This guideline was developed according to the Australian National Health and Medical Research Council (NHMRC) standards and procedures for rigorously developed external guidelines (National Health and Medical Research Council, 2007, 2016) and according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (The GRADE Working Group, 2009).
The multidisciplinary guideline development group
The multidisciplinary Guideline Development Group (GDG) was convened by inviting people with experience living with ADHD, caring for people with ADHD, and academics with experience in ADHD, to participate in the development of the guideline. Disciplines represented included psychology, psychiatry, paediatrics, speech pathology, occupational therapy, nursing, education, clinical pharmacology, and health services. See Introduction and Appendix 2 for a list of GDG members and their affiliations. Four GDG members represented the voice of the lived experience.
Wherever possible AADPA sought to ensure that members of the GDG:
- came from diverse geographical regions, including those in rural settings;
- were diverse in terms of the discipline areas they represented, acknowledging that many different professions are involved in the diagnosis, treatment and support of ADHD;
- were diverse in terms of ethnicity, culture and gender; and
- people with a lived experience of ADHD were involved.
The process for selecting members of the GDG were as follows:
- expressions of interest were received in response to email call-out by suitably qualified professionals and those with a lived experience of ADHD at the commencement of the guideline development. Many nominations were not endorsed due to conflicts of interest. If conflicts of interest were deemed appropriate and the individual had relevant expertise they were considered for inclusion
- AADPA President, Professor Mark Bellgrove, requested relevant professional organisations and consumer groups to nominate members for inclusion. Conflict of interests were rigorously assessed. Members representing organisations can be found in section ‘Representation from relevant colleges and societies’ above
- where there was a lack of relevant content expertise Professor Bellgrove directly requested the involvement of individuals in the GDG based on their professional expertise and credentials, subject to conflict of interest
- direct approaches by the guideline project management team to Aboriginal and Torres Strait Islander peoples with relevant expertise were made.
Ethnicity and culture were considered when identifying evidence and when developing all recommendations. Issues related to Aboriginal and Torres Strait Islander peoples were led by an Aboriginal clinical and counselling psychologist, with further input from an Aboriginal researcher.
An online workshop was held to detail the methods of reviewing evidence and preparing the associated GRADE frameworks. GDG members were informed at this meeting of when input would be requested and the level of input required.
Identification of previous guidelines
ADAPTE II methods (ADAPTE Collaboration, 2009) were followed to identify existing current high-quality, evidence-based guidelines published during the previous 5 years (prior to 2019) (Figure 2). The objective was to choose an existing evidence-based guideline in which the clinical questions were sufficiently similar to the scope agreed during the stakeholder engagement process led by the Australian ADHD Professionals Association (AADPA) (Table 4), and adapt or update the evidence and/or recommendations to the Australian setting. Where the supporting evidence was superseded by new research, the supporting systematic evidence review was updated and recommendations redrafted.
Figure 2. Process for identifying candidate ADHD clinical practice guidelines suitable for adaptation
Notes. EtD, GRADE Evidence to Decision Framework
According to the selection criteria, data were extracted from included studies into ‘Characteristics of included studies’ tables (see Technical Report). Information was collected on general details (title, authors, reference/source, country, year of publication, setting), participants (age, gender, withdrawals/losses to follow-up, subgroups), results (point estimates and measures of variability, frequency counts for dichotomous variables, number of participants, intention-to-treat analysis) and validity of results.
In order to make a summary statement about the effect of the intervention to inform evidence-based recommendations, data were presented in tables, and where appropriate, using statistical methods such as meta-analyses. When participants, interventions, outcome measures and timing of outcome measurements were considered sufficiently similar, the Review Manager 5.3 software was used for meta-analyses. Where appropriate, subgroup analysis was conducted according to the specifications of the a priori selection criteria/PICO. Network meta-analysis was considered for the intervention questions but was deemed inappropriate due to differences in study populations, the aspects of the interventions and insufficient data available for the relevant outcomes.
Certainty of the body of evidence using GRADE evidence profiles
A GRADE evidence profile/table was prepared for each comparison within each clinical question, listed by outcome. For comparisons where no new evidence was found for a question addressed by the existing NICE guideline, GRADE tables can be found in the NICE guideline (NICE, 2018) evidence documents (https://www.nice.org.uk/guidance/ng87). For comparisons where new evidence was integrated with NICE evidence, this is indicated in the GRADE tables (see Technical Report).
For each prioritised outcome, a certainty rating was documented based on consideration of the number and design of studies addressing the outcome, and on judgments about the risk of bias of the studies and/or synthesised evidence, inconsistency, indirectness, imprecision and any other considerations that may have influenced the quality/certainty of the evidence.
This overall quality/certainty of evidence reflected the extent to which our confidence in an estimate of the effect is adequate to support a particular recommendation (The GRADE Working Group, 2009) and results in an assessment of the quality/certainty of a body of evidence in one of four grades (Table 9) adapted from GRADE (The GRADE Working Group, 2009).
Table 9. Quality/Certainty of the body of evidence
|We are very confident that the true effect lies close to that of the estimate of the effect.|
|We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.|
|Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.|
|We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.|
The GRADE Working Group notes that the certainty of evidence is a continuum; any discrete categorisation involves some degree of arbitrariness. Nevertheless, advantages of simplicity and transparency, outweigh these limitations (The GRADE Working Group, 2009).