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Table 1 Summary of the Key recommendations in the adapted clinical practice guideline for the management of children and adults with ADHD

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

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

  1. For the complete set of recommendations of the adapted guideline, please refer to the official website: https://cpg.adhd.org.sa/recommendations/