[redactions made under s47F of the FOI Act]
From:
Sent:
Monday, 28 June 2021 3:52 PM
To:
Clinical Guidelines
Cc:
Mark Bellgrove;
Subject:
Re: ADHD guideline progress report [SEC=OFFICIAL]
Attachments:
Appendix A_GDG members and clinical questions.pdf; Appendix C_Evidence to Recommendation
Framework template.pdf;
[attachment redacted under s47G of the FOI Act]
Dear Sally,
Thank you for your response about the new Council and meeting dates. We will aim to submit in time
for the March 2022 (or thereabouts) meeting.
So sorry for forgetting the Appendices! They are attached here.
Best wishes,
Diagnosis, management and treatment of ADHD - an Australian ADHD Professionals Association
(AADPA) evidence-based guideline, in development.
Monash University Affiliate, Monash Centre for Health Research and Implementation
I acknowledge the Traditional Owners and Custodians of the lands on which I live and work and pay my
respect to Elders both past and present.
On 28/06/2021 3:37 pm, Clinical Guidelines wrote:
> Dear
>
> Thank you for your progress email/report and welcome
. Nice to e-meet you!
>
> I too want to apologise for the delay in responding to you. We've had some staff changes which has
delayed our response to some of our work.
>
> July 2021 marks the new triennium for NHMRC, with the appointment of new members to Council and
Principal Committees for a three year period.
>
> Council meeting dates are not confirmed until the new Council has been appointed. NHMRC is in the
process of doing this now. I anticipate that the first meeting of the new Council will be mid October
2021. The following dates are usually March and June. Once we have more information we can pass that
on.
>
> Upon reading your report I note that it refers to appendices A, B & C. Could you please send this
through for review.
>
> Many thanks & Kind regards,
> Sally
>
>
> Sally Wright
> Senior Project Officer, Clinical Practice Guidelines Research
> Translation National Health and Medical Research Council
> xxxxx.xxxxxx@xxxxx.xxx.xx
> +61 03 8866 0411
1
> Hours: Please note I do not work Wednesdays.
>
> nhmrc.gov.au
>
>
>
> I acknowledge the Traditional Custodians of the lands around Australia and pay my respects to Elders
past and present.
>
>
>
> -----Original Message-----
> From:
> Sent: Tuesday, 15 June 2021 3:41 PM
> To: Clinical Guidelines <xxxxxxxxxxxxxxxxxx@xxxxx.xxx.xx>
> Cc: Mark Bellgrove <xxxx.xxxxxxxxx@xxxxxx.xxx>;
> Subject: ADHD guideline progress report
>
> Dear Sally and Stephanie,
>
> Apologies for the long silence. We have been getting through as much evidence review as possible. I
have cc'd
into this email.
>
is managing our deliverables and liaising with the clinical groups to ensure they are supported
to interpret the evidence and draft recommendations. I am happy to remain the NHMRC contact.
>
> Our next GDG meeting in July is intended to discuss recommendations and GRADE evidence to
recommendation considerations. We hope to begin public consultation in October.
>
> Please find attached the progress report according to the NHMRC template. I note that we will miss
the October NHMRC guideline council meeting. Is there a date for the next council meeting after
October?
>
> Thank you and best wishes,
>
>
>
2
Evidence-based guideline for diagnosis, management and treatment of
attention deficit hyperactivity disorder (ADHD)
Lead Organisation: The Australian ADHD Professionals Association
Clinical Co-Chairs: Professor Katrina Williams and Dr Edward Petch
Guideline Development Group:
Name
Discipline
Representin
Email
Initial
Area,
g an
Relevant
Organisation
Role
Mark Bellgrove Academic
AADPA
mark.bellgrove@monash
M.A.B
Psychology
.edu
Katrina
Pediatrics
K.W
Williams
Edward Petch
Adult
E.P
Forensic
Psychiatrist
Edwina Birch
Clinical
ADHD
E.B
Psychologist
Foundation
Noel
Paediatrician
N.C
Cranswick
Clinical
Pharmacologi
st
Evelyn
Transition
E.C
Culnane
Manager
Jane Delaney
Speech
Speech
J.D
Pathologist,
Pathology
Senior
Australia
Advisor for
Early
Childhood
and
Education
Maddi Derrick
Clinical
M.D
Psychologist,
Consumer,
Parent
Valsamma
Child and
V.E
Eapen
Adolescent
Psychiatrist
Daryl Efron
Paediatrician RACP
D.E
Tatjana Ewais Child, Youth, RANZCP
T.E
CL and adult
Psychiatrist
Ingrid Garner
Parent,
I.G
Nurse,
Lawyer
Michael
Clinical and
M.G
Gathercole
Counselling
Psychologist
and
Aboriginal
man
Martha Mack
Psychologist, ANSA
M.M
supervisor of
Ed Dev,
President
ANSA
John Kramer
GP
RACGP
J.K
Tamara May
Psychologist,
T.M
Senior
Research
Fellow
Peter Melville
Adult
P.M.S
Smith
Psychiatrist
Evan Savage
School
E.S
Principal
Lisa Vale
Occupational OTA
L.C.V
Therapist
Karina Chaves Paediatrician NBPSA
K.C
Chantele
Speech
SPA
C.E
Edlington
Pathologist,
Senior
Advisor
Justice and
Mental Health
Alyssa
Parent, Board NAF
A.W
Weirman
Member NAF
Project Management: Tamara May, Psychologist, Senior Research Fellow
Methodologist: Dr Marie Misso
The Remit:
Attention deficit hyperactivity disorder (ADHD) is a prevalent childhood-onset
disorder with negative lifetime outcomes. Deloitte access economics has
estimated that annual cost of ADHD to Australia is $20 billion. The Australian
ADHD Professionals Association (AADPA) has commissioned the development
of national clinical guidelines for ADHD with a view to these ultimately being
endorsed the National Health and Medical Research Council of Australia
(NHMRC). AADPA has registered their intent to formulate this guideline with
NHMRC.
https://www.clinicalguidelines.gov.au/register/evidence-based-guideline-
diagnosis-management-and-treatment-attention-deficit-hyperactivity
Why develop an Australian evidence based guideline for ADHD when
international guidelines exist? There are multiple reasons that AADPA wishes
to develop an evidence-based guideline for ADHD. First, there is overwhelming
support from a broad range of discipline areas that Australia needs an evidence-
based guideline for ADHD that will: (1) provide clear advice regarding evidence-
based diagnostic, management and treatment practices; (2) harmonise clinical
practices across Australia; (3) not just focus on symptom-based measures or
classifications but also include consideration of everyday functioning and quality
of life (QoL); (4) identify areas of unmet need and opportunities for research,
advocacy and policy development; (5) take into account the voices and opinions
of those with lived experience; (6) take into consideration age, gender, culture,
setting and geography. It is firmly the intention that the developed document will
be a “living guideline” that will provide a roadmap for ADHD clinical practice,
research and policy into the future for the betterment of those individuals living
with ADHD in Australia.
The Framework
It became clear after the first meeting of the Guideline Development Group
(GDG) that it would be useful to adopt a conceptual framework to anchor
discussions and deliberations. The WHO’s International Classification of
Functioning, Disability and Health (ICF) was determined to be a useful
framework to adopt for the Australian ADHD Guideline. The ICF complements
traditional diagnostic systems such as the DSM-5 and ICD-10 but offers a
comprehensive, integrative framework of functioning and disability. Adopting
the ICF framework was deemed to have utility since the Australian ADHD
Guideline will explicitly seek to identify ways in which ADHD impacts everyday
functioning and disability and the ways in which professionals, society and the
government might improve their response/s to these functional challenges
experienced by individuals with ADHD. This framework may also serve a
pragmatic purpose in aligning the Australian ADHD Guideline and its
recommendations more closely with the priorities of major funding agencies
such as the National Disability and Insurance Scheme (NDIS).
The Scope of the Australian ADHD Guideline
Dr Marie Misso, Dr Edward Petch and Professor Katrina Williams conducted
several rounds of stakeholder engagement with the aim of developing a set of
indicative questions to be addressed within the Australian ADHD Guideline.
These questions underwent successive rounds of input and peer review and
were ultimately further revised at the first meeting of the GDG. The purpose of
this document is prioritise and synthesise the questions that will be addressed.
Purpose of this document
This document has been formulated with the intention of providing a structure
for the clinical questions that will be reviewed (either narrative or evidence-
based). Links to questions that were formulated and prioritised during the
stakeholder engagement are provided. A column is also available to indicate
which GDG leads will lead specific questions.
Wherever possible the following will be considered:
Age groups to be considered separately for each question: preschool, school
age, adult, older adult
Settings: primary or specialist health; school or educational institution;
workplace; aged-care; prison; welfare/foster care; rehabilitation; home
Subgroups to be considered for every question: Indigenous groups; CALD
groups; those with learning disabilities; substance use; co-occurring conditions
Narrative Review Sections
ADHD- What is it?
Question
Link to
Link to
Narrative/
GDG Leads
Stakeholder NICE
Evidence
Q’s
Review
What is ADHD?
1.1; 1.2
New
Narrative
MAB; DE; TM
Definition of clinical diagnosis
(NICE 08
in Australia
1.5)
What is the prevalence of
1.3
Update
Narrative
MAB; DE; TM
ADHD in Australia and
(NICE18
internationally?
A)?
Aetiology
1.4; 1.5
Update
Narrative
MAB, VE
Biological, environmental,
(NICE18
personal risk factors
A)?
What are the outcomes (i.e.
1.4
Narrative
DE; MAB
prognosis) for individuals
diagnosed with ADHD?
Consider: Symptoms
(hyperactivity and
inattention), Impairments,
Functional Issues,
Participation, Quality of Life
(QoL)
Does ADHD have a
1.5
Narrative
DE; MAB; TM
characteristic course and does
its presentation change
across the lifespan?
What other conditions
9.1
New
Narrative
DE; MAB;
commonly co-occur with
ADHD
Evidence-based Review Sections
Screening for ADHD
Question
Link to
Link to
Narrative/
GDG
Stakeholder NICE
Evidence
Membership
Q’s
Review
Should screening for ADHD
2.4
New
Evidence
T.M; JD; KC; EB;
occur at a population level?
JK; CE; M.G
Which groups are at high risk
2.2
Update
Evidence
T.M; JD; KC; EB;
of developing ADHD?
(NICE18
JK; CE; M.G
A)
Consider: add common
comorbid conditions
9.1
Should screening for ADHD
2.3
New
Evidence
T.M; JD; KC; EB;
occur in high-risk
JK; CE; M.G
populations?
How to diagnose ADHD
Question
Link to
Link to
Narrative/
GDG Leads
Stakeholder NICE
Evidence
Q’s
Review
How should ADHD be
3.1
New
Evidence
T.M; JD; KC; EB;
assessed, diagnosed and
(NICE08
JK; CE; L.V
monitored, and by whom?
1.6.1-.5)
Diagnostic test accuracy; use
of biomarkers; available
diagnostic tests/tools
Which disorder/s need to be
3.2
New
Evidence
T.M; JD; KC; EB;
excluded to make a diagnosis
JK; CE; L.V
of ADHD?
Which disorder/s should be
3.3
New
Evidence
T.M; JD; KC; EB;
considered for co-diagnosis
JK; CE; L.V
with ADHD?
Effective Interventions
The following matrix will be used to consider the effectiveness of all interventions:
Intervention
Outcomes
Type
Reductions in core
Reductions
Improved
Improved
Improved
Adverse
symptoms
in
adaptive
participation
QoL
Events
(hyperactivity/impulsivity impairment
functioning
(school,
(individual,
and /or inattention
community,
family,
tertiary,
carers)
employment
Question
Link to
Link to
Narrative/
GDG Leads
Stakeholder NICE
Evidence
Q’s
Review
Non-pharmacological
interventions: What is the clinical
5.1
Update
Evidence
DE; MAB; MD;
effectiveness of non-
(NICE18
M.M; M.G; L.V;
pharmacological interventions
E)
J.D; E.S; P.M.S;
for people with ADHD?
E.B; A.W
What are the adverse events
Update
Evidence
DE; MAB; MD;
associated with non-
(NICE18
M.M; M.G; L.V;
pharmacological treatments
E)
J.D; E.S; P.M.S
for people with ADHD?
;E.B; A.W
Should treatments be
5.2
New
Evidence
DE; MAB; MD;
provided individually or in
M.M; M.G; L.V;
groups? Who should deliver
J.D; E.S; P.M.S
them?
;E.B; A.W
Is there a role for ADHD
New
Evidence
DE; MAB; MD;
coaches
M.M; M.G; L.V;
J.D; E.S; P.M.S
;E.B; A.W
Is there a role for peer support
11.2
New
Evidence
DE; MAB; MD;
workers? Lived experience
M.M; M.G; L.V;
J.D; E.S; P.M.S
;E.B; A.W
Is there a role for consumer
11.3
New
Evidence
DE; MAB; MD;
groups? E.g., online forums
M.M; M.G; L.V;
J.D; E.S; P.M.S
;E.B; A.W
What
5.4
Update
Evidence
DE; MAB; MD;
educational/school/teacher
(NICE08
M.M; M.G; L.V;
interventions are possible, and
6.1)
J.D; E.S; P.M.S
are they effective?
;E.B; A.W
Question
Link to
Link to
Narrative/
GDG Leads
Stakeholder NICE
Evidence
Q’s
Review
Pharmacological interventions:
What is the clinical
6.1
Update
Evidence
TE; VE; NC;A.W;
effectiveness of
(NICE18
I.G; J.K; K.C
pharmacological treatments for
C1)
people with ADHD?
What are the adverse events
6.2
Update
Evidence
TE; VE; NC;A.W;
associated with
(NICE18
I.G; J.K; K.C
pharmacological treatments for
D)
people with ADHD?
Combined pharmacological and
non-pharmacological
interventions: What is the clinical
7.1
Update
Evidence
TE; VE; NC;A.W;
effectiveness of combined non-
(NICE18
I.G; J.K; K.C; M.D;
pharmacological and
F)
M.M; M.G
pharmacological interventions
for people with ADHD?
What are the adverse events
7.2
Update
Evidence
TE; VE; NC;A.W;
associated with combined non-
(NICE18
I.G; J.K; K.C; M.D;
pharmacological and
F, no
M.M; M.G
pharmacological treatment for
evidence)
people with ADHD?
Care Pathway Questions: Treatment Specific (pharma and non-pharma)
Question
Link to
Link to
Narrative/
GDG Leads
Stakeholder NICE
Evidence
Q’s
Review
What is/are the most clinically
8.1
Update
Evidence
TE; VE; NC;A.W;
effective initial sequence(s) of
(NICE C2)
I.G; J.K; K.C; M.D;
pharmacological/non-
M.M; M.G; E.B;
pharmacological treatment for
D.E; P.M.S; L.V
people with ADHD?
Check is covered in search for
8.9
New
8.1; if not add.
• What are the
indicators of remission
and when should
treatments be
stopped?
Which factors need to be
8.2
New
Narrative
TE; VE; NC;A.W;
considered when making
I.G; J.K; K.C; M.D;
initial treatment decisions for
M.M; M.G; E.B;
ADHD?
D.E; P.M.S; L.V
a. When is it appropriate to
start with pharmacological
treatment? b. Are there
situations when a stimulant
medication should not be first
choice?
Incorporating in search for 8.1,
8.2 above:
New
• How should initial
8.5
medications be
New
titrated?
8.6
• How does ADHD
symptom severity and
New
profile impact on
8.7
treatment decisions?
• How should adequacy
New
of treatment response
8.8
be assessed?
• What is the most
clinically effective
subsequent sequence
of
pharmacological/non-
pharmacological
treatment for people
with ADHD when the
initial treatment is
ineffective,
inadequate or
treatment is not
tolerated?
How do comorbid conditions
9.2
New
Evidence
TE; VE; NC;A.W;
impact treatment effects
I.G; J.K; K.C; M.D;
M.M; M.G; E.B;
Consider for common
D.E; P.M.S; L.V
comorbid conditions
Does treatment approach for
9.3
New
Evidence
TE; VE; NC;A.W;
ADHD vary when comorbidity
I.G; J.K; K.C; M.D;
is present?
M.M; M.G; E.B;
D.E; P.M.S; L.V
Consider for common
comorbid conditions
What are the most effective
10.8
Update
Evidence
TE; VE; NC;A.W;
approaches to increasing
(NICE18
I.G; J.K; K.C; M.D;
treatment adherence in ADHD
G)
M.M; M.G; E.B;
for both pharmacological and
D.E; P.M.S; L.V
non-pharmacological
approaches?
How should treatment
6.3, 10.2
New
Evidence
TE; VE; NC;A.W;
effectiveness be monitored
I.G; J.K; K.C; M.D;
and managed?
M.M; M.G; E.B;
D.E; P.M.S; L.V
Care Pathway questions: pharmacological specific
Question
Link to
Link to
Narrative/
GDG Leads
Stakeholder NICE
Evidence
Q’s
Review
Who should initiate
6.4
New
Evidence
TE; VE; NC;A.W;
pharmacological therapy, and
I.G; J.K; K.C;
continue it long term?
What principles should
10.1
Update
Evidence
TE; VE; NC;A.W;
clinicians follow when
(NICE18
I.G; J.K; K.C;
discussing decisions to start,
H)
adjust, or discontinue
pharmacological treatment for
people with ADHD?
Are there specific clinical
10.5
Update
Evidence
TE; VE; NC;A.W;
effects of discontinuing from
(NICE18
I.G; J.K; K.C;
pharmacological treatment
I1)
and if so how should these be
managed?
Should ‘drug holidays’ from
10.7
Update
Evidence
TE; VE; NC;A.W;
pharmacological treatment for
(NICE18
I.G; J.K; K.C;
ADHD be recommended and if
I2)
so when?
Care Pathway Principles
Question
Link to
Link to
Narrative/
GDG Leads
Stakeholder NICE
Evidence
Q’s
Review
What referral pathways
12.5
New
Narrative
TE;
NC; A.W; I.G;
should be established?
J.K; K.C; M.D;
M.M; M.G;
E.B; L.V;
E.C; C.E; E.S
Which agencies should be
12.1
New
Narrative
TE;
NC; A.W; I.G;
involved in the management
J.K; K.C; M.D;
of ADHD?
M.M; M.G;
E.B; L.V;
E.C; C.E;E.S
How should services be
12.2
New
Narrative
TE;
NC; A.W; I.G;
configured?
J.K; K.C; M.D;
M.M; M.G;
E.B; L.V;
E.C; C.E; E.S
What are the information,
4.1
Update
Evidence
TE;
NC; A.W; I.G;
support and educational
(NICE B)
J.K; K.C; M.D;
needs of those diagnosed with
M.M; M.G;
E.B;
ADHD, family, carers and
L.V;
E.C; C.E; E.S
agencies dealing with people
with ADHD?
How often should patients be
10.3
New
Evidence
TE;
NC; A.W; I.G;
seen?
J.K; K.C; M.D;
M.M; M.G;
E.B; L.V;
E.C; C.E; E.S
Are health professionals,
11.1
New
Narrative
TE;
NC; A.W; I.G;
including psychiatrists,
J.K; K.C; M.D;
paediatricians, psychologists
M.M; M.G;
E.B;
GPs, nurses, allied health
L.V;
E.C; C.E; E.S
professionals and educators
adequately trained to manage
ADHD?
For which patients should a
10.9
New
Narrative
TE;
NC; A.W; I.G;
transition to further treatment
J.K; K.C; M.D;
take place (preschool to
M.M; M.G;
E.B;
school, primary to secondary
L.V;
E.C; C.E; E.S
school, school to adulthood,
older adults)?
Considering:
a. When should planning be
initiated?
b. Who should initiate the
discussion and how?
c. Who should initiate
treatment? d. How should the
transition take place?
e. Who should monitor
progress?
What are shared care models
11.5
New
Evidence
TE;
NC; A.W; I.G;
and are they effective?
J.K; K.C; M.D;
M.M; M.G;
E.B; L.V;
E.C; C.E; E.S
What services should prison
11.6
New
Evidence
TE;
NC; A.W; I.G;
mental health services
J.K; K.C; M.D;
provide? Across life-stages?
M.M; M.G;
E.B; L.V;
E.C; C.E; E.S
Considerations for implementing clinical recommendations (narrative)
This section will consider the broad implications of the above evidence review and
the clinical recommendations of the GRADE process. In particular we will consider
implications for: clinician training; educator training (schools, university, TAFE);
carer/support worker training; employer training; impact on service delivery
(organisations working together); impacts for funding (clinical, education, research),
policy development; identified gaps for research.
Will inevitably incorporate the questions below:
12.3 How should services for those with ADHD in
Im 6.56 New
Narrative
Australia be funded?
12.4 What should services provide and to whom?
Im 6.67 New
Narrative
12.6 How should a health professional maintain
Im 5.89 New
Narrative
professional integrity and practice?
Are the desirable effects large relative to the undesirable effects?
attach to the desirable and undesirable outcomes) the more likely it is that
an option should be recommended.
Resource
How large an investment of resources would the option
The greater the cost, the less likely it is that an option should be a priority.
requirements
(recommendation) require or save?
Conversely, the greater the savings, the more likely it is that an option
should be a priority.
The following statement along with clinical consensus opinion is suggested:
An economic evaluation was outside the scope of the current review.
Cost relative to
Is the cost small relative to the net benefits (benefits minus harms)?
The greater the cost per unit of benefit, the less likely it is that an option
net benefit
should be a priority.
Impact on health
Would the option reduce or increase health equity?
Policies or programmes that increase equity are more likely to be a priority
equity
than ones that do not (or ones that increase inequities).
Acceptability to
Are key stakeholders likely to find the option acceptable (given the
The less acceptable an option is to key stakeholders, the less likely it is that
key stakeholders
relative importance they attach to the desirable and undesirable
it should be recommended, or if it is recommended, the more likely it is
consequences of the option; the timing of the benefits, harms and
that the recommendation should include an implementation strategy to
costs; and their moral values)?
address concerns about acceptability.
Acceptability might reflect who benefits (or is harmed) and who pays (or
saves); and when the benefits, adverse effects, and costs occur (and the
discount rates of key stakeholders; e.g. politicians may have a high
discount rate for anything that occurs beyond the next election).
Unacceptability may be due to some stakeholders:
• Not accepting the distribution of the benefits, harms and costs
• Not accepting costs or undesirable effects in the short term for
desirable effects (benefits) in the future
• Attaching more value (relative importance) to the undesirable
consequences than to the desirable consequences or costs of an
option (because of how they might be affected personally or because
of their perceptions of the relative importance of consequences for
others)
• Morally disapproving (i.e. in relationship to ethical principles such as
autonomy, nonmaleficence, beneficence or justice)
Feasibility to
Can the option be accomplished or brought about?
The less feasible (capable of being accomplished or brought about) an
implement
option is, the less likely it is that it should be recommended (i.e. the more
barriers there are that would be difficult to overcome).
Justification
What is the justification for the recommendation, based on the
A concise summary of the reasoning underlying the recommendation
criteria in the framework that drove the recommendation?
Subgroup
What, if any, subgroups were considered and what, if any, specific
A concise summary of the subgroups that were considered and any
considerations
factors (based on the criteria in the framework) should be considered
modifications of the recommendation in relation to any of those
in relation to those subgroups when implementing the option?
subgroups. This may include low SES, Aboriginal and Torres Strait Islander
people, substance misuse, and incarcerated groups.
Implementation
What should be considered when implementing the option, including
Key considerations, including strategies to address concerns about
considerations
strategies to address concerns about acceptability and feasibility?
acceptability and feasibility, when implementing the option.
Monitoring and
What indicators should be monitored? Is there a need to evaluate the
Any important indicators that should be monitored if the option is
evaluation
impacts of the option, either in a pilot study or an impact evaluation
implemented. This is in relation to the recommended intervention. For
considerations
carried out alongside or before full implementation of the option?
example, if an antidepressant is recommended, suicidal behaviour requires
monitoring.
Research
Are there any important uncertainties in relation to any of the criteria
Any research priorities
priorities
that are a priority for further research?
