Contributions to the literature
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Adaptation of guidelines is a valid alternative to de novo development for generation of evidence-based guidelines.
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The ‘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.
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Balanced clinical and methodological expertise in the guideline group is essential for the success of similar projects.
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We describe the process and outputs of a comprehensive national guideline adaptation initiative with multidisciplinary contributions for management of people with ADHD.
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These findings contribute to the work to enhance adaptation or customization of clinical practice guidelines and highlight implementability issues for ADHD.
Background
Methods
Guideline adaptation methodology
Phase one (set up)
Phase two (adaptation)
Phase three (finalization)
Results
Phase one (set up)
Phase two (adaptation)
Phase three (finalization)
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 International 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 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 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 Lisdexamfetamine 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 environmental 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 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 first-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 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 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 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 |
Plan for scheduled review and update
Implementation considerations and tools
Medications | Dose | Comments |
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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 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 |
Modified-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 | |
Lisdexamfetamine | 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, discontinue 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 hypertension, and symptomatic cardiovascular disease 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,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, 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, 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; maintenance 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 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 |
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 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 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 effects: Constipation, depression, dizziness, dry mouth, fatigue, headache, nausea, postural hypotension, salivary gland pain, sedation, sexual dysfunction, sleep disorders, and vomiting |