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).
Introduction
Methods
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.
Conflict of interest
Conflict of interest was managed by the Conflict of Interest Management Group (see Introduction and Appendix 4).
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
Search methods
The evidence expert undertook a systematic search for existing guidelines that addressed ADHD (search conducted in July 2019). To be eligible, the guideline must have included a description of evidence-based guideline development methods and must have contained the following benchmark criteria:
- multidisciplinary working group
- evidence review with search strategy
- methodological quality/risk of bias assessment of included evidence.
Phase 1: Searches of relevant guideline websites
- Websites of national and international guideline clearinghouses, guideline developers, centres of evidence-based practice, government health services and websites of specific relevance known to contain evidence-based guidelines were searched.
- 18 websites and 9 guidelines were identified.
Phase 2: Internet searches to identify topic-specific websites
- Additional websites of specific relevance were sought via an internet search using the Google ‘Advanced Search’ function with the following string and the English language filter:
- (Attention Deficit Hyperactivity Disorder OR attention deficit OR ((hyperactivity OR hyperkinetic) AND disorder) OR ADHD) AND (professional OR association OR organisation OR organization OR college OR society OR academy OR peak)
- 155 results were retrieved, of these there were 17 websites that were further examined.
Phase 3: Topic-specific website searches to identify relevant evidence-based guidelines
- Where an internal search engine was available, websites were searched. If no search engine was available, lists of guidelines, publications or other resources identified on the site were scanned for relevant documents.
- 2 guidelines were identified.
Phase 4: Internet searches to identify relevant evidence-based guidelines
- An internet search strategy was conducted to identify evidence-based guidelines using the Google ‘Advanced Search’ function with the following string and the English language filter:
- (Attention Deficit Hyperactivity Disorder OR attention deficit OR ((hyperactivity OR hyperkinetic) AND disorder) OR ADHD) AND (guideline OR evidence OR systematic)
- 128 results were retrieved.
A total of 25 guidelines published between 2001 and 2018 were identified. Of these, 3 guidelines completed evidence review searches within the previous 5 years. The most current of these guidelines (NICE 2018) covered the same content as the other two guidelines (German Association of the Scientific Medical Societies (AWMF), 2017; Kemper et al., 2018). The existing guideline selected for adaptation was the UK National Institute for Health and Care Excellence (NICE) 2018 guideline Attention Deficit Hyperactivity Disorder: diagnosis and management [NICE guideline NG87], referred to as ‘the NICE guideline’ in this guideline. Approval was provided to AADPA to update the NICE 2018 guideline by the National Institute for Health and Care Excellence, UK on 25th October 2021.
Clinical question identification
The evidence expert compiled and consolidated the questions addressed by these three existing high-quality guidelines, which helped to engage stakeholders to identify and prioritise the key areas of interest for these guidelines.
To develop a set of indicative questions to be addressed within the Australian ADHD guideline, AADPA led several rounds of stakeholder engagement, including via face-to-face meetings and email correspondence. AADPA sought engagement from relevant stakeholder groups who were involved in the diagnosis, treatment, support or education of Australians living with ADHD. An indicative list of questions to be addressed was developed from these rounds of stakeholder engagement.
Clinical question prioritisation and management
Clinical questions were prioritised by the GDG to guide the evidence expert and to reach consensus on which clinical questions were addressed either by an update of a NICE evidence review, a new evidence review, or clinical expert narrative review (Table 6).
The prioritisation consensus process was led by Dr Marie Misso and the GDG Chairs, Dr Edward Petch and Professor Katrina Williams. GDG members were asked to rank each question using a 1–9 scale, where 9 was the highest priority (Figure 3). This approach to consensus priority assignment was based on the GRADE approach devised for prioritising clinical questions. The directory of clinical questions (Table 6) lists all questions addressed by this guideline. These questions were rated as ‘Important’ or ‘Critical’ and were therefore included in the guideline.
Figure 3. Rating scale for assigning priorities to clinical questions
Adapted from GRADE.
Table 6. Guideline scope and directory of clinical questions
Question | Guideline Section | Evidence Review In Tech Report | Narrative Review In Tech Report |
Characterising ADHD | |||
| What is ADHD? | Background | NA | NA |
| What is the prevalence of ADHD in Australia and internationally? | Background | NA | NA |
| What is the aetiology of ADHD? | Background | NA | NA |
| What are the outcomes (i.e. prognosis) for people diagnosed with ADHD? | Background | NA | NA |
| Does ADHD have a characteristic course and does its presentation change across the lifespan? | Background | NA | NA |
| What other disorders commonly co-occur with ADHD | Background | NA | NA |
Diagnosis and assessment | |||
| Should screening for ADHD occur at a population level? C | Chapter 1 | – | Section 2.4 |
| Which groups are at high risk of developing ADHD? A | Chapter 1 | Section 2.2 | – |
| Should screening for ADHD occur in high-risk populations? C | Chapter 1 | – | Section 2.4 |
| How should ADHD be assessed, diagnosed and monitored, and by whom? C | Chapter 2 Principles | – | Section 3.1 |
| Which condition/s need to be excluded to make a diagnosis of ADHD? C | Chapter 2 | – | Section 3.2 |
| Which condition/s should be considered for a co-occurring diagnosis with ADHD? C | Chapter 2 | – | Section 3.2 |
Non-pharmacological interventions | |||
| What is the clinical effectiveness of non-pharmacological interventions for people with ADHD? A | Chapter 4 | Section 5.1 | – |
| What are the adverse events associated with non-pharmacological treatments for people with ADHD? A | Chapter 4 | Section 5.1 | – |
| Should treatments be provided individually or in groups? Who should deliver them? A | Chapter 4 | Section 5.1 | – |
| Is there a role for ADHD coaches? C | Chapter 4 | – | Section 5.4 |
| Is there a role for peer support workers? C | Chapter 4 | – | Section 11.2 |
| Is there a role for consumer groups (e.g., online forums)? C | Chapter 4 | – | Section 11.3 |
| What educational/school/teacher interventions are possible, and are they effective? A | Chapter 4 | Section 5.1 | – |
Pharmacological Interventions | |||
| What is the clinical effectiveness of pharmacological treatments for people with ADHD (and what is the optimal sequence?)? A | Chapter 5 | Section 6.1 | – |
| What are the adverse events associated with pharmacological treatments for people with ADHD? A | Chapter 5 | Section 6.2 | – |
| How should initial medications be titrated? C | Chapter 5 | Section 6.3 | |
| Which clinicians should initiate pharmacological therapy, and continue it long term? C | Chapter 5 Principles | Section 6.4 | |
| What principles should clinicians follow when discussing decisions to start, adjust, or discontinue pharmacological treatment for people with ADHD? B | Chapter 5 | Section 6.4 | |
| Which factors need to be considered when making initial treatment decisions for ADHD? B | Chapter 3 | Section 6.4 | |
| How should ADHD symptom severity and clinical profile guide treatment decisions? B | Chapter 3 | Section 6.4 | |
Multimodal treatment | |||
| What is the clinical effectiveness of combined non-pharmacological and pharmacological interventions for people with ADHD? A | Chapter 3 | Section 7.1 | |
| What are the adverse events associated with combined non-pharmacological and pharmacological treatment for people with ADHD? A | Chapter 4 | Section 7.1 | |
Care pathways – (non-pharmacological and pharmacological) | |||
| What is/are the most clinically effective initial sequence(s) of non-pharmacological/pharmacological treatment for people with ADHD? B | Chapter 3 | Section 6.4 | |
| What is the most clinically effective subsequent sequence of non-pharmacological/pharmacological treatment for people with ADHD when the initial treatment is ineffective, inadequate or treatment is not tolerated? B | Chapter 3 | Section 8.6 | |
| How should treatment effectiveness be monitored and supported? C | Chapter 5 | – | Section 6.6 |
| How should adequacy of treatment response be assessed? C | Chapter 5 | – | Section 6.6 |
| What are the indicators of remission and when should treatments be stopped? B | Chapter 5 | – | Section 6.6 |
| What are the most effective approaches to increasing treatment adherence in ADHD for both non-pharmacological and pharmacological approaches? A | Chapter 4 | Section 10.8 | |
| How do co-occurring disorders impact treatment effects? B | Chapter 4 | – | Section 6.5 |
| Does the optimal treatment approach for ADHD vary when co-occurring disorders are present? B | Chapter 4 | – | Section 6.5 |
Care pathways – pharmacological | |||
| Are there specific clinical effects of discontinuing from pharmacological treatment and if so how should these be supported? A | Chapter 5 | Section 10.5 | – |
| Should ‘drug holidays’ from pharmacological treatment for ADHD be recommended and if so when? A | Chapter 5 | Section 10.7 | – |
Care pathways – principles | |||
| What are the information, support and educational needs of those diagnosed with ADHD, family, carers, and agencies who support people with ADHD? C | Chapter 2 | – | Section 4.1 |
| At what intervals should clinical care be reviewed for people with ADHD? C | Chapter 5 | – | Section 6.7 |
| What are shared care models and are they effective? B | Chapter 7 | Section 11.5 | Section 11.4 |
| What services should prison mental health services provide across life-stages? C | Chapter 6 | – | Section 11.6 |
| What referral pathways should be established? C | Chapter 7 | – | Section 12.5 |
| Which agencies should be involved in the treatment and support of ADHD? C | Chapter 7 | – | Section 11.4 |
| How should services be configured? C | Chapter 7 | – | Section 11.4 |
| Are health professionals, including psychiatrists, paediatricians, psychologists GPs, nurses, allied health professionals and educators adequately trained to support ADHD? C | Chapter 7 | – | Section 11.1 |
| For which people with ADHD should a transition to further services take place (preschool to school, primary to secondary school, school to adulthood, older adults)? C | Chapter 3 | – | Section 10.9 |
Implementation considerations | |||
| How should services for those with ADHD in Australia be funded? | Beyond scope of current guidelines – economic evaluation required | NA | NA |
| What should services provide and to whom? | Chapter 7 | NA | NA |
| How should a clinician maintain professional integrity and practice? | Principles | NA | NA |
A: This question was answered by an evidence review updated from NICE 2018 (Table 5). For detailed methods including selection criteria and search strategy, as well as search results, methodological assessment of included studies and evidence synthesis, please see the technical report.
B: This question was unable to be answered by an evidence review (Table 5), as insufficient evidence was identified. A narrative review was prepared by a GDG member with specific clinical knowledge and experience. For detailed methods including selection criteria and search strategy, as well as search results, please see the technical report.
C: This question was answered by a narrative review (Table 5) prepared by a GDG member with specific clinical knowledge and experience. Evidence review was not conducted and all literature in this section is selected based on the knowledge of the GDG member. This approach was taken as informed by the question prioritisation exercise outlined in the Methods.
Narrative reviews prepared by GDG members
Narrative reviews were completed:
- where questions were less well suited to a systematic evidence review format
- for lower prioritised questions
- where there was insufficient evidence identified for a question where an evidence review was conducted.
Narrative reviews were prepared by GDG members according to their content expertise. Reviews included key information to answer the clinical question and to guide the GDG to draft clinical consensus recommendations (CCR) and/or clinical practice points (CPP) and were informed by research and clinical experience. For some questions, the narrative review was based on an existing guideline, systematic review or other existing guidance document. Narrative reviews cited source references.
Updated evidence reviews for questions addressed by the NICE guideline
The selection criteria and search methods used in the NICE guideline (NICE, 2018) (https://www.nice.org.uk/guidance/ng87) were adopted and rerun from the NICE 2018 search date specific for each question (detailed in Technical report).
Additional identified evidence was tabulated, assessed for certainty and GRADE (The GRADE Working Group, 2009), and integrated with the existing NICE evidence. The processes for appraisal, extraction and synthesis are described below.
Evidence reviews for questions not addressed by an existing guideline
The PICO framework was used to explore the components of each clinical question and finalise the selection criteria:
P: population
I: intervention
C: comparison
O: outcomes
These components were used to design the search strategies and to include and exclude studies in the evidence review screening stage.
Systematic search for evidence
A broad-ranging systematic search strategy for terms related to ADHD was adopted from the NICE guideline (NICE, 2018) (https://www.nice.org.uk/guidance/ng87). It was combined with specific searches tailored for the clinical question according to the selection criteria/PICO developed by the GDG.
The search terms used to identify studies addressing the population of interest were not limited, so that studies addressing people with ADHD in all cultural, geographical and socio-economic backgrounds and settings would be identified by the search.
While a formal analysis of cost-effectiveness was not conducted for this guideline, studies addressing a clinical question that also reported cost-effectiveness were documented in the GRADE process. The search strategy was limited to English language articles and there were no limits on year of publication.
The following electronic databases were employed to identify relevant evidence:
- Medline (OVID) with Medline in-process and other non-indexed citations (OVID)
- PsycINFO (OVID)
- EBM Reviews (OVID)
- Cochrane Database of Systematic Reviews (Cochrane Reviews)
- Database of Abstracts of Reviews of Effects (Other Reviews)
- Cochrane Central Register of Controlled Trials (Clinical Trials)
- Cochrane Database of Methodology Reviews (Methods Reviews)
- The Cochrane Methodology Register (Methods Studies)
- Health Technology Assessment Database (Technology Assessments)
- NHS Economic Evaluation Database (Economic Evaluations)
- EMBASE (OVID)
The bibliographies of relevant systematic reviews and primary studies identified by the search strategy were also searched for identification of additional studies.
Inclusion of studies
To determine the evidence to be assessed further, an evidence team reviewer scanned the titles, abstracts and keywords of every record retrieved by the search strategy using the PICO selection criteria established a priori. Full articles were retrieved for further assessment if the information in the citation and abstract suggested that the study met the selection criteria and needed to be confirmed. Uncertainty was resolved through discussion among the evidence team and the GDG clinical leads.
In addition to articles of primary studies, systematic reviews that met benchmark criteria (Table 7) and selection criteria (Technical Report) were used if they reported outcomes and data, additional to the highest quality included evidence and/or the search date preceded the highest quality included evidence (see Technical Report for the selection criteria specific to each systematic evidence review).
Where a systematic review met the benchmark criteria but did not meet the selection criteria and contained studies that did and did not meet the selection criteria, we adopted the systematic review’s appraisals of the risk of bias for studies that did meet the selection criteria.
This approach was adopted for efficiency, to optimise the use of resources by avoiding unnecessary duplication of time and work.
For these reasons, we excluded many high-quality systematic reviews of clinical trials evaluating the effectiveness of interventions that had been identified.
Table 7. Benchmark criteria for existing systematic reviews
Existing systematic reviews were included if they met all the following conditions:
- The reviewers completed a search in at least Medline/Pubmed and another relevant database.
- The systematic review lists key search terms.
- The systematic review lists selection criteria.
- The reviewers used an appropriate framework to assess risk of bias/quality appraisal.
- (This criterion applies to intervention questions.) Where a systematic review included non-RCT studies, it also conducted a sub-analysis restricted to RCT evidence.
Appraisal of the methodological quality/risk of bias of included studies
Methodological quality of the included studies was assessed using criteria developed a priori according to study design (i.e. quality appraisal criteria used for an RCT is different to that used for a cohort study) as outlined in GRADE. Using this approach, each study was allocated a risk of bias rating (see, Table 8).
Table 8. Risk of bias ratings
Rating | Description |
Low | All the criteria have been fulfilled or, where criteria have not been fulfilled, it is very unlikely the conclusions of the study would be affected. |
Moderate | Some of the criteria have been fulfilled and those criteria that have not been fulfilled may affect the conclusions of the study. |
High | Few or no criteria fulfilled, or the conclusions of the study are likely or very likely to be affected. |
Insufficient information | Not enough information provided on methodological quality to enable risk of bias to be determined. |
Data extraction
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.
Data synthesis
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
High | ⨁⨁⨁⨁
| We are very confident that the true effect lies close to that of the estimate of the effect. |
Moderate | ⨁⨁⨁◯
| 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. |
Low | ⨁⨁◯◯
| Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. |
Very Low | ⨁◯◯◯
| 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).
Drafting recommendations
Specific, unambiguous, actionable recommendations were drafted by GDG members. For evidence-based recommendations, the GDG members documented their considerations according to the following domains:
- the balance of benefits and harms of the intervention (based on the data reported in the evidence review)
- the certainty of the evidence (based on quality/certainty assessments in the evidence review)
- resource requirements
- equity
- acceptability
- feasibility
- subgroup considerations
- implementation considerations
- monitoring and evaluation
- research priorities using the GRADE evidence-to-recommendation framework.
Clinical consensus recommendations were drafted within the narrative review process as described above. Clinical practice points were formulated to address important issues relating to the evidenced-based and clinical consensus recommendations.
Types and wording of recommendations
Recommendation type is either evidence-based (EBR) or clinical consensus (CCR). In addition, clinical practice points (CPP) were included for implementation issues such as safety, side effects and risks (Table 10).
For evidence-based recommendations (EBRs) and consensus clinical recommendations (CCRs), and for clinical practice points on some occasions, the terms ‘should’, ‘could’ and ‘should not’ were used to reflect the interpretation of the quality/certainty of the body of evidence and judgements of the multidisciplinary GDG.
The word ‘should’ was used in the recommendations where the GDG judged that the benefits of the recommendation exceed the harms.
The word ‘could’ was used when the quality of evidence was limited or the available studies did not clearly demonstrate advantage of one approach over another, or when the balance of benefits to harm was unclear.
The words ‘should not’ were used when there was either a lack of appropriate evidence, or the harms were judged to outweigh the benefits.
Table 10: Recommendation types
| EBR | Evidence-based recommendation: a structured/systematic evidence review was performed to answer a prioritised question to inform the recommendation. |
| CCR | Clinical consensus recommendation: recommendation was developed in either of the following ways:
|
| CPP | Clinical practice point: guidance based on expert opinion and clinical experience, provided on important issues arising from discussion of evidence-based or clinical consensus recommendations, outside the scope of the evidence-finding process. |
GRADE evidence-to-recommendation framework to achieve consensus
The GRADE evidence-to-recommendation framework drafted by GDG members (described above) was used to document the discussion, judgments and decisions of the GDG including the lived experience and clinical expertise to reach consensus about each evidence-based recommendation.
Using the framework, each of the evidence-based recommendations was given an overall grading of conditional or strong for or against the option/intervention within the recommendation (The GRADE Working Group, 2009). The system for classifying the strength of the recommendations, as defined in Table 11, was adapted from the GRADE approach (The GRADE Working Group, 2009).
Consensus was achieved through discussion in GDG meetings and surveys to capture final votes. The GDG acknowledges that lack of evidence is not evidence of the lack of an effect. This consideration is reflected in the strength assigned to recommendations on interventions that are not supported by evidence.
For some interventions, the evidence review found a lack of evidence of effect. The GDG acknowledges that this refers to lack of evidence of effect greater than that of placebo; people with ADHD may receive some benefits from the intervention, but these do not exceed the beneficial effects that can be expected from a placebo therapy (The Royal Australian College of General Practitioners, 2009).
Table 11: Strength of recommendations
Target group | Strong recommendations# | Conditional (weak) recommendations for the option (test or treatment) | Conditional (weak) recommendation for either the option or the comparison | Research only recommendations |
| Rating | **** | *** | ** | NA |
| People with ADHD | Most people in your situation would want the recommended course of action and only a small proportion would not. | The majority of people in your situation would want the recommended course of action, but some would not. | There is considerable lack of clarity over whether the majority of people in your situation would want the recommended course of action or not. | The test or intervention should only be considered by people and clinicians within the setting of a research trial for which appropriate approvals and safety precautions have been established. |
| Health Professionals | Most people should receive the recommended course of action. | Recognise that different choices will be appropriate for different people and that greater effort is needed with individuals to arrive at management decisions consistent with values and preferences. Decision aids and shared decision making are important here. | The test or intervention should only be considered by people and clinicians within the setting of a research trial for which appropriate approvals and safety precautions have been established. | |
| Policymakers | The recommendation can be adopted as policy in most situations. | Policy making needs to consider perspectives and involvement of diverse stakeholders. | Policy decisions remain unclear. | Policy makers need to be aware of the need for evidence gaps and health professional and consumer prioritised research gaps. |
Adapted from GRADE (The GRADE Working Group, 2009)
# Strong recommendations based on high-quality evidence will apply to most people with ADHD for whom these recommendations are made, but they may not apply to all people in all conditions; it is not possible for any recommendation to take into account all of the often-compelling unique features of individual people and clinical circumstances.
Clinical considerations statement
Clinical considerations accompany each set of recommendations. These considerations are documented by the GDG when drafting recommendations and discussing the GRADE evidence-to-recommendation framework. Caveats to implementation and considerations, such as barriers to implementation are noted here. The extensive full evidence tables and individual GRADE evidence-to-recommendation frameworks supporting each recommendation can be found in the Technical Report.
Public consultation
Public and targeted consultation of the drafted guideline was open for a period of 35 days in accordance with the legislative requirements set out in section 14A of the National Health and Medical Research Council Act 1992 as outlined in the NHMRC standards and procedures for externally developed guidelines (National Health and Medical Research Council, 2007, 2016). The guideline was changed in response to the public consultation. The full submissions and a public consultation summary report which details the GDG responses to the feedback is available with the accompanying documentation at https://www.aadpa.com.au/guideline.
External review
The guideline was reviewed independently by relevant professional experts, professional colleges and societies and through public consultation. An independent AGREE II assessment was also conducted. The guideline was modified in response to feedback from these reviews.
Scheduled review and update of the guideline
The GDG will be re-convened to review relevant sections of this guideline if any of the following occur within five years:
- there is a change in the indications registered by regulatory bodies for any medication included in this guideline; or
- publication of any new major randomised controlled trials or systematic reviews that potentially have a bearing on the safety of the recommendations in this guideline.
After 5 years the guideline panels will be reconvened, and the guideline updated as per NHMRC processes.