Clinical Practice Guidelines for the Evaluation and Diagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents A systematic review of the literature *Hira Abdul Razzak,1 Nariman Ghader,2 Ateeq A. Qureshi,3 Mehnaz Zafar,4 Jeena F. Shaijan,5 Muna Al Kuwari2 Sultan Qaboos University Med J, February 2021, Vol. 21, Iss. 1, pp. e12–21, Epub. 15 Mar 21 Submitted 14 May 20 Revision Req. 5 Jul 20; Revision Recd. 20 Jul 20 Accepted 13 Aug 20 1Statistics and Research Center and 2Specialized Care Department, Ministry of Health & Prevention, Dubai, United Arab Emirates; 3Department of Child & Adolescent Mental Health, Maudsley Health, Dubai, United Arab Emirates; 4Department of Psychiatry, Al Amal Psychiatry Hospital, Dubai, United Arab Emirates; 5Department of Psychiatry, NMC Medical Centre, Dubai, United Arab Emirates *Corresponding Author’s e-mail: Hira.AbdulRazzak@mohap.gov.ae Attention deficit/hyperactivity disorder (ADHD) is a frequently diagnosed, pervasive and controversial neurobehavioural childhood disorder that has received extensive attention from the media, public and researchers.1 ADHD makes focusing on everyday requests and routines challenging.2 Indiv- iduals suffering from ADHD often have trouble with focus, organisation, impulsivity and practical planning. They may be noisy, jittery or incapable of adapting to environmental changes.3 It is a chronic impairing disorder that negatively impacts several aspects of a child’s life like social skills, academic attainment, review دالئل إرشادية للممارسة السريرية لتقييم وتشخيص اضطراب فرط احلركة وتشتت االنتباه عند األطفال واملراهقني مراجعة منهجية هريا عبد الرزاق، نارميان غادر، عتيق اأحمد قر�شي، مهناز ظفار، جينا فيجي �شاجان، منى الكواري abstract: This article presents a comprehensive review of clinical practice guidelines (CPGs) for the evaluation and/or diagnosis of attention deficit/hyperactivity disorder (ADHD) in children and adolescents. A systematic review was undertaken to summarise the recommendations reported in CPGs. MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA), Cumulative Index to Nursing and Allied Health Literature® (EBSCO Information Services, Ipswich, Massachusetts, USA) and other databases were searched to retrieve CPGs. A total of five guidelines were included for analysis. The selected CPGs were appraised independently by five reviewers using the AGREE II instrument. The highest total score was achieved by the National Institute for Health and Care Excellence guidelines (91.4%) followed by the CPGs from the Scottish Intercollegiate Guidelines Network, Canadian Attention Deficit Hyperactivity Disorder Resource Alliance, British Association of Psychopharmacology and the American Academy of Paediatrics. By appraising current ADHD guidelines, clinicians cannot only identify CPGs related to ADHD but can also determine which guidelines should be considered of high quality and trustworthy to follow during clinical practice. The researchers recommend using the AGREE II instrument for CPG appraisal in healthcare professional education and training. Improvements in the applicability of guidelines are warranted in the future to enhance its clinical use and relevance. Keywords: Attention Deficit Hyperactivity Disorder; Practice Guidelines; Adolescents; Children; Diagnosis. امللخ�ص: تقدم هذه الدرا�شة مراجعة �شاملة للدالئل االإر�شادية للممار�شة ال�رسيرية عند تقييم وت�شخي�ص ا�شطراب فرط احلركة وت�شتت االنتباه عند االأطفال واملراهقني. مت عمل مراجعة منهجية لتلخي�ص التو�شيات الواردة يف اإر�شادات املمار�شة يف ميد الين MEDLINE )مكتبة الطب القومية، بيثثدا، مرييالند، الواليات املتحدة االأمريكية( والفهر�ص الرتاكمي للتمري�ص واالأدبيات ال�شحية امل�شاعدة )خدمات املعلومات EBSCO، اب�شوي�ص، ما�شات�شو�شت�ص، الواليات املتحدة االأمريكية( وقواعد بيانات اأخرى مت البحث فيها عما ُن�رس من دالئل اإر�شادية للممار�شة .AGREE II ال�رسيرية. وت�شمنت هذه هذه الدرا�شة خم�شة اإر�شادات مت تقييمها من قبل خم�شة مراجعني-ب�شورة م�شتقلة -با�شتخدام اأداة وح�شلت اإر�شادات املمار�شة ال�رسيرية للمعهد القومي لل�شحة والرعاية على اأعلى جمموع نقاط )%91.4(، يليها اإر�شادات املمار�شة ال�رسيرية لل�شبكة االأ�شكتلندية لالإر�شادات امل�شرتكة بني الكليات، وحتالف املوارد الكندي الإر�شادات املمار�شة ال�رسيرية، ثم جمعية علم االأدوية النف�شية، واالأكادميية االأمريكية لطب االأطفال. وعند تقييم الدالئل االإر�شادية ال�شطراب فرط احلركة وت�شتت االنتباه، ال ي�شتطيع الطبيب املعالج فقط التعرف على تلك االر�شادات، بل ميكنه اأن يحدد اأي االر�شادات اأف�شل نوعية وموثقه واأجدر باالتباع يف ممار�شته معاينه املراجعني. ويو�شي الفريق البحثي لهذه الدرا�شة با�شتخدام اأداة AGREE II لتقييم الدالئل االإر�شادية للممار�شة ال�رسيرية عند تعليم وتدريب املهنيني العاملني يف جمال الرعاية ال�شحية. ومن الالزم اأي�شا اإحداث حت�شينات يف قابليتها للتطبيق م�شتقبال من اأجل تعزيز مالئمتها وا�شتخدامها عياديا. الكلمات املفتاحية: ا�شطراب فرط احلركة وت�شتت االنتباه؛ الدالئل االإر�شادية للممار�شة ال�رسيرية؛ املراهقون؛ االأطفال؛ الت�شخي�ص. This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. https://doi.org/10.18295/squmj.2021.21.01.003 https://creativecommons.org/licenses/by-nd/4.0/ Hira Abdul Razzak, Nariman Ghader, Ateeq A. Qureshi, Mehnaz Zafar, Jeena F. Shaijan and Muna Al Kuwari Review | e13 child-parent relationship as well as the well being of the entire family. The aetiology of ADHD has been linked to genetic factors, potential gene-environment interactions and other environmental risk factors such as toxic metal exposure.4 A study from the United Arab Emirates (UAE) found that increased blood concentrations of lead, manganese and zinc levels were found to be significantly associated with ADHD. Other potential risk factors include low birth weight, prenatal exposure to alcohol, tobacco use and premature birth.4 ADHD is manageable if appropriate treatments are used. While several treatment and management options are available, what works best is mostly based on the individual and their family members. Whilst seeking the best treatment/management options, parents should work closely with other people who are involved in a child’s life including therapists, coaches, healthcare providers, educators and other family members. Treat- ment may consist of medications or behaviour therapy, including training for parents. Epidemiological data on ADHD are scarce due to the fact that few population-based studies have been conducted globally and also because of changing diagnostic criteria. Nevertheless, due to its high prevalence, ADHD represents a public health problem.5 This condition manifests in 5.9–7.1% of children and adolescents worldwide.6 Several studies have estimated ADHD prevalence; it has been reported at 5% in the USA, 7.6–9.5% in Korea and 10– 20% in India, whereas the prevalence of hyperactivity symptoms was reported to be 14.9% in the UAE.7–10 Prevalence rates are markedly different based on the diagnostic criteria utilised, the sample’s origin (i.e. general or clinical population), gender and age of focus and the methodology used. The definition of ADHD was amended in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).7 Although ADHD is a disorder that begins in childhood, it can linger through adulthood. It is often categorised by persistent patterns of impulsivity, hyperactivity and inattention. Symptoms are usually present for a minimum of six months and are commonly observed in children below seven years of age; however, normal diagnostic criteria are mostly applicable to children aged 6–12 years.11 The intensity of symptoms of hyperactivity may subside with age or can be replaced in older individuals with restlessness, which is difficult to quantify. Characteristics such as organisational dysfunction (i.e. executive function), inattentiveness and impulsivity often persists past the initial diagnosis. ADHD diagnosis is complicated by a variety of factors and patients suffering from ADHD often present to different medical services for assessment, diagnosis and treatment. Application of different diagnostic classification systems, like DSM-IV TR, DSM-5 criteria or ICD-10, often tend to present challenges for the practising physicians.7,12,13 These challenges may also include under-diagnosis, high levels of comorbidity, misuse of pharmacological treatments, and the risks of diversion.11 Statements about ADHD should be developed systematically to information about diagnostic strategies and management of the condition to mental health practitioners, paediatricians and families with children suffering from ADHD or with children suspected to have ADHD. The evolution of medical understanding of ADHD reflects the complicated nature of the condition. The DSM-IV retained ADHD terminology and outlined three specific subtypes: hyperactive- impulsive, inattentive and combined.12 These subtypes are defined by excessive symptoms of hyperactivity- impulsivity and/or inattention. DSM-IV-TR modified the classification of ADHD as a disruptive behaviour disorder.12 The DSM-5 saw the addition of the Neurodevelopmental Disorders category which brought a significant adjustment to ADHD classification and resulted in revisions to ADHD’s diagnostic criteria;7 The diagnostic criteria of ADHD also underwent some revisions in DSM-5. The same 18-symptom criteria were involved as previously, with the addition of specific examples under each criterion, to facilitate classification of the disorder across the individual’s lifespan. The age of ADHD onset was also revised to 12 years in the DSM-5 compared to the previous restrictive barrier for diagnosis of seven years of age.11 Some of the specifiers were included to designate either hyperactive/impulsive or inattentive ADHD presentations. The adult ADHD diagnosis criterion endured a symptom threshold variation: adults have a cut-off of five symptoms of hyperactivity or inattention, unlike the six symptoms needed in younger people. Hence, the DSM-5 chapter on neurodevelopmental disorders allows for a comorbid ADHD diagnosis which had previously not been acceptable under the DSM-IV-TR.4,12 Such a diagnosis can currently be made based on the presentation of only mild symptoms or the inability of individuals to compensate for their difficulties through various coping mechanisms. In contrast to the DSM goals, the primary goal of the ICD-10 lies in classification instead Clinical Practice Guidelines for the Evaluation and Diagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents A systematic review of the literature e14 | SQU Medical Journal, February 2021, Volume 21, Issue 1 of diagnosis. ADHD is found in the ICD-10 under the code F90.0.13 Consistent clinical guidelines are important for providing better quality care, evidence-based medical practice and cost-efficient services and for improving clinical outcomes, care planning, multidisciplinary communications and resource allocation. Such guidelines, however, have limitations. Guidelines can become out-dated, be of methodologically poor quality or command unavailable or biased care standards. Several international medical societies have targeted different groups of health professionals in their published guidelines on the evaluation and diagnosis of ADHD. Globally, ADHD has been researched extensively because of the potential repercussion it has on children’s families and personal development.11 No agreement, however, exists about which instrument should be utilised in diagnosing children with possible ADHD and there are several controversies regarding the criteria currently used for diagnosis. Such complications in the diagnostic processes, detection and methodology have given rise to considerable changes (demographic or geographic), mainly leading to over- or under-diagnosis of ADHD.11 Due to a lack of biological markers, ADHD diagnosis is mainly clinical. Given the large body of international evidence on the topic, healthcare providers working in the fields of psychiatry, psychology, neurology and paediatrics must have practical guidelines on ADHD’s diagnosis and evaluation.11 Such guidelines should be based on the best scientific evidence and be useful in helping health practitioners select the best options for diagnosis and treatment, support clinical audits and aid in risk management. This article aims to conduct a comprehensive review of CPGs, mainly emphasizing on diagnosis, evaluation and management recommendations. It identifies established differences in practice and standards for the evaluation and diagnosis of ADHD by comparing recommendations in the guideline documents. In addition, the methodological quality of the selected ADHD guidelines will be further analysed in adolescents and children. This article provides a recommendation about which guidelines will help healthcare professionals provide higher quality care for adolescents and children with ADHD and their caregivers. Method This literature review used systematic methods to collect secondary data generated between 2008–2018 and critically appraised research studies to synthesise findings on ADHD in adolescents and children. MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA), Cumulative Index to Nursing and Allied Health Literature® (EBSCO Information Services, Ipswich, Massachusetts, USA), National Guideline Clearinghouse, NHMRC (the Australian National Health and Medical Research Council), and the Centre for Reviews and Dissemination of the University of York (University of York, York, UK) Figure 1: Flowchart showing the process used to identify clinical practice guidelines for the evaluation and diagnosis of attention-deficit/hyperactivity disorder in children and adolescents. Hira Abdul Razzak, Nariman Ghader, Ateeq A. Qureshi, Mehnaz Zafar, Jeena F. Shaijan and Muna Al Kuwari Review | e15 were searched for best practice global evidence and guidelines related to ADHD. The following keywords were used: ‘attention deficit hyperactivity disorder’, ‘ADHD’, ‘Practice guidelines’, “Diagnosis” and ‘children and adolescents’ [Figure 1]. Cross-referencing was also performed to collect further information. CPGs that were conducted exclusively among school-aged children and adolescents with ADHD, guidelines that focused on assessment and/or management of ADHD, English-language articles and studies conducted by international or national medical societies, health ministries and professional bodies were included. Case reports, local protocols, consensus statements, animal studies and previous reviews were excluded. Studies not showing results and evidence unrelated to the established objectives were also excluded. The quality of the CPGs was assessed independently by five reviewers, using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool. AGREE is an internationally accepted standard for evaluating the methodological quality of all CPGs and was used to assess methodological quality.14 The revised version (AGREE II) was launched in 2009. AGREE II consists of 23 key items which are rated on a four-point Likert scale organised under six domains: applicability, clarity and presentation, rigour of development, stakeholder involvement, scope and purpose and editorial independence. The sum of all domain scores gives a total score. These scores can be presented as a maximum possible percentage for that domain or as a maximum possible total score. The AGREE II Instrument Training Manual was used as a resource to guide us. Final selection of guidelines was based on the scores on each criterion according to AGREE-II Instrument.15 The five reviewers performed the scoring and agreed upon the consensus rating for each item score in the cases of initial differences. Guidelines that met established inclusion criteria were reviewed and recommendations on assessment/screening and diagnosis were extracted. AGREE-II guidelines do not include specific cut-off scores to distinguish between low- or high- quality guidelines. To be considered acceptable for this study, a guideline score had to be 60% or above in all domains. These statistics were mainly founded on cut- off scores reported in prior published appraisals of the guidelines.16 Scores were calculated as follows: Based on the scores, various guidelines were identified as acceptable for the evaluation and diagnosis of ADHD. Results A total of 18 relevant guidelines were extracted of which five were selected for inclusion: the American Academy of Paediatrics’ (AAP) guidelines, the British Association of Psychopharmacology (BAP) guidelines, the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guideline Network (SIGN) guidelines and the Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA) practice guidelines. Table 1 provides an overview of the selected guidelines. The AAP (2000, 2001 and 2011) guideline consists of two-parts and were created for primary care physicians by the AAP Committee on Quality Improvement.17,18,19 The first part (2000) addressed evaluation and diagnosis and the second part, which was published in 2001, addressed the treatment for uncomplicated ADHD cases in 6–12-year- olds presenting to primary care physicians. These guidelines were then updated in 2011. The BAP guidelines (2006 and 2014) were the first and foremost ADHD guidelines created in the year 2006 and dealt with the management as well as diagnosis of ADHD in adolescents and adults who were in a transitional phase to receiving adult services.20,21 The NICE guidelines (2008 and 2018) were developed for the National Health Service (NHS) in Wales and England.22,23 These extensive guidelines covered treatment and assessment of patients three years or older. This work was considered to supersede a technology appraisal, which addressed the utilisation of dexamphetamine, atomoxetine and methylphenidate in 2006 among children and adolescents with ADHD. For treatment and diagnosis of children over three years of age as well as adults and adolescents suffering from ADHD, key priorities were precisely defined. In England and Wales, the NICE guidelines demonstrated a significant impact on the provision of public health along with extending its influence on some other commonwealth and European countries. This set of guidelines also makes a differential recommendation for ADHD pharmacological treatment. NICE recommends that pharmacological treatment shall be considered Maximum possible score= 7 (strongly agree) × 3 (items) × 5 (appraisers) = 105 [Equation 1] Minimum possible score= 1 (strongly disagree) × 3 (items) × 5 (appraisers) = 15 [Equation 2] Scale domain score = × 100 [Equation 3]Obtained score − Minimum possible score Maximum possible score Clinical Practice Guidelines for the Evaluation and Diagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents A systematic review of the literature e16 | SQU Medical Journal, February 2021, Volume 21, Issue 1 first-line treatment in adolescents and children and adults with a severe ADHD impairment. It should also be part of a comprehensive treatment plan which includes educational, behavioural and psychological interventions. These guidelines additionally recomm- end the formation of multiagency groups in all training provisions and localities for teachers or health professionals as well as multidisciplinary specialist ADHD clinics or teams. In 2018, these guidelines were updated to improve diagnosis, recommendations Table 1: Overview of included clinical practice guidelines used for the evaluation and diagnosis of attention-deficit/hyper- activity disorder in children and adolescents19,21,23,26,27 Clinical practice guideline SIGN CADDRA AAP BAP NICE Author(s) Forbes et al. Doron Almagor et al. Wolraich et al. Bolea- Alamañac Baird et al. Publication year of latest version 2009 2011 2011 2014 2018 Publication year(s) of previous version 2001 2006 and 2008 2001 - 2006 and 2008 Origin Scotland Canada USA UK UK Target group Health professional Physician Primary care clinician GP, paediatrician, CAMH and psychologist Clinician Grading of evidence Yes Yes Yes Yes Yes Funding Public funding Self-funded with individual disclosures Unclear Pharmaceutical Unclear Diagnosis Yes Yes Yes Yes Yes Treatment Yes Yes Yes Yes Yes Diagnostic Criteria ICD-10 and DSM-IV DSM-IV DSM-IV ICD-10 and DSM-IV ICD-10 and DSM-IV Screening - Yes Yes Yes Yes Screening for Comorbidities Yes Yes Yes Yes Yes ADHD specialist Yes Yes - Yes Yes Psychiatric Interview Patient, parents and school Patient, parents, school and informants Patient, parents, school and informants Patient and informants Patient and informants Questionnaires and rating scales - CAAT To be used optionally: CTRS-R, CPRS or SSQ-R Not recommended for diagnosis: CBCL-R and DSMD–Total Scale or TRF, CPRS-R or CTRSR- Global Problem Index ASRS, WURS, BSOPA-SC, BADDS, ADHD-RS-IV, ASRS-V1.1 or CCSC CAADID, Conners’ rating scales, SDQ or C-GAS Physical Examination Yes Yes Yes Yes Yes Other Investigations EEG, blood analysis and brain imaging if essential to exclude underlying medical issues EEG, polysomnography and brain imaging may be indicated Thyroid function, blood lead levels, brain imaging, continuous performance tests and EEG not routinely recommended - ECG if clinical/ historical indications SIGN = Scottish Intercollegiate Guideline Network; CADDRA = Canadian Attention Deficit Hyperactivity Disorder Resource Alliance; AAP = American Association of Psychopharmacology; BAP = British Association of Psychopharmacology; NICE = National Institute for Health and Care Excellence; GP = general practitioner; CAMH = Child and Adolescent Mental Health; ICD = International Classification of Diseases; DSM = Diagnostic and Statistical Manual of Mental Disorders; CAAT = Clinical Assessment of Attention Deficit; CTRS-R = Conners’ Teacher Rating Scale-Revised; CPRS = Conners' Parent Rating Scale; SSQ-R = School Situations Questionnaire-Revised; CBCL-R = Child Behaviour Checklist-Revised; DSMD = Deveraux Scales of Mental Disorders; TRF = Teacher Report Form; CPRS-R = Conners' Parent Rating Scale-Revised; ASRS = ADHD Self-Report Scale; WURS = Wender Utah Rating Scale; BSOPA-SC = Barkley Self, Other and Past ADHD symptom checklist; BADDS = Brown Attention-Deficit Disorder Scales; ADHD-RS = ADHD Rating Scale; CCSC = Canadian Consensus Screening Checklist; CAADID = Conners' Adult ADHD Diagnostic Interview for DSM-IV; SDQ = Strengths and Difficulties Questionnaire; C-GAS = Children’s Global Assessment Scale; EEG = electroencephalogram; ECG = electrocardiogram. Hira Abdul Razzak, Nariman Ghader, Ateeq A. Qureshi, Mehnaz Zafar, Jeena F. Shaijan and Muna Al Kuwari Review | e17 Table 2: Pharmacological and psychosocial treatment of attention deficit/hyperactivity disorder recommendations in selected clinical practice guidelines19,21,23,26,27 Treatment Clinical practice guideline (version) SIGN (2009) CADDRA (2011) AAP (2011) BAP (2014) NICE (2018) Pharmacological treatment MPH FLO NRF FLO FLO FLO MPH-MR FLO FLO FLO FLO FLO Dexamphetamine FLO FLO FLO FLO FLO (In young people and children aged five and above) Mixed amphetamine NRF FLO FLO NRF NRF Salts lisdexamphetamine NRF FLO NRF NRF - Atomoxetine EFLR FLO NRF FLO FLO (In children and adolescents) Bupropion EFLR EFLR OS EFLR EFLR Clonidine EFLR NRF OS EFLR EFLR Guanfacine NRF NRF NRF EFLR NRF Modafinil - EFLR NRF EFLR EFLR Pemoline NRF NRF - - NRF TCA EFLR EFLR OS EFLR EFLR Pre-treatment safety Measures EFLR EFLR NRF NRF EFLR Explicit dose For some agents only EFLR EFLR NRF EFLR Titration EFLR EFLR OS NRF EFLR Monitoring EFLR EFLR EFLR EFLR EFLR Adverse effects EFLR EFLR EFLR EFLR EFLR Contra-indications NRF EFLR EFLR NRF EFLR Cost consideration NRF EFLR NRF EFLR EFLR Drug holidays NRF NRF (Exceptions permitted) NRF NRF NRF (Exceptions permitted) Psychosocial treatment Individual interventions NRF EFLR NRF NRF EFLR Group interventions NRF NRF NRF NRF EFLR Family-based interventions EFLR EFLR NRF NRF EFLR School-based interventions EFLR EFLR EFLR EFLR EFLR Occupational interventions NRF EFLR NRF EFLR NRF Behavioural training for parents EFLR EFLR EFLR NRF EFLR Behavioural management NRF EFLR NRF NRF EFLR Psychoeducation EFLR EFLR EFLR EFLR EFLR Family therapy NRF EFLR NRF NRF NRF Social skills training NRF EFLR NRF NRF EFLR Cognitive therapy NRF NRF - NRF NRF CBT NRF EFLR - NRF EFLR SIGN = Scottish Intercollegiate Guideline Network; CADDRA = Canadian Attention Deficit Hyperactivity Disorder Resource Alliance; AAP = American Association of Psychopharmacology; BAP = British Association of Psychopharmacology; NICE = National Institute for Health and Care Excellence; MPH = methylphenidate; FLO = first line option; NRF = no recommendation found; MR = modified release; EFLR = explicitly favourable recommendation; TCA = Tricyclic antidepressant; OS = outside scope; CBT = cognitive behavioural therapy. Clinical Practice Guidelines for the Evaluation and Diagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents A systematic review of the literature e18 | SQU Medical Journal, February 2021, Volume 21, Issue 1 and quality of care for people with ADHD. Further clarifications and updates were also made on some of the recommendations, impacts and rationales. Both documents (2008 and 2018 versions) have a vibrant cost-effectiveness investigation which addresses the impact of recommendations on the provisions of the healthcare services and healthcare economics. The NICE guidelines influence not only ADHD care but also the needs for the NHS to offer age-appropriate services for all ADHD patients. Developed in 2009 to disseminate and develop national CPGs in Scotland, the SIGN (2001, 2005 and 2009) guidelines cover ADHD treatment and diagnosis in adolescents and children.24,25,26 SIGN guidelines play a role in ADHD resource allocation and policy-making in Scotland’s NHS. In 2011, the CADDRA practice guidelines for primary care practitioners and specialists were issued both in English and French.27 The guidelines were developed through the consensus of general practitioners, psychiatrists and paediatricians with declared objectives of simplifying care in training and practice and standardising ADHD care worldwide. The guidelines are organised based on the complexity of the presenting case and include templates and assessment tools for liaison with and monitoring by external agencies. An online tool kit for primary care practitioners provides free ADHD rating scales and structured interview tools for every age group, with precise usage instructions. The CADDRA guidelines simplify assessment across age groups and allow ADHD to be better managed in primary care settings. The most recent versions of the selected guidelines were published between 2009 and 2018. Originating from the United Kingdom, United States and Canada, guidelines showed no significant differences when compared to each other. However, a single particularity was noted for NICE and CADDRA; both guidelines provided recommendations to all age groups, whereas all others focused on only children and adolescents. These guidelines supported the utilisation of categorical diagnostic criteria; the majority recommend using either ICD-10 or DSM-IV. Recommendations for collateral informants, psychiatric interviews and questionnaire/rating scale use are also provided. All guidelines vary widely in terms of laboratory tests and psychoeducational assessment. Neuropsychological evaluation is not essential for establishing an ADHD diagnosis through these guidelines. Table 2 displays pharmacological and psycho- social treatments for ADHD. In most guidelines, stimulants constitute the first-line pharmacological choice for the treatment of ADHD. CADDRA (2011) is the only guideline that recommends lisdexam- phetamine. In most guidelines, the noradrenaline reuptake inhibitor atomoxetine was considered the preferable treatment option. Other drugs, such as tricyclic antidepressants, guanfacine, clonidine and bupropion, are highly recommended for those who have had unsuccessful treatment(s) or suffer any comorbidities, notwithstanding first-line options. Pemoline received negative recommendations from AAP and BAP, based on evidence of liver failure cases. Table 2 (cont’d): Pharmacological and psychosocial treatment of attention deficit/hyperactivity disorder recommendations in selected clinical practice guidelines19,21,23,26,27 Treatment Clinical practice guideline (version) SIGN (2009) CADDRA (2011) AAP (2011) BAP (2014) NICE (2018) Self-help EFLR EFLR NRF NRF EFLR Counselling NRF EFLR NRF NRF NRF Cognitive remediation NRF Academic skills NRF NRF NRF Carer support EFLR EFLR EFLR NRF NRF Other therapies Recommended to avoid omega-3 and omega-6 fatty acid supplements, case- specific food additives (þ), zinc supplements, iron supplements, Bach flower remedies, antioxidants, neurofeedback, massage therapy and homeopathy Anger management, play therapy, interpersonal therapy and expressive arts therapy. Play therapy is not recommended NRF Elimination and restriction diets not recommended. Fatty acid supplements not routinely recommended Multimodal interventions EFLR EFLR EFLR NRF EFLR SIGN = Scottish Intercollegiate Guideline Network; CADDRA = Canadian Attention Deficit Hyperactivity Disorder Resource Alliance; AAP = American Association of Psychopharmacology; BAP = British Association of Psychopharmacology; NICE = National Institute for Health and Care Excellence; MPH = methylphenidate; FLO = first line option; NRF = no recommendation found; MR = modified release; EFLR = explicitly favourable recommendation; TCA = Tricyclic antidepressant; OS = outside scope; CBT = cognitive behavioural therapy. Hira Abdul Razzak, Nariman Ghader, Ateeq A. Qureshi, Mehnaz Zafar, Jeena F. Shaijan and Muna Al Kuwari Review | e19 Twenty-eight antipsychotics received three positive recommendations in the different guidelines.18,20 A strong disagreement among guidelines related to certain psychosocial interventions for ADHD treatment was found. Most of the guidelines precisely agreed on the requirements for certain specific forms related to the psychosocial interventions comprising education programmes performed individually with suitable adaptations as required, psychoeducation, support for caregivers and parent training. Most of the guidelines recommended that optimal ADHD management should usually include some form of psychosocial intervention either with or without medication. Table 3 shows the aggregated score results of the five reviewed guidelines. The highest total score was achieved by the NICE guidelines followed by the SIGN, CADDRA, BAP and AAP guidelines. All the selected guidelines provide unambiguous and specific recommendations, along with different management options. These recommendations generally yielded scores that reflect clarity in presentation. Patient preferences and views were only considered by the NICE guidelines. None of the reviewed CPGs was piloted among target users. The documents developed by NICE, CADDRA and SIGN were revised through an external review process before publication. Only the NICE guidelines offered a clear timeline and procedure for a continuous revision and considered detailed cost implications of its implementation. Two of the guidelines from the UK (i.e. SIGN and NICE) provided materials and criteria for auditing and monitoring purposes mainly derived from their key recommendations. However, only three of the guidelines, CADDRA (62; 86.6%), SIGN (62; 86.6%) and BAP (60; 83.3%) provided satisfactory information on their editorial independence from the funding body. Discussion This comprehensive review of CPGs related to the treatment, management and diagnosis of ADHD included five CPGs developed by national medical associations or specialist groups in the UK, USA and Canada were reviewed. The reviewed guidelines reflect a diversity of healthcare systems and professionals from primary care to tertiary specialists. The methodol- ogical quality of the individual CPGs on the domains of the AGREE-II were assessed, allowing for a comparison of CPGs based on these domains. The AGREE-II can, therefore, guide clinicians and CPG groups in identifying trustworthy and high-quality evidence- based ADHD CPGs using AGREE-II criteria.15 The findings of this review can be utilised to inform the development of revised and improved ADHD guidelines. Most guidelines reviewed describe ADHD diagnosis based on a complete clinical interview that comprises impairment assessment, mental state examination, development, family history, comorbidity and physical examination. The child and adolescent ADHD guide- lines also included a family interview. All guidelines reviewed indicated that clinical interview remains the gold standard of an ADHD evaluation. The utilisation of rating scales has improved as has standardised efficiency and their breadth and reliability of assess- ment. The importance of excluding psychiatric and physical comorbidity has also been addressed in most of the reviewed guidelines. Regarding pharmacological treatment, all the reviewed guidelines suggested utilising stimulants in adolescents and children.19,21,23,25,27 NICE recommends prescribing an atypical antipsychotic (i.e. risperidone) along with stimulants for children aged five years and above, young persons and adults with ADHD. This recommendation also applies to Table 3: Aggregated results of selected guidelines according to the Appraisal of Guidelines for Research & Evaluation II tool19,21,23,26,27 Category (maximum score) Obtained Score (%)* SIGN (2009) CADDRA (2011) AAP (2011) BAP (2014) NICE (2018) Scope and purpose (105) 100 (94.4) 87 (80) 99 (93.3) 87 (80) 105 (100) Stakeholder involvement (105) 81 (73.3) 84 (76.6) 87 (80) 84 (76.6) 93 (86.6) Rigour of development (280) 240 (83.3) 232 (80) 240 (83.3) 224 (76.6) 264 (93.3) Clarity and presentation (105) 90 (83.3) 99 (93.3) 69 (60) 84 (76.6) 102 (96.6) Applicability (140) 124 (86.6) 108 (73.3) 100 (66.6) 108 (73.3) 128 (90) Editorial independence (70) 62 (86.6) 62 (86.6) 42 (53.3) 60 (83.3) 54 (73.3) Total score (805) 693 (83.7%,) 672 (80.7%) 637 (75.6%) 647 (77.1%) 746 (91.4%) SIGN = Scottish Intercollegiate Guideline Network; CADDRA = Canadian Attention Deficit Hyperactivity Disorder Resource Alliance; AAP = American Association of Psychopharmacology; BAP = British Association of Psychopharmacology; NICE = National Institute for Health and Care Excellence. *The percentages were calculated based on Equation 3. Clinical Practice Guidelines for the Evaluation and Diagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents A systematic review of the literature e20 | SQU Medical Journal, February 2021, Volume 21, Issue 1 patients with coexisting pervasive aggression, with rage or irritability causing severe impairment and for those who are inadequately responsive to behavioural interventions.23 Moreover, healthcare practice is becoming cons- iderably more complex because of several factors. One such aspect is the increasing amount of scientific evidence available. For clinical decisions to be correct, safe and efficient, healthcare providers primarily need to update their knowledge and, to this end, a great deal of effort is being invested in the UAE. All CPGs logically defined scope and purpose of the guidelines. CADDRA and AAP guidelines, however, lacked clarity and detail in defining scope and purpose compared to the other included guidelines. The involvement of the patient, family members and other stakeholders at every step of the development process is an essential part of good quality CPGs. Such involvement recognises patients as experts and helps develop CPGs that are patient-centred, improving implementation and acceptability.31,32 Although all CPGs described stakeholder involvement, this element was not clearly described for every step of the development process; only AAP and NICE scored ≥80% on this important domain which is a key element of high- quality evidence-based CPGs.33 All CPGs, except the BAP guidelines, demonstr- ated good rigor of development with scores ≥80%. This domain is a strong indicator of overall guideline quality.34,35 Three out of the five CPGs scored ≥80% for clarity and presentation, with NICE scoring part- icularly high; the appraisers’ score for that category in the AAP were low (60%), reflecting a lack of clarity in presentation. Only the SIGN and NICE guidelines scored >80% on the applicability domain. Scores on the applicability domain are a strong indicator of overall quality as well as recommendations for use. Low scores on applicability domains for CPGs can raise questions on how recommendations can be implemented.15 The SIGN, CADDRA and BAP guidelines were scored >80% in the category of editorial independence showing that they are clear and detailed in describing editorial independence. Some research has shown that adherence to guidelines by health professionals can be improved by trainings grounded in guideline recommendations.33 This review was subject to certain limitations. One of the limitations of this review is the evaluation of recommendations that do not essentially share a common denominator. Moreover, CPGs included were published only in the last ten years and looked at the evidence available at the time, which can explain some of the chronological variability of the recommendations. Finally, it is possible that other guidelines might have been missed or may not have been identified. Conclusion All CPGs investigated within this systematic review had overall strong scores according to the AGREE- II instrument. Some relevant information such as stakeholder involvement or editorial independence were not always easily accessible or clearly described; future CPG developers should keep these findings in mind. The NICE guidelines most recent CPG included, had the highest total score and the highest scores on all domains except editorial independence. The NICE guidelines can be used as a model in developing the future ADHD guidelines for the UAE and globally. CPGs for ADHD in the UAE must be developed using high quality evidence, while diminishing bias with openness, methodological rigor, stakeholder involvement and transparency. 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