUATOR network to report the updating of CPGs [26].
Implementation considerations andtools
A full set of CPGI tools was an integral component of the
adapted CPG full document (Fig.2, Tables1, 2). Several
CPGI interventions or strategies were highlighted and
proposed to promote future multi-faceted CPGI includ-
ing; (i) leadership engagement and commitment, (ii)
dissemination, (iii) clinical and quality champions, (iv)
training and education, (v) audit and feedback, (vi) net-
working with existing projects in the organizations (e.g.
performance improvement, accreditation, educational,
and scientific activities), and (vi) patients as champions
for change [27–29]. Social media, online audio-visual and
educational material are key components for launching
the dissemination and implementation of this national
CPG.
e 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 implementa-
tion were identified 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 sup-
port implementation. Contribution of representatives of
multiple local healthcare sectors are designed to facilitate
early dissemination and implementation. Furthermore,
leadership engagement and support from the organizing
society and from the contributing and endorsing national
organizations played a major role in the success of this
CPG project.
Identified 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 sustain-
ability; (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 health-
care 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-Modi-
fied-ADAPTE methodology is provided in Appendix,
Table5.Additional details of the CPG adaptation meth-
odology is made available from the Saudi ADHD Society
(Link:https ://cpg.adhd.org.sa/devel opmen t/).
Discussion
e aim of this study was to adapt the international CPGs
and their recommendations to the Saudi healthcare con-
text for the comprehensive management of people with
ADHD across all local healthcare sectors.
e iterative process of the ADHD CPG adaptation
reveals the nature of intensive work and capacity build-
ing that was an integral component of this project, and
the specialized expertise required for such a process irre-
spective of the clinical or methodological expertise. e
long timeline observed was not unique to this CPG adap-
tation project and was reported in other local CPG adap-
tation projects as well [12].
e 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
[28]. is 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.
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 rand-
omized controlled trials.
A strength of this study is the use of the ‘KSU-Modi-
fied-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 finalized adapted CPG.
ere are increasing initiatives and projects related to
knowledge translation in general and CPGs in particular
nationally and regionally [12, 30, 31]. e World Health
Organization Regional Office of the Eastern Mediterra-
nean promotes and supports all advances in the devel-
opment, adaptation, and implementation of CPGs at the
regional level [32]. Furthermore, ‘National guidelines’ are
core components of the ‘Model of Care’ of the new Saudi
Arabian National Healthcare Plan [33, 34]].
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Table 2 Summary ofmedications prescribed forthemanagement ofchildren andadults withADHD
Medications Dose Comments
Methylphenidate
Immediate‑release
(RITALIN)
Child 4–5years:
Starting dose: 2.5 mg twice daily, PO, 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, PO, 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
Cautions:
Agitation, anxiety, drug dependence, epilepsy (discontinue if increased seizure fre‑
quency), 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 eects:
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
Modied-release
CONCERTA ® XL 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
Lisdexamfeta-
mine Child 6–17years:
Starting dose: 30 mg once daily, PO, alternatively initially 20 mg once daily, increased
in steps of 10–20 mg every week if required, dose to be taken in the morning, discon‑
tinue if response insufficient 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 hyper‑
tension, and symptomatic cardiovascular disease
Common side eects:
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 disor‑
ders, skin reactions, tachycardia, tremor, vomiting, and decreased weight
Dexamfetamine Child 6–17years:
Starting dose: 2.5 mg 2–3 times a day,PO, 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, hyperthy‑
roidism, moderate hypertension, severe hypertension, and structural cardiac abnor‑
malities
Common side eects:
Abdominal pain, anxiety, decreased appetite, arrhythmias, arthralgia, abnormal behav‑
iour, depression, dry mouth, headache, altered mood, movement disorders, muscle
cramps, nausea, palpitations, poor weight gain, sleep disorders, vertigo, vomiting, and
decreased weight
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Bashirietal. Child Adolesc Psychiatry Ment Health (2021) 15:6
Table 2 (continued)
Medications Dose Comments
Atomoxetine Child 6–17years (body-weight up to 70kg):
Starting dose:
0.5 mg/kg daily, PO, 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; mainte‑
nance 80 mg 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, high daily doses to be given under the direction of
a specialist
Maximum dose: 120 mg per day
Cautions:
Aggressive behaviour, cardiovascular disease, cerebrovascular disease, emotional lability,
history of seizures, hostility, hypertension, mania, psychosis, QT interval prolonga‑
tion, structural cardiac abnormalities, susceptibility to angle‑closure glaucoma and
tachycardia
Contraindications
Phaeochromocytoma, severe cardiovascular disease. Severe cerebrovascular disease
Common side eects:
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
Guanfacine Child 6–12 years (body‑weight 25 kg and above):
Starting dose: 1 mg once daily; PO, 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 kg): maximum dose 5 mg,
Child 13–17 (body weight 49.5–58.4 kg): maximum dose 6 mg
Child 13–17 (body weight 58.4 kg 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 eects:
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 year and adolescent):
Immediate-release product (PO):
Starting dose: 0.05 mg at bed time; if needed, increase by 0.05 mg every 3–7 days
Maximum dose: 0.4 mg/24 h in 3–4 divided doses
Extended-release product (PO):
Starting dose: 0.1 mg at bed time; if needed increase by 0.1 mg every 7 days BID
Maximum dose: 0.4 mg/24 h
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 eects:
Constipation, depression, dizziness, dry mouth, fatigue, headache, nausea, postural hypo‑
tension, salivary gland pain, sedation, sexual dysfunction, sleep disorders, and vomiting
For the complete Medication tables, please refer to the ocial link: https ://cpg.adhd.org.sa/imple menta tion-tools -consi derat ions/medic ation -table s/
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For the medication recommendations and monitoring
for both children and adults, we have minimal concerns
about stimulant abuse in the local population since medi-
cation prescription has strict regulations in the country
and has a clear system for controlled drugs regulations.
Conducting the needs assessment, that had a signifi-
cant impact, is by default part of the set-up phase of
adaptation and this is consistent with the experience of
the GAG, which coincides with published evidence. is
is an essential prerequisite of such a CPG adaptation
project to practically determine the expected workload,
resources, expertise, and the need for dedicated leader-
ship and project management.
Conclusions
e ‘KSU-Modified-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 dem-
onstrated to be particularly feasible for national CPG
projects.
Our experience with this adaptation methodology pro-
vides useful insight into its utilization on a national level
in Saudi Arabia, and further demonstrates its potential
suitability for the Eastern Mediterranean region. Addi-
tional modifications to the adaptation process and tools
as per the context are recommended and accepted [12,
17].
Participation of a large number of healthcare sectors
through multi-disciplinary groups in the CPG adapta-
tion 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 suf-
ficient to guarantee ultimate standardization of patient
healthcare. e degree of positive impact on peo-
ple with ADHD will highly depend on the effective-
ness of 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 follow-
ing areas: (i) early identification 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) regu-
lar assessment of the response to medication, and (vi)
annual review of drug treatment.
Supplementary information
The online version contains supplementary material available at https ://doi.
org/10.1186/s1303 4‑020‑00351 ‑5.
Additional le1. AGREE Reporting Checklist
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Abbreviations
ADHD: Attention deficit 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.
Acknowledgments
The authors wish to thank the Saudi ADHD Society for its initiative in support‑
ing this CPG adaptation project as a part of the Unified 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 Transla‑
tion, Deanship of Scientific Research, King Saud University, Riyadh, Saudi
Arabia.
Furthermore, we would like to thank the Research Support and Services
Unit (RSSU), Deanship of Scientific Research, King Saud University for their
technical support.
Authors’ contributions
YSA, FAB, and MHH conceptualized and wrote the first 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 scientific
committee) where THA was the project lead and YSA was the CPG method‑
ologist. 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 considera‑
tion of feedback from co‑authors. All authors read and approved the final
manuscript.
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 influence the selection of the
Source CPG or the final adapted CPG’s recommendations. Hayfaa Wahabi, Amr
Jamal, and Yasser Amer were supported by the Research Chair for Evidence‑
Based Health Care and Knowledge Translation, Deanship of Scientific
Research, King Saud University, Riyadh, Saudi Arabia.
Availability of data and materials
The data that support the findings of this study has been made available in
the tables, figures 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 authors and the Saudi ADHD Society.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Consent for publication was obtained from all participants.
Competing interests
The authors declare that they have no competing interests. Conflict of interest
declaration documents can be made available from the Saudi ADHD Society
upon request.
Author details
1 Pediatrics Department, Pediatric Neurology Division, College of Medicine
and King Saud University Medical City, King Saud University, Riyadh, Saudi
Arabia. 2 Saudi Pediatric Neurology Society, Riyadh, Saudi Arabia. 3 Psychiatry
Department, Child Psychiatry Unit and King Saud University Medical City, King
Saud University, Riyadh, Saudi Arabia. 4 Saudi ADHD Society, Riyadh, Saudi
Arabia. 5 Ministry of Education, Abdullatif Alfozan Autism Center, Al Khobar,
Saudi Arabia. 6 Department of Neurosciences, King Faisal Specialist Hospital
& Research Centre, Riyadh, Saudi Arabia. 7 Ada’a Program, Assistant Deputy‑
ship for Hospital Services, Ministry of Health, Riyadh, Saudi Arabia. 8 King
Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman
University, Riyadh, Saudi Arabia. 9 King Abdulaziz Medical City, Riyadh, Saudi
Arabia. 10 Department of Special Education, King Saud University, Riyadh,
Saudi Arabia. 11 Department of Neurosciences, Center for Autism Research,
King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
12 Department of Mental Health, Neuroscience Center, King Faisal Specialist
Hospital‑Dammam (KFSH‑D), Dammam, Saudi Arabia. 13 Research Center,
King Khalid Medical City (RC‑KKMC), Dammam, Saudi Arabia. 14 Department
of Pediatrics, Developmental‑Behavioral Pediatrics Division, College of Medi‑
cine and King Saud University Medical City, King Saud University, Riyadh, Saudi
Arabia. 15 Saudi Pharmaceutical Society, Riyadh, Saudi Arabia. 16 Neuroscience
Institute, Psychiatry Division, Johns Hopkins Aramco Healthcare, Dhahran,
Saudi Arabia. 17 Department of Psychiatry, University of Michigan, Ann
Arbor, USA. 18 Child and Adolescent Services, Ann Arbor, USA. 19 Research
Chair for Evidence‑Based Health Care and Knowledge Translation, King Saud
University, Riyadh, Saudi Arabia. 20 National Centre for Evidence‑Based Health
Practice, Saudi Health Council, Riyadh, Saudi Arabia. 21 Family and Community
Medicine Department, College of Medicine and King Saud University Medical
City, King Saud University, Riyadh, Saudi Arabia. 22 National Centre for Health
Information, Saudi Health Council, Riyadh, Saudi Arabia. 23 CPG Unit, Quality
Management Department, King Saud University Medical City, Riyadh, Saudi
Arabia. 24 Pediatrics Department, King Saud University Medical City, Riyadh,
Saudi Arabia. 25 Alexandria Center for Evidence‑Based Clinical Practice Guide‑
lines, Alexandria University, Alexandria, Egypt.
Appendix
See Tables3, 4, 5.
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Table 3 Guideline adaptation working plan
CPG Phase Tasks Assigned to Corresponding modules Timeline
Set up phase
Meeting 1 Prepare for the adaptation process
Decide on health topic area
Assess feasibility of adaptation
Identify needed resources
Establish multidisciplinary panel (adap‑
tation working group)
Write/ submit protocol
Identify endorsing body
Discuss authorship and accountability
Discuss dissemination and implemen‑
tation
CPG Adaptation Group (GAG) Preparation module January 2017
Adaptation phase
Meeting 2 Decide on terms of reference/con‑
sensus process
Establish CPG inclusion/exclusion
criteria
Help identify key search terms
Help identify key documents/
sources
Capacity building for CPG adapta‑
tion methodology (KSU‑Modified‑
ADAPTE)
GAG Preparation module February 2017
Define Health Questions
Refine topic area GAG Scope and purpose module
Meetings3–5 Search and 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 recommen‑
dations (optional)
Prepare recommendations matrix
Assess acceptability
GAG Search and screen module
Assessment Module March 2017
April 2017
April 2017
Finalization Phase
Meeting 6 Decide & select
Review all data
Decide on recommendations for
adapted CPG
GAG Decision and selection module July 2017
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Table 3 (continued)
CPG Phase Tasks Assigned to Corresponding modules Timeline
Online communication Draft CPG report
Write first draft of CPG and/or report on
process
GAG Customization module March 2018
Online Communication Approve first draft by CGC‑s (Clinical
content and Methodology) GAG July 2018
External review
Send for external review and consulta‑
tion (Clinical content and Methodol‑
ogy)
Get formal endorsement
External review panel for clini‑
cal content and methodol‑
ogy
External review module December 2018–February 2019
Meetings 7–10 Discuss feedback
Review and consultation GAG Aftercare planning module April–May 2019
December 2019
Plan for future review & update
Decide on update process GAG
Meeting 11 Produce final CPG
Create final adapted CPG
Including Implementation tool(s) and
Performance Measures
GAG Final production module
Implementation Phase
Online communication Consider implementation issues and
strategies based on the Implementa‑
tion tools and performance measures
GAG July 2020
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Table 4 Assessment ofcurrency oftheselected, Source CPG, currency survey oftheCPG developer
Source CPG: Attention decit 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/guida nce/ng87
Table 5 Decision support record for the ADHD CPG adaptation group (GAG) using the KSU-Modied-ADAPTE
methodology
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 √
17 √Decision making and selection (5 options). The GAG adopted
the recommendations with their evidence
2.5. Customization 18 16 √
THREE: FINALIZA-
TION 3.1. External review and
acknowledgment
module
19 17 √
20 √
21 √
22 √
3.2. Aftercare planning 23 18 √
3.3. Final production 24 √
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Received: 13 July 2020 Accepted: 17 November 2020
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et al. Appraisal of clinical practice guidelines for the management of
attention deficit hyperactivity disorder (ADHD) using the AGREE II Instru‑
ment: a systematic review. PLoS ONE. 2019;14(7):e0219239.
2. American Psychiatric Association. Diagnostic and statistical manual
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