Background: Despite evidence-based national guidelines for ADHD in the United Kingdom (UK), ADHD is under-identified, under-diagnosed, and under-treated. Many seeking help for ADHD face prejudice, long waiting lists, and patchy or unavailable services, and are turning to service-user support groups and/or private healthcare for help.Methods: A group of UK experts representing clinical and healthcare providers from public and private healthcare, academia, ADHD patient groups, educational, and occupational specialists, met to discuss shortfalls in ADHD service provision in the UK. Discussions explored causes of under-diagnosis, examined biases operating across referral, diagnosis and treatment, together with recommendations for resolving these matters.Results: Cultural and structural barriers operate at all levels of the healthcare system, resulting in a de-prioritization of ADHD. Services for ADHD are insufficient in many regions, and problems with service provision have intensified as a result of the response to the COVID-19 pandemic. Research has established a range of adverse outcomes of untreated ADHD, and associated long-term personal, social, health and economic costs are high. The consensus group called for training of professionals who come into contact with people with ADHD, increased funding, commissioning and monitoring to improve service provision, and streamlined communication between health services to support better outcomes for people with ADHD.Conclusions: Evidence-based national clinical guidelines for ADHD are not being met. People with ADHD should have access to healthcare free from discrimination, and in line with their legal rights. UK Governments and clinical and regulatory bodies must act urgently on this important public health issue. Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by persistent and impairing inattention and/or hyperactivity-impulsivity , 2. ADHDADHD is common. Worldwide prevalence, estimated by standardized procedures in representative samples of the community, falls between 5 and 7% in children and adolescents , and 2–4ADHD is associated with a range of adverse outcomes. People with ADHD are more prone to accidents and injuries, and have a higher mortality rate compared to the rest of the population , 12. TheTimely detection and treatment is likely to moderate risks and improve outcomes , 19. ADHThere has been a stepped change in clinical policy for treating ADHD in the United Kingdom (UK) over the past three decades. This has co-occurred with the mainstreaming of childhood ADHD into generic mental health services, and the publication of the first national clinical guidance on adult ADHD by the National Institute for Clinical Excellence in 2008. As a result of these changes and increased recognition of ADHD in the population, there has been a significant increase in rates of first diagnosis and prescribing of childhood ADHD , 29, andHowever, ADHD and its treatment remains controversial in public, policy, and clinical spheres both in the UK –33 and iHowever, contrary to concerns of over-medication, ADHD is more likely to be under-identified, under-diagnosed and under-treated in the UK , 40. ManThese problems have been exacerbated since the advent of the COVID-19 pandemic. Efforts to delay the spread of the virus have had an impact on demand and capacity to deliver support for people with mental health needs. The pandemic is associated with a range of social, financial, educational, health, and personal concerns, which are all stressors associated with mental health issues . IndividWhilst acknowledging current challenges for mental health provision and the increase in service provision for ADHD over the past three decades, the existence of a significant unmet clinical need for individuals with ADHD in the UK demands scrutiny. With evidence of personal, clinical, social, and economic benefits of investing in adequate treatment for ADHD, access to clinical support must be improved not only in the context of the pandemic, but also beyond. It is on the basis of these key issues that professionals specializing in ADHD convened for a consensus meeting to discuss the gap in ADHD provision in the UK.https://www.adhdfoundation.org.uk); (2) The UK ADHD Partnership  and; (3) the UK Adult ADHD Network . Meeting attendees were academics, mental health professionals, educational and occupational specialists, service-user support services and charity workers specializing in ADHD. Healthcare practitioners represented both those working within private practice, and the National Health Service (NHS), the UK-wide universal healthcare system providing free or low-cost healthcare to UK residents.The consensus group convened in London on the 11th February 2019. The meeting was hosted by three leading UK ADHD organizations; (1) the ADHD Foundation (The meeting commenced with presentations on (1) ADHD provision in the UK from the viewpoint of the ADHD Foundation, and (2) an overview of research on treatment and short- and long-term outcomes of ADHD. This was followed by a question and answer session, after which attendees separated into three breakout groups, in which discussions were facilitated by group leaders. Following the group work, all attendees re-assembled. Group leaders then presented findings to all meeting attendees for another round of discussion and debate, until consensus was reached.The National Institute for Health and Care Excellence (NICE) guidelines provide clinical guidance for the diagnosis and treatment of ADHD within the NHS across England and Wales , 51, andGroup discussions included the following three main topics, each of which was explored for differences between children and young people (age <18) and adults (age >18):How do we know children, young people and adults with ADHD are not being diagnosed and why is this happening?Are the NHS services provided adequate?What is happening to those with ADHD who cannot access NHS healthcare for their ADHD?Presentations and debate amongst attendees were audio-recorded and transcribed. During group breakout meetings, a note-taker was allocated to each breakout group, and after the consensus meeting notes were circulated to participants in each breakout group for review. All materials  were synthesized jointly by the lead author and writer.Where relevant and available, consensus discussion points are provided alongside references to the supporting research literature, gray literature, policy or legislative documentation. Where reports are anecdotal only and relate to the clinical or professional experiences of consensus attendees, these are described as such in the following report. A final draft was circulated to all authors for approval before submission. The consensus outcomes therefore represent the views and recommendations of the authors in the consensus group as a whole, reflecting the views of a range of professionals involved in ADHD care and some key organizations working in this area.Shortfalls in detection and service provision can be inferred from discrepancies between community prevalence rates  and administrative prevalence  . PopulatWhen considering community prevalence studies  world estimates of the prevalence of childhood ADHD have not changed in the past three decades . By contADHD administrative prevalence (based on rates of diagnosis and/or prescriptions) in children and adolescents in the UK has been estimated to fall between 0.2 and 0.9% since the mid-2000s . These rPeople with ADHD can face a long and difficult journey to reach diagnosis and long-term management, described in some cases as “an uphill struggle” . A numbeADHD can only be diagnosed and treated as quickly as the condition is identified in the community. However, there are several reasons that it may go undetected. Expectations that ADHD expresses only as hyperactive, restless, and disruptive behavior may limit detection of the many more subtle presentations. Although more subtle inattentive problems can present across both sexes, they may disproportionately affect detection of ADHD in girls and women . FurtherADHD symptoms in those with higher intellectual functioning and/or individuals applying a range of compensatory strategies to reduce or mask their difficulties may also go undetected. Even if detected, these individuals may not appear to meet impairment thresholds for referral to secondary health services and assessment.Comorbidity is common and complicates identification and treatment in ADHD. Common comorbidities in children include autism spectrum disorders (ASD), mood, anxiety, oppositional, and conduct disorders, as well as specific learning and language disorders, epilepsy and Tourette's syndrome , 61. In As children age and become more independent, their environmental support declines, whilst social, academic and environmental demands increase . There iPeople with ADHD may come in contact with a range of mental health, social care or criminal justice professionals in their lifetime. However, ADHD often remains unrecognized and provisions are put in place for other conditions. This is evidenced by the high rates of unrecognized ADHD in patient populations treated for other psychiatric conditions [15.8–17.4% ], and inADHD symptoms tend to decline with increasing age , with grIn the UK healthcare system, a patient with ADHD passes through multiple stages in the process of seeking help. The knowledge and attitudes of the network of gatekeepers can facilitate or hinder their access to support. One problem noted repeatedly during the consensus meeting is that there is no consistent referral route across all regions of the UK.Parents/carers are often the first to seek out referral and diagnosis for their children and their perception of the presenting problem is a key contributor to primary care referrals to community pediatric and/or Child and Adolescent Mental Health Services (CAMHS) , 74. SimTeachers are often the first (and may be the only) professionals approached by parents or carers . TeacherPrimary care services are another main point of contact for parents/carers and are usually the first port of call for adults for onward referral for ADHD assessments. Unfortunately, some primary and even some secondary care physicians express uncertainty about the legitimacy of an ADHD diagnosis , 79. TheProgressive revisions to diagnostic criteria and clinical practice over the last 30 years have broadened the ADHD phenotype. Some healthcare practitioners may not be aware of these changes or may have limited “buy-in” , and stiThe consensus group noted that there are local and regional idiosyncrasies in referral pathways and treatment arrangements for both child and adult ADHD services, which can make it challenging to navigate access to care.Insight into health service provision in the UK can be obtained from public authorities through legislative rights under the Freedom of Information (FOI) act of 2000 , which aAt primary school age, ADHD is diagnosed and treated by Developmental Pediatricians in some regions or CAMHS in others; at secondary school-age it is usually managed through generic mental health services for children and young people [Community Child Health (CCH) or CAMHS]; in older teenagers and in adulthood the service is provided by specialist ADHD services or Adult Mental Health Services (AMHS) with expertise in ADHD.After diagnosis and medication titration (where indicated) in secondary care, clinical care is often, but not always, transferred back to primary health through shared care protocols. Where this is the case, GPs assume responsibility for prescribing and providing routine physical check-ups. NICE then recommends that annual reviews of ADHD medication be conducted by healthcare professionals with training and expertise in managing ADHD .A report from the Education Policy Institute using data from FOI requests from CAMHS Services revealed a “postcode lottery” for access to general mental healthcare. Median waiting times ranged from 1 day to 6 months and there was wide variation in the rates of referral rejection, with specialist mental health services rejecting referrals from as many as one in four children (24.2%) in 2017/18 . The mosThe consensus group discussed the erratic way in which exclusionary criteria from service provision is applied. From the experience of the consensus group, some services only accept children and young people with ADHD when a patient presents with comorbidity. Others only accept those presenting with acute comorbidity (such as self-harming behaviors or eating disorders). Charity representatives spoke of instances when access to services had been declined to children as young as 14 years due to waiting lists that were so long the child would exceed the age cut-off for the service before they were seen. Anecdotal accounts were provided of young people with ADHD and severe comorbidities  being refused treatment for these comorbidities, on the basis that they were attributed to impulsivity  and their existing diagnosis of ADHD. The effect of these policies is that vulnerable young people and families seeking support are turned away, refused access to healthcare, and do not receive any support at all.Evidence suggests a similar “postcode lottery” for access to adult ADHD services, albeit with even longer waiting lists. A national survey found patchy provision of services for adults with ADHD , and in Clinical Commissioning Groups (CCGs) are regional bodies of the NHS, which allocate, plan and provide services for populations within specific service regions. A review of ADHD provision in CCGs in England was undertaken in 2018 with Freedom of Information (FOI) requests by Takeda pharmaceuticals and the report was supported and endorsed by the ADHD Foundation charity . This reInternal reports from NHS governing bodies in certain parts of the country show the tensions that arise between the desire to reduce long patient waiting times, the likely additional costs from increased service investment and resultant increased prescription rates , 91. TheNICE guidelines emphasize the importance of recognition of ADHD, diagnosis and treatment, continuity of care, and ensuring that people with ADHD have a comprehensive, holistic shared treatment plan that addresses psychological, behavioral, and occupational or educational needs . HoweverTransition in healthcare refers to the process of transferring the clinical care of a patient from child to adult services, which occurs by the age of 18 years in most cases. There are multiple possible transition pathways in the NHS which vary regionally, and include referral to Adult Mental Health Services (AMHS), to specialist ADHD services or to GPs in primary care.NICE guidelines recommend that young people with ADHD receiving treatment from CAMHS or pediatric services should be assessed at transition age, and then if needed transferred to adult services, where they should be re-assessed . TransfeTransition takes place at a critical juncture in young people's lives and there are understandable concerns about the effects of sudden treatment cessation on their educational and/or occupational outcomes . One stuThe consensus group noted that treatment cessation may arise from adolescents electively disengaging with clinical services. Others may be discharged or lost to follow-up during the transition stage for a range of reasons: a lack of adult services to which they can be referred, not meeting criteria for inclusion in adult service criteria (severity or impairment); a lack of knowledge or resources for treating ADHD within available services; and failure to attend the first post transition appointment , 97–99. When transition to adult ADHD services is unsuccessful, child mental health services may be left with the responsibility of continuing care, further decreasing their capacity to respond to new referrals . In someIn cases where treatment is stopped during adolescent years, the consensus group noted that it can be difficult for young people to restart treatment again.NICE guidelines state that ADHD diagnosis and medication initiation and titration should be conducted by a specialist in ADHD . Once paHowever, often shared care arrangements fall apart, seriously disadvantaging patients caught in the middle. This can be due to lack of agreement or inadequate communication, or where primary care practitioners are concerned about assuming responsibility for an unfamiliar treatment . InsuffiPrimary care practitioners may feel that ADHD symptom monitoring is not in their remit, and some believe that prescribing for ADHD should not be carried out by primary care , 102. ReProblems with shared care may lead to patients navigating a complex system of referral for assessment, obtaining a diagnosis and initiating treatments under a specialist (sometimes after many years of seeking treatment), and then having treatment denied due to the failure of shared care.As well as posing a risk to the safety, health and well-being of patients, breakdown of treatment provision due to failure of shared care represents a waste of health resources that are already in short supply.Pharmacotherapy for ADHD as a standalone treatment is unlikely to address the needs and impairments associated with ADHD fully . It doesFor children and young people, treatment options are often rigid in nature, and not tailored to patients' needs. Parent/carer training interventions are the main (and sometimes only) option. However, since many of these interventions have been developed for children with externalizing and conduct problems , they arPsychological interventions are rarely available for adults with ADHD, and medication is often the only treatment offered. A recent mapping study found that only 12 out of 44 dedicated adult ADHD services (27%) provided the full range of treatments recommended by NICE including psychological therapy . The conWhen faced with long waiting times, patchy and unavailable services, blame or dismissal, affected individuals and their families may turn to other services and sectors to gain the support they need see .Charitable and other support organizations provide a range of invaluable non-clinical services for people with ADHD at low cost or free of charge. These services include: information dissemination, signposting, peer and social support, friendship and preventing loneliness, advice clinics, coaching and psychoeducation, group and family therapy, and parenting programmes. Their websites provide access to freely available curated resources and/or help to direct people to relevant tools and support information. Services are not regulated however, and availability, resources and expertise vary considerably between areas and organizations, giving uneven coverage across the UK.Support group representatives at the consensus meeting reported that patients are seeking out (and in some cases being actively directed to) local or national support groups for help. Informal referrals from the NHS led them to feel like a “secondary NHS” service, inundated with support requests that they felt ill-equipped and unqualified to fulfill. Their staff do not always have the training or expertise to support the vulnerable, distressed and at times suicidal individuals with ADHD, for whom help from clinical health services is delayed or refused.Some affected individuals and families are driven to seek out costly private clinical services . For manSome patients and families seek only ADHD assessment in private clinics in order to circumvent gaps or blockages in access to care, in the hope of reintegrating into public healthcare provision by returning to the NHS e.g., . HoweverConcerns around the quality of assessments and clinical reports for ADHD were an area of serious debate during the consensus meeting. Consensus participants  reported problems with private healthcare providers capitalizing on the desperation of patients who feel let down by the public healthcare system. The upshot is that some patients seeking out private services for ADHD do not receive appropriate assessments or treatment that follow clinical guidelines. In some cases, private ADHD assessment reports do not contain enough information to show that diagnostic thresholds had been met or do not clarify if the required in-depth examination was carried out, and therefore patients' diagnoses cannot be accepted at other clinics until they are given a more comprehensive assessment. Consensus participants reported cases of ADHD diagnostic reports written by assessors without appropriate clinical qualifications  and/or who are not registered with a UK health regulator .The consensus group identified essential changes that can and should be made to improve outcomes for people affected by ADHD. Solutions include training and education across all sectors; revising models of care to improve access to treatment; a focus on joining up services; methods to improve consistency in diagnosis and treatment across service sectors; broadening access to non-pharmacological treatments; and funding and commissioning for ADHD.Access to evidence-based training will address the issue of awareness and attitudes of key professional groups in the public sector and improve recognition and support for individuals with ADHD. Ideally, this should reach all healthcare professionals (including primary care providers), educational professionals, youth center employees, social workers, the police, and those working with prisoners or youth offenders.Training should incorporate heterogeneity of ADHD (described in section Detection of ADHD and associated problems), to improve detection of more subtle presentations. Key professionals need to be informed of the biological and medical evidence to help shift blame away from parenting and the home environment. An emphasis on longer-term outcomes of effective treatment may help to reduce the perception that those seeking ADHD treatment are looking for a “quick fix.”ADHD awareness for educational professionals should be developed for schools and higher education institutions to improve referrals from the education sector. Where possible, educational psychologists or mental health professionals working in schools should be engaged to assist with development and implementation of training.The consensus group agreed that competency in ADHD should ideally occur alongside competency for other common mental health conditions: for clinicians already diagnosing and treating anxiety and depression, concurrent assessment and treatment for ADHD (where appropriate) would improve the targeting of treatments, lead to better outcomes, and reduce patient and clinical burden. There should be adequate knowledge and specialism of ADHD within all secondary mental health practices, as there is for other common mental health conditions.In accordance with NICE guidelines , a broadPrimary care physicians, including general practitioners (GPs), already have an important role in raising suspicion for a possible diagnosis, making a timely referral and supporting monitoring and continuation of treatment under shared care protocols. Providing, and encouraging primary care practitioners to participate in, training about ADHD was considered to be an important first step, and encouraging some GPs and practice nurses in taking on additional training to qualify as GPs with extended roles (GPwERs) or specialist nurses with extended roles, respectively, was considered practical and sustainable for improving expertise in in primary care in the first instance. Overall, the group was in agreement that a level of competence in the recognition and understanding of ADHD was key, as well as clear pathways to more specialist support.In the longer term, integration of ADHD into broader mental healthcare provision in primary care would be required to further streamline provision and remove bottlenecks. However, this arrangement has implications for GP workloads, and would require additional workforce management, staff and resource provision. The new Primary Care Network model, described in the NHS Long Term Plan in 2019 , aims toWe have shown a disjoint between primary and secondary care, and child and adult services, which leaves patients with ADHD unable to access or maintain treatment. Improved communication is key to joining up services. When primary care services are asked to take over prescribing from secondary health providers there needs to be support and guidance available for treating clinicians, with specialist advice readily available. Examples of integrated care between GPs and specialist services for chronic illnesses such as heart failure have been reported previously, resulting in improved coordination, GPs feeling more confident in supporting their patients, specialists receiving more detailed feedback from primary care, and patients themselves benefiting from more streamlined and holistic care .Longer-term, staff with specialist or extended roles within primary care networks, as described above, could help to close the gap in accessing diagnostic and intervention services, and liaise with and between secondary care services and psychological services as needed to provide the correct intensity of support and the required continuity of care.Consensus meeting discussions highlighted the importance of regulating private ADHD practices to improve consistency of ADHD diagnosis, assessment reporting and treatment, and to ensure adequate qualification of providers.The consensus group also noted varying quality in ADHD assessments within the NHS, albeit to a lesser extent. These problems led to discussions within the consensus group on the minimum standards for an ADHD diagnostic assessment. These were agreed on and are summarized in The consensus group agreed that access to non-pharmacological treatment should be improved for patients with ADHD. Treatment options should include a broader range of non-pharmacological interventions, tailored to developmental age and need.In accord with NICE guidelines, the group emphasized the importance of access to high-quality age-appropriate psychoeducation for everyone with a new diagnosis of ADHD and their families. Evidence suggests that psychoeducation may help to improve clinical and subjective outcomes as well as medication adherence . Some inIn children and young people, age- and presentation-appropriate psychological interventions  should be made available in line with NICE guidelines.Psychological interventions should also be increased for adults with ADHD. Aside from symptom management, these should address the specific difficulties experienced by young people and adults with ADHD . Services such as IAPT , which provide psychological therapies for adults with anxiety and depression in the community, could be useful resources for adults with ADHD if opened up or adapted for this patient group.ADHD is a common mental health condition. However, this contrasts to the clinical provision model, where diagnosis, treatment initiation and monitoring is constrained to scarce and limited capacity specialist health resources. The experience of the consensus group was that services struggle with the capacity vs. demand conundrum, and that many service providers are passionate about providing the best support that circumstances and local commissioning parameters allow.The rights of people with ADHD are supported by the UK Equality Act . Clear gThe rights of people with ADHD in the UK are also protected under the Human Rights Act 1998 (article 14: right to non-discrimination), and further under the UK Equality Act 2010, which protects people with a disability (including ADHD). People with ADHD also have rights under the Public Sector Equality Duty in England, Scotland and Wales, which places an obligation on public authorities to positively promote equality, not merely to avoid discrimination.However, the existence of these clinical guidelines and the legislation to underpin them has not hindered people in key positions for referral, diagnosis and service commissioning from denying access to treatment and support to affected individuals. It is also clear that some CCGs are not commissioning or staffing adequate services for ADHD, and are therefore disregarding clinical evidence, national clinical guidelines, and their legal duty to prevent health inequality and discrimination. This problem is most clearly shown for adults with ADHD, for whom services are simply not available in certain regions, or to whom access to NHS services in other areas are not made available. In order for UK-wide clinical guidelines to be meaningful and effectively implemented, funding and service development needs to increase to meet the burden of illness.The fragmentation of funding across public services in the UK means that it can be difficult to convince health commissioners to see ADHD treatment as a broader investment in health, education, social services, the criminal justice system and the economy in general. Longer-term benefits are also a hard sell for commissioners who work toward a fixed annual budget, with competing needs from different mental health groups and services that are already over-stretched. Commissioners must be informed on the robust evidence for the long-term negative outcomes associated with ADHD  and their economic implications .Long-term planning of funding (now implemented in some regions in the UK) is needed to circumvent problems arising from “short-termism” of care. Joined-up commissioning between state-funded health, social services, and judicial services may help to reduce fragmentation of care and cost burdens.ADHD is the most highly prevalent childhood condition and is also common in adults. There is robust evidence for negative health and social outcomes. Yet many young people and adults are not able to obtain a timely diagnosis and treatment. Clinical guidelines are not being implemented and there is huge variation in the commissioning of ADHD services across the UK.The current paper highlights discrepancies between clinical guidelines and provision in key areas . These discrepancies occur at multiple points in the healthcare system and often have complex socio-cultural, health-structural, funding, commissioning, and resource-based underpinnings. However, despite the underlying complexity of the system, it must be said that unmet needs correspond to denied rights, particularly in a universal health service.The greatest barrier to services for people with ADHD is lack of awareness and stigma associated with the ADHD diagnosis. From the patient perspective, stigma and lack of recognition of the condition create a barrier to accessing treatment and support systems. From a commissioning and service delivery standpoint, lack of understanding and stigma constrict allocation of funding and resources. As the current report shows, prejudice and lack of understanding influence all levels of the healthcare system, resulting in a de-prioritization of ADHD and its treatment. This also has an effect on the physical and mental health and well-being of patients and their families who struggle to access the support they are entitled to and face ill-placed blame. Delays and inability to obtain treatment lead to increasing morbidity and functional impairment.Most importantly, we need to end acceptance of stigma against people with ADHD as a valid viewpoint in the healthcare sector. The growing strength of vocal and active support groups and charities across the country have provided an emergent patient voice and public visibility of the condition has improved. Widely publicized reports produced by, or in association with, these charities and support groups have also helped to raise the profile of ADHD and associated problems , 88, andWe should now be looking toward improving access to treatment for children and adults with ADHD. A brief overview and summary of the consensus recommendations is presented in Information provision and training for key professional groups, including healthcare and educational professionals, could lead to more timely and appropriate referrals, assessment and treatment. Reducing stigma and increasing understanding of ADHD may help to improve understanding and increase referrals to clinical services.Whilst the rights of individuals with ADHD are strong under current UK legislation and existing clinical guidelines, accountability of services and service commissioners to these rights and guidelines is uneven. Greater regulatory and legislative support for ADHD could go a long way toward reducing stigma and opening up pathways to healthcare. In 2018 an All-Party Parliamentary Group for ADHD was launched at the Houses of Parliament. Whilst this provided a positive platform there have yet to be any tangible outcomes. In 2017 the charity ADHD Action called upon the Government to pass an ADHD Act that would meet the needs of adults and children with ADHD . Their pHowever, legislation and regulation alone will not ease the problems of overly complex, overstretched and fragmented services. Mainstreaming ADHD provision into general adult mental health services, and introducing new expertise within primary care across child and adult ADHD healthcare provision can help to improve detection, take the pressure away from over-stretched specialist services, and enhance communication throughout the healthcare system. Enhancing information flow between primary and secondary care services, and child and adult services can help to reduce the likelihood that diagnosed patients find themselves falling between the edges of service boundaries, unable to access the treatment they need.Whilst implementing the above recommendations will entail additional costs to the UK healthcare system in the short term, economic analyses indicate that leaving ADHD untreated or undetected is not a cost-saving exercise. Evidence suggests delays in effective treatment lead to high long-term personal and public costs, including reduced economic productivity, and increased health, social care and state benefit costs , 26. FurAs we move toward resuming mental health services in the post COVID-19 era, we must look to how we can improve access and treatment in the future. Guidelines now exist on ADHD management and treatment initiation during the COVID-19 pandemic , 119. MuThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.SY, PA, and TL were responsible for the planning and scientific input of this consensus statement. All authors (except CS and AL) attended the consensus meeting. CS completed the first draft of the manuscript. This was reviewed by SY, who also consulted further with some authors about specific points. A second draft was then generated jointly by SY and CS and circulated to all authors for comment. Following further amendments, a final draft was circulated for comment and endorsement of the consensus. All authors have read and approved the final manuscript.SY, SCu, BZ, CJ, HR, ND, AL, WC, and PM have pecuniary affiliations with consultancy organizations and/or private practices. CS was employed by the company Cambridge Cognition. SY received honoraria for consultancy and educational talks years from Janssen, HB Pharma and/or Shire. She is author of the ADHD Child Evaluation (ACE) and ACE+ for adults. She is a consultant at the Cognitive Center of Canada, who publish R&R2 for ADHD Youths and Adults. PM received honoraria for consultancy and educational talks from Shire, Takeda, and Flynn Pharma. KvR received honoraria for educational talks from Shire/Takeda, Lilly, Janssen, Medice, and Flynn. CJ provided educational talks for Lilly and Janssen. MP received honoraria for talks and advisory board participation, and travel support for conference attendance, from Shire/Takeda & Flynn Pharma. TN-D reported travel and consultation fees paid for attendance at Transition into Adulthood ADHD (TiAA) Advisory Board Meeting hosted by Shire, October 2018. BZ reported paid lectures for Flynn Pharma. MAr received sponsorships to educational/scientific meetings and honoraria for consultancy and educational talks from Janssen, Lily, Takeda (Shire), and Flynn-pharma. SCo declares reimbursement for travel/accommodation expenses and honoraria in relation to lectures/courses delivered for the Association for Child and Adolescent Health (ACAMH), Canadian ADHD Alliance Resource (CADDRA), British Association of Psychopharmacology (BAP), and Healthcare Convention. PA/King's College London (KCL) received honoraria for consultancy to Takeda/Shire, Eli-Lilly, Medice, Novartis and Janssen, and for speaking at sponsored events for Shire, Lilly, Flynn Pharma, Medice, Novartis and Janssen. KCL was supported by funds for education and research from Shire, Medice, Flynn, Janssen, Vifor Pharma, GW Pharma, and QbTech. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To investigate risk factors of disability pension (DP) in young adults diagnosed with ADHD in Sweden.In total, 9718 individuals diagnosed with incident ADHD in young adult age (19–29 years) 2006 to 2011, were identified through national registers. They were followed for 5 years and Cox regression models were applied to analyze the DP risk , associated with socio-demographics, work-related factors, and comorbid disorders.Twenty-one percent of all received DP. Being younger at diagnosis ; low educational level ; work-related factors at baseline ; and schizophrenia/psychoses , autism , anxiety  were significantly associated with an increased risk of DP. Similar risk patterns were found in men and women.Work-related factors and comorbid mental disorders need to be highlighted in early vocational rehabilitation for individuals with ADHD. As a neurodevelopmental disorder, ADHD is usually diagnosed in childhood and may further persist into adulthood . The preADHD has far-reaching negative impacts on the affected individuals’ well-being and social integration, posing a great societal burden . For exaPrevious studies suggested that sociodemographic factors  , and comWork participation among young adults with ADHD diagnosis should be closely monitored and followed in combination with unfavorable baseline work-related factors, in order to prevent these individuals from being stuck in a state of labor market marginalization permanently. So far, there is very little research on the relationship between ADHD and young adults’ future work disability. The extent of permanent isolation from the labor market for these individuals remains unknown. The few existing studies are often only based on small study populations and short follow-up . TherefoPresently, we employed a large cohort study based on longitudinal Swedish register data, in order to inform clinicians of factors that are associated with a greater risk of disability pension in patients with ADHD and those patients that may benefit from early vocational interventions. Specifically, we aimed to investigate the associations between disability pension and factors including sociodemographic and work-related ones, and comorbid disorders, in individuals with ADHD. Further, we studied these associations separately in men and women.n = 3,058). The final study population consisted of 9,718 people. The project was approved by the Regional Ethical Review Board of Stockholm, Sweden.Using data from Swedish national registers, we identified all 12,776 young adults between 19 and 29 years of age with an incident diagnosis of ADHD from specialized health care between January 2006 and December 2011. The day of diagnosis was defined as cohort entry date (CED). The diagnosis of ADHD was defined as having the diagnostic code (F90) from the International Classification of Diseases, 10th Revision (ICD-10). Those who had an ongoing disability pension during the year of their ADHD diagnosis year were excluded  (s (LISA)  : The Microdata for Analyses of Social Insurance (MiDAS) ( (MiDAS) , all basThe outcome was the granting of disability pension within a 5-year period after the first ADHD diagnosis in adult age.Time-restricted disability pension can be granted to individuals between 19 and 29 years of age, given that their work capacity is reduced, or compulsory education is not finished when they become 19 years old. Thereafter, if the same conditions remain, the temporary disability pension will become permanent when they turn 30 years of age . DisabilThree sets of individual characteristics were investigated: (1) socio-demographic factors including sex, age, educational level, region of birth, family composition, and type of living area; (2) work-related factors including having income from work, unemployment status, and sickness absence status at baseline (socio-demographic and work-related factors were measured during the year before the year of ADHD diagnosis); and (3) comorbid disorders based on the primary and secondary diagnoses of inpatient and specialized outpatient health care during 1 year before their ADHD diagnosis dates. The Prescribed Drug Register was used to ascertain the diagnosis of diabetes.The comorbid diagnoses were categorized as any mental  and any somatic  diagnoses respectively. The detailed categorization of different covariates and the classification of comorbid diagnoses is presented in The distribution of different individual characteristics in the study population was illustrated by descriptive analyses. A Cox proportional hazard regression (with a module of competing risks) was applied to study the associations between the risk of disability pension and different covariates. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. All included individuals were followed 5 years from the day after CED, until they were granted disability pension, emigrated from Sweden, died or the end of follow-up , whichever came first.Besides applying a crude model to analyze the associations between individual characteristics and the risk of disability pension, we further performed three adjusted models: Model 1, with adjustment for sex, age, educational level, family composition, type of living area and region of birth; Model 2, with Model 1 and additional adjustment for unemployment, income from work and sickness absence at baseline; Model 3, the same as Model 2 with further adjustment for comorbid mental and/or somatic disorders. In order to study the sex-specific associations, we stratified the abovementioned analyses regarding sex. All statistical analyses were performed using SAS, version 9.4 (SAS Institute Inc.).The majority of persons diagnosed with ADHD in the study were men, between the age of 19 and 24 and born in Sweden . At basen = 2,075) diagnosed with ADHD received disability pension , compared with those with some income from work before diagnosis, in the fully adjusted model . CompareHaving schizophrenia/psychoses , autism-spectrum disorders , anxiety and/or stress-related disorders , and depression and/or bipolar disorders , were associated with significantly increased risk of disability pension .Similar tendencies for the associations between most of the covariates and disability pension were presented in both genders . Men diaMen with depression and/or bipolar disorders at baseline had a nearly 40% increased risk of disability pension compared with those without these disorders, whereas the risks were similar between women with and without such diagnoses . Having In this longitudinal population-based prospective cohort study on 9,718 young adults diagnosed with ADHD, 21% of them received disability pension during the 5 years’ follow-up. An increased risk of future disability pension was associated with female sex, younger age at diagnosis, low educational level, without income from work at baseline, with long period of sickness absence at baseline, and comorbid mental disorders .Both the incidence and prevalence of ADHD has increased in young women in Sweden, even though the majority of the young adults with ADHD diagnosis consists of men . CurrentInterestingly, we noted an elevated risk of having disability pension in patients diagnosed at younger age (19–24 years) compared with those diagnosed at older age (25–29 years), which was in contrast with a previous study . One of In our study, work-related factors, such as having no income from work and having sickness absence over 90 days during the year before CED, were associated with an increase in the risk of future disability pension. One possible explanation is that individuals with long-term sickness absence tended to be in the process for disability pension  and therComorbid mental disorders are highly related to ADHD, in terms of etiology . The comTo illustrate the subtypes of comorbid mental disorders is critical in designing targeted intervention programs to prevent potential work disability related to specific subtypes. In general, ADHD has been shown to have a negative impact on one’s attention and cognitive ability , while iIn the sex-stratified analyses, we found higher risk estimates of disability pension among men with depression and bipolar disorders than among women with such comorbidities. Men and women seem to perceive depression differently , which mOf all the studied comorbid mental disorders, schizophrenia/psychoses rendered the highest risk associated with receiving future disability pension in patients with ADHD diagnosis—about a 2-fold risk compared with those patients with ADHD diagnosis without such disorders. Additionally, the increased risk was observed in both sexes. Schizophrenia and psychoses as severe mental disorders have been associated with high rates of both unemployment and work disability . TargeteOne of the most prominent strengths of our study is the use of multiple longitudinal population-based Swedish registers. These registers contain high-quality data covering information on sociodemographic, work- and health-related variables for the study population, with long follow-up possibilities. All the data used were administrative, instead of self-reported information that is often hampered by misclassification. The use of these data further ensured the quality of the information acquired. Besides, our study took the advantage of complete registration of the relevant information in the Swedish labor market which has high work participation .Several limitations were also noted in the study, which warrant consideration. The diagnosis of incident ADHD was only based on the specialized healthcare visits that derived from the National Patient Register, without data from the primary healthcare. However, according to the recommendation of ADHD clinical care guideline , the diaSpecial attention should be given to early vocational rehabilitation of patients diagnosed with ADHD as young adults, in order to prevent future long-term marginalization from the labor market. Risk factors such as previous low involvement in the labor market, common comorbid mental disorders such as depression, bipolar disorders, anxiety, and stress-related disorders need to be monitored for young adults with ADHD diagnosis.


Adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) commonly experience impairments in multiple domains of daily living. Work has a central role in daily life and is susceptible to ADHD due to its cognitive demands. The present study seeks to examine the nature of work-related problems and impairments of adults with ADHD, and explores the association to ADHD symptoms and neuropsychological test performance. A community sample of 1231 individuals took part in this study and completed a set of questionnaires assessing ADHD symptoms and work-related problems. Furthermore, a clinical sample of 134 adults diagnosed with ADHD were recruited from an ADHD outpatient clinic, who completed the same set of questionnaires. A subsample of 51 patients with ADHD additionally performed a neuropsychological assessment using tests of attention and executive functions. Work-related problems were found both in individuals of the community sample with symptoms of ADHD and individuals diagnosed with ADHD. Individuals with ADHD reported work related problems particularly in not meeting their own standards and perceived potential, yet it less commonly manifests in negative performance evaluations at work or job loss. ADHD symptoms, in particular symptoms of inattention, were found to be strongly associated with work-related problems, whereas neuropsychological test performance was no meaningful predictor of functioning at work. This study emphasizes the susceptibility of individuals’ functioning at work to ADHD symptoms and impairments associated with ADHD. ADHD related difficulties at work should be considered in the clinical evaluation and targeted screening at the work place to provide support when indicated. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental childhood disorder that persists into adulthood in a sizable number of patients and affects about 1.2–7.3% of adults world-wide  with no established diagnoses of ADHD as well as a clinical sample of individuals diagnosed with ADHD from an ADHD outpatient clinic. In the clinical sample of patients with ADHD, work-related problems will not only be linked to ADHD symptoms but also to cognitive abilities as assessed with neuropsychological performance tests. The outcome of an objective cognitive performance assessment seems to be particular interesting because of the cognitive requirements that many tasks at work require. We expect significant and meaningful associations between ADHD symptoms and work-related impairments both in the community sample and patients with ADHD  in age, gender, and education years. For each patient with ADHD, two individuals from the community sample were selected with the same or similar characteristics in the three variables of interest , yielding a community comparison group of 268 individuals. The community comparison group did not differ significantly from patients with ADHD in age, gender or education  underwent cognitive testing using a neuropsychological battery. This subsample had a mean age of 36.2 years (11.4 years SD), contained 21 females, and averaged to 12.2 years of education (2.3 years SD). Most of the patients with ADHD from this sample were diagnosed with the combined (n = 28) or inattentive (n = 21) symptom presentation. One patient was diagnosed with hyperactive-impulsive presentation, while the symptom presentation was not reported for another patient.A subsample of the group of patients with ADHD . Scores on individual items are summed up yielding eight different scales, with some items contributing to more than one scale. In the present study scales scores for Inattention, Hyperactivity, Impulsivity, and the ADHD index, were used.The Conners’ Adult ADHD Rating Scale , Work (11 items), School (11 items), Life Skills (12 items), Self-concept (5 items), Social (9 items), and Risk (14 items). Each item is scored on a four-point Likert scale scored from 0 to 3 . An additional answering option is given with Not Applicable. A scale score per domain is calculated by summing up the responses to all items per domain , and dividing this sum by the number of endorsed items (thereby not considering items that are answered with Not Applicable). Furthermore, any item score ≥ 2 was scored to indicate impaired functioning  and the Work mean score. Table Work subscale of the WFIRS.The Weiss Functional Impairment Rating Scale (WFIRS) is a self-report measure for impairments that commonly occur in patients with ADHD and that are likely to represent the patients' targets of treatment CADDRA, 2017). The WFIRS comprises 70 items that are divided into seven domains: . The WFIA number of neuropsychological tests were performed to assess aspects of attention and executive control, i.e., selective attention , vigilance , cognitive flexibility , verbal fluency , working memory , and planning . The tests WAFS, WAFV, TMT, NBV, and TOL-F were taken from test battery Cognitive Functions ADHD  affiliated with the University of Groningen, The Netherlands.n = 51) additionally performed the neuropsychological battery using cognitive tests. Tests were administered in an office of the psychiatric hospital without distraction. Test administration was led by a trained psychologist and took about 60 min. The study involving patients was approved by the medical ethical committee affiliated to the University of Heidelberg, Germany.Patients with ADHD gave written informed consent and completed the survey as well as the test battery, if applicable, as part of a larger research project. Participation in this project was voluntary, unpaid, and was separated from their diagnostic assessment and treatment. All patients with ADHD were asked to complete the set of questionnaires to the best of their knowledge and not to seek help from the examiner or to discuss questions or their responses. A subsample of patients with ADHD  and frequencies . Responses of patients with ADHD and the community comparison group were compared using t-tests for independent samples (continuous data) and Chi-Square tests . Associations between ADHD symptom severity and WFIRS Work score, and impairments in each of the WFIRS Work items per group are presented in Tables Work items, a considerable larger proportion of impairments (in 37 to 53% of participants) were observed in the subgroup of the community sample with elevated levels of ADHD symptoms. A larger variation in work-related problems was observed in individuals diagnosed with ADHD, with 20 to 23% of patients with ADHD reporting impairments in items #5 (“getting fired from work”), #7 (“problems with your attendance”), and #11 , whereas up to 55 to 69% of patients with ADHD reported impairments in items #2 (“problems with getting your work done efficiently”) and #10 . Group comparisons revealed that patients with ADHD reported significantly more often work-related problems than the community comparison group in each of the Work items, with the exception of item #5. Differences between patients with ADHD and the community comparison group are visually depicted in Fig. ADHD symptom scores per domain, work status, the WFIRS Work score and ADHD symptoms in all four groups examined, with largest associations found to inattention symptoms , vigilance (omissions and commissions), flexibility (TMT-B), and verbal fluency, whereas functioning in working memory and planning was impaired in a fewer number of patients (around a quarter of patients). None of the test variables revealed significant associations to the WFIRS Work score. Furthermore, regression analysis on this subsample failed to find a significant model that predicts WFIRS Work scores when entering all neuropsychological test scores into one model; F = 0.481; p = 0.920; R2 = 0.163.Table Work score in the subsample of the community with elevated ADHD symptoms (CAARS ADHD index at least one standard deviation above the mean). Furthermore, correlation analyses underlined the role of ADHD symptoms in work-related functioning by showing moderate to strong associations between ADHD symptom severity and functioning at work in both the total sample of the community as well as the subsample of individuals with elevated ADHD symptoms. Comparing the roles of different ADHD symptom domains, it becomes apparent that symptoms of inattention may have the strongest predictive ability for functioning at work.Initial analyses on work-related functioning were performed in a large community sample of individuals equal or older than 18 years, no established diagnoses of ADHD, and who were in paid work at the time of the assessment in 73% of the cases. In this sample, we observed only a small number of self-reported work-related problems, with rates of 5–9% per item. Work-related problems in the community appeared to be clearly associated to ADHD symptoms, which is evidenced by high rates (37 to 53%) of work-related problems and a heightened WFIRS getting fired from work”) item. High scores are observed in particular in “getting your work done efficiently”  and “working to your potential” . Fewer impairments were reported on “getting fired from work” , “problems with your attendance” , and “poor performance evaluations” . This discrepancy in the occurrence of work-related problems indicate that patients with ADHD commonly feel that their ADHD hinders their functioning at work and performing to their perceived potentials, and results in not meeting their own standards, but still their work performance may not always strike out negatively to their managers  and may not result in losing their jobs in most cases. Further, the group comparisons showed that problems of adults with ADHD at work do not only refer to work performance itself, but also to situations involving social interaction with colleagues and supervisors . The number of impairments across all eleven aspects of functioning of the WFIRS Work scale (Table Work score) was significantly associated with ADHD symptoms, even though of slightly smaller size than in the community sample, with correlation coefficients reaching medium size for symptoms of inattention and impulsivity, and non-significant correlations of small size for symptoms of hyperactivity. The significant and meaningful associations between work-related problems and ADHD symptoms in all groups of this study is in agreement with results of Fredriksen et al. , as more patients with ADHD were currently in training or followed an education (27% vs. 5%). Compared to the community comparison group, patients with ADHD reported marked impairments in several work-related aspects of functioning, with significantly higher scores in all but one  requirements of the specific job. The issue of occupational diversity and complexity may need to be studied in further research when trying to achieve a more accurate and balanced analysis of work-related problems experienced by individuals with ADHD.This study identified a number of work-related problems in both individuals with symptoms of ADHD and individuals diagnosed with ADHD. Individuals with ADHD experienced problems at work in particular in not meeting their own standards and perceived potential, yet this is less often accompanied by negative performance evaluations or losing their job. ADHD symptoms, in particular symptoms of inattention, were found to be strongly associated with work-related problems, whereas neuropsychological test performance did not predict work-related problems. Even though the measurement scale of this study was subjective and the design correlational in nature, the present results emphasize the susceptibility of individuals’ functioning at work to ADHD symptoms and impairments. Work-related issues should be considered in the clinical evaluation but also at the work place by means of targeted screening for ADHD symptoms and related impairments. Self-reports should preferably be complemented by other reports  and objective data of work performance and functioning.The data that support the findings of this study are available from the corresponding author upon reasonable request.


With the development of society and the economy, the prevalence of attention deficit hyperactivity disorder (ADHD) has been increasing. Due to its high comorbidity and high harm, it has received increasing attention. It causes damage to functions in multiple areas, and this damage may continue into adulthood. ADHD is a common developmental disorder characterized by persistent attention deficit and hyperactivity/impulsivity. ADHD often merges with other diseases, such as oppositional defiant disorder, conduct disorder, personality disorder, anxiety disorder, mood disorder, and substance dependence. The disease tends to cause children with learning difficulties, poor grades, strained relationships with family members and children of the same age, lack of self-esteem, and children with low occupation, low income, substance abuse, and antisocial personality characteristics when they grow up to adults. Many countries have formulated ADHD treatment guidelines for this purpose, but there is still a lack of consensus. This article uses literature research and the meta method: RevMan 5.3 software is used for data analysis. The analysis results show that traditional Chinese medicine has characteristics and advantages in the clinical total effective rate and hyperactivity index score in the treatment of ADHD. The overall clinical syndrome differentiation of the treatment can be summarized as liver and kidney yin deficiency and liver yang partial prosperity. The overall medication is based on the methods of nourishing yin and clearing heat, calming the liver and nourishing kidney, and nourishing yin and suppressing yang. The efficacy and safety evaluation of traditional Chinese medicine in the treatment of ADHD need to be further verified by large-sample clinical trials with strict design and standardized outcome index reporting. Attention deficit hyperactivity disorder is a common neurobehavioral disorder of school-age children, and its symptoms are characterized by attention deficit and hyperactivity impulse that are not commensurate with the level of development. The global prevalence of children with ADHD has risen to 10%, and the prevalence of children in China is about 6.26%. With the spread of ADHD symptoms in society and the increasing importance of people on them, many parents and teachers will overdiagnose and improperly intervene in children's inattention and hyperactive behaviors in daily life. However, because it is difficult to diagnose the core symptoms of ADHD in the early stage, the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) have extended the age of onset of ADHD from 7 to 12 years.This indicates that some school-age children have not been diagnosed but still show symptoms of ADHD, and the symptoms are at risk of continuous development. Studies have shown that children with ADHD symptoms are prone to academic problems, poor peer relationships, and offensive behaviors. Their symptoms persist into adulthood and are more related to offensive crime and antisocial behavior , 4.This article first introduces the treatment of children with ADHD, mainly from the two aspects of Western medicine and traditional Chinese medicine, including pathogenic factors and treatment methods. Then it introduces the nondrug treatment of ADHD. This article mainly introduces parental training and art therapy. Finally, a systematic review and meta-analysis of the treatment of ADHD are carried out.The pathogenic factors of ADHD include genetics, neurophysiology, drug abuse during pregnancy, lead exposure, lack of early attachment, or childhood posttraumatic stress disorder. Genetic factors have always been considered to have an important relationship with the formation of ADHD , 6. FamiAt present, the research on the treatment of ADHD mainly focuses on drug treatment, with less emphasis on psychotherapy and psychosocial intervention and less research on complementary and alternative drugs. The generally accepted standard method for the treatment of ADHD is pharmaceutical intervention, and the first choice is medical stimulants, such as methylphenidate (MPH) and dexamphetamine sulfate, of which methylphenidate is used in a wider range. In many western countries, the drugs currently used to treat ADHD include stimulants , nonstimulants , and some antidepressants  , 12.In the past two decades, the number of ADHD patients has continued to increase. The long-term use of psychostimulants in children has been controversial. Due to the occurrence of side effects or lack of curative effect, poor compliance and treatment failure of patients generally occur. Therefore, other alternative treatment options are welcome . In diffThe current literature reports many different complementary and alternative medicine (CAM) treatment methods, such as diet adjustment, physical therapy, massage, lifestyle changes, chiropractic treatment, acupuncture, and traditional Chinese medicine. There is evidence that they can effectively improve the treatment of ADHD symptoms. Complementary and alternative medicine therapies, including traditional Chinese medicine, are widely used worldwide because they have fewer side effects and are safer , 15.When a child is born with inadequacy, improper postpartum care, improper education, environmental influences, trauma or emotional disorders, and so on, it will cause the five internal organs to lose coordination, qi and blood disorder, and corresponding diseases. The diagnosis and treatment of ADHD by traditional Chinese medicine are based on the unique overall concept and syndrome differentiation in the basic theories of traditional Chinese medicine . It collThe ultimate goal of TCM treatment of children with ADHD is to completely relieve it. The specific content is “when the patient is receiving or not receiving drug treatment, the clinical symptoms are reduced or disappeared, and the body's function reaches the best state.” In other words, the standard for curative effect of traditional Chinese medicine treatment is that the core symptoms of ADHD are eliminated, the comorbidities are improved, and the children's behavior, mood, social function, and quality of life are maximized. TCM treatment also aims to strengthen the body's adaptability, eliminate endogenous and exogenous pathogenic factors, and eliminate the root cause of ADHD disease. At the same time, TCM treatment can strengthen and consolidate the effects of conventional medications, promote the gradual reduction of conventional medications within a safe range or even stop them completely, and help reduce side effects during treatment and the recurrence rate after treatment. Another goal of TCM treatment is to reduce the side effects of traditional medicines and reduce the cost of medical care.When treating diseases, TCM will comprehensively consider five interrelated dimensions, namely real-time space-society-environment-psychobiology, which is slightly more complicated than the modern Western biological-psychosocial medicine model. The formulation of Western medicine treatment plans is often based on the results of laboratory tests so that drugs that target specific symptoms and biological mechanisms are used. However, Chinese medicine focuses on the overall improvement of all aspects centered on the patient.(1) Research on Monoamine Neurotransmitters and Related Signal Pathways. Some experts have found that Anshen Dingzhiling can increase the relative expression of AC, cAMP, CDK5, p35, and CREB in the downstream signal pathway of DA and reduce the related expression of PP1 and DARPP32; related studies have found that Anshen Dingzhiling can reduce the correlation of dopamine transporters; it also increases the relative expression of dopamine DI and D2 receptors. Studies have shown that Anshen Dingzhiling can increase the expression of the specific protein SLOOP related to the growth and development of the nervous system. In summary, the mechanism of Anshen Dingzhiling is related to the dopamine signaling pathway and the norepinephrine system. Some experts believe that Duodongting decoction can regulate the expression level of the second messenger of monoamine neurotransmitters. Some researchers have found that Kong Sheng Zhen Zhong Dan can reduce the expression level of DAT and increase the expression level of TH in the prefrontal striatum, and the expression of DAT, DRD1, and DRD2 genes in the right brain is higher than that in the left brain. The possible mechanism of action of Dan is to regulate the prefrontal cortex in the brain. The DA nerve signal transduction of the striatum circuit can upregulate the expression levels of NET genes and proteins in the right prefrontal lobe and striatum. It is believed that the mechanism of Longmu Guizhi decoction is closely related to the norepinephrine system. Related studies have shown that Yizhining can increase the related expression of TH in the prefrontal lobe and striatum of SHR rats and reduce the related expression of DAT, DRD1, and DRD2.(2) Research on Other Mechanisms. Studies have found that ginsenoside Rgl can increase the expression of a glial cell-derived neurotrophic factor in SHR rats. Researchers found that acupuncture can reduce the expression of c-Fos in the hippocampus of mice and increase the related expression of Bcl-2. Its mechanism may be related to neuron protection and antiapoptosis.When treating children with ADHD, it is difficult to expect satisfying results only by relying on drug therapy; especially, the additional consequences caused by lack of attention, impulsive solutions, lack of systematic thinking, and inefficient anger handling mechanisms, distorted relationships, and other problems cannot be solved by medication. Therefore, not only medical treatment is needed, but we also need psychosocial treatment mechanisms. Commonly used psychotherapy methods include cognitive action therapy, parenting training, and so on.The dimensions and types of parental rearing styles are shown in Tables Studies have shown that parental rearing style affects the symptoms of attention deficit and hyperactivity in school-age children. This is consistent with the results of previous ADHD studies. Active parenting methods increase the protective function of ADHD children, and negative parenting methods increase the symptoms and negative emotions of ADHD children. The results indicate that the authoritative parenting method is a more active and suitable parenting method for children with symptoms of attention deficit or hyperactivity, while the authoritarian parenting method can increase the symptoms of ADHD.Studies have evaluated the parenting styles based on different reporters, and the results show the difference in the impact of parenting styles on ADHD between fathers and mothers. In the authoritative parenting style, only the authoritative parenting style evaluated by the mother as a protective factor negatively affects the symptoms of ADHD. Studies have found that the mother's self-evaluation authority score is significantly higher than that of his father's evaluation and that whether the mother evaluates herself or her husband's authoritative parenting style directly affects children's ADHD symptoms. There was no significant difference between the father's self-evaluated authority score and his mother's authority score, and neither the father's evaluation of himself nor his wife's authoritative parenting style was related to ADHD symptoms. The relevant results of the study show that the authoritative parenting styles under all reporting forms are negatively correlated with ADHD symptoms, but the path analysis results show that the authoritative parenting style evaluated by the father does not affect ADHD symptoms. Therefore, some studies speculate that there is a possibility that fathers are not sensitive to the characteristics of authoritative parenting styles.In addition, the results of children's reports of parental rearing styles showed that only the mother's authoritarian rearing styles positively affected ADHD symptoms. The mother's authoritarian parenting style is closely related to the inattention and hyperactivity of children aged 3–18. Calkins, Dedmon, Gill, Lomax, and Johnson's frustration research results also show that when mothers have too many intrusive behaviors and low sensitivity, young children have more negative emotions and show poor attention control ability. On the contrary, mother's positive response and warm and supportive behaviors can promote children's effort control and have a significant predictive effect on the later stage of children's effort control. This may be because the mother is the child's main caregiver and bears the main responsibility of nurturing in daily life. Parent-child interaction time is longer than that of the father. Autocratic mothers have more opportunities to pay attention to and control their children's ADHD symptoms.The art therapy items are mainly shown in Art is more useful for children whose language is not smooth enough, and art activities can provide an interesting environment for the children. In such an environment, the child treats the treatment project as a game and naturally integrates it into his/her environment. Therefore, art therapy for children with ADHD is meaningful.Treatment guidelines play a vital role in the prevention and treatment of ADHD. Evidence-based guidelines based on evidence-based methods have their own outstanding advantages. There are already many evidence-based treatment guidelines for other physiological diseases in China, and it is necessary and urgent to formulate evidence-based treatment guidelines for ADHD. Foreign mature evidence-based guidelines provide reference evidence and mature treatment plans, and their concepts of evidence-based and collaboration are more worthy of reference. In the future, when formulating evidence-based guidelines in our country, we should combine localized research evidence and consider patients' personality characteristics and preferences to formulate localized evidence-based guidelines with scientific evidence, strong feasibility, and suitable for domestic conditions.According to foreign evidence-based guidelines, family participation is one of the most important contributors to the treatment effect and an important link that must be considered in the treatment process. As the first environmental system for individuals, the family has attracted the attention of researchers due to its unique position. The four evidence-based guidelines retrieved in this study all focus on family preference for treatment methods and the influence of the parent-child relationship on treatment results. Moreover, a large number of studies have shown that treatment methods such as group parent training programs, PBT, and PTBM have good effects on the treatment of ADHD; even for patients with severe symptoms, family participation can also play a good auxiliary role. In the future, our country should pay more attention to the active participation of families in the formulation of treatment guidelines, consider the preferences of families and patients on treatment options, give full play to the positive impact of the parent-child relationship on treatment, and help families better manage patients' behaviors so that patients cooperate with treatment to the greatest extent possible.2.4.3. Constructing a Multiparty ADHD Prevention SystemThe treatment of ADHD is a long-term, multiparty collaborative process. At present, our country still lacks information communication and multiparty cooperation. Compared with foreign countries, domestic schools have an insufficient investment in ADHD treatment. Teachers' understanding of ADHD, adjustment of the teaching environment, curriculum settings, treatment referral, and other aspects need to be improved.In the future, our country should build a multiparty ADHD prevention and treatment system, emphasizing family participation; formulating school intervention plans; attaching importance to social publicity, early detection, and early treatment; establishing a collaborative system of information exchange; and integrating family, school, and society into a system framework to participate in ADHD prevention and treatment.Search is conducted in six major databases; all search deadlines are until December 2020; search terms include Chinese medicine, herbal medicine, Chinese medicine (topic), attention deficit hyperactivity disorder (topic), hyperactivity, brain dysfunction, and random; and English search terms are traditional Chinese medicine, herbal medicine, attention deficit hyperactivity disorder, hyperactivity, and brain dysfunction. The collected data have been retrieved separately according to the characteristics of different databases. The technical route is shown in Data analysis mainly depends on heterogeneity detection.di is the individual study statistic, Var(di) is the variance of the statistic, Q is the chi-square statistic, and df is the degree of freedom.Wi is the weight of each study, and the weight Wi of each i-th study is calculated as follows:The heterogeneity detection formula is as follows:After searching six databases, 959 papers were retrieved; duplicates were removed; 75 were included after initial screening by reading the title and abstract; and 55 were further screened by reading the full text to exclude nonrandomized controlled trials and interventions that did not meet and duplicate studies. Finally, 20 papers were included, and the literature screening process is shown in I2 = 70%; P=0.0001). Using a random effect model, the total clinical effectiveness of traditional Chinese medicine and western medicine was different. It is statistically significant . A total of 6 studies were included in the comparison of traditional Chinese medicine combined with western medicine and western medicine. The total clinical effective rate was compared, and the difference was statistically significant. Significance .The meta-analysis results showed that a total of 24 studies were included comparing traditional Chinese medicine and western medicine, with large heterogeneity  expand the search database, increase the sample size, and use more objective test indicators for literature screening; (2) expand the research object to make the research more meaningful; and (3) select high-quality literature; in the treatment process, the occurrence time, symptoms, duration, severity and disappearance time of adverse events should be determined and recorded in detail so as to obtain more effective scientific evidence.


Background: Drug utilization studies based on real-world data are vital for the identification of potentially needed improvements to rational prescribing. This is particularly important for the pharmacological treatment of children and adolescents with attention-deficit hyperactivity disorder (ADHD) due to the associated potential side effects and the frequent use. Whereas prevalent use is well-characterized, studies on first-time use of ADHD medication are scarce. This study aimed to evaluate off-label prescribing in first-time users of ADHD medication among children and adolescents in Germany based on three criteria: (i) lack of a documented ADHD diagnosis; (ii) first-time pharmacological treatment with a second-line drug; and (iii) patient age below 6 years.Methods: Based on German claims data, we included children and adolescents aged 0–17 years with a first-time dispensation of any ADHD medication in the period 2015–2017. These first-time users were characterized with regard to sex, age, specialty of the prescribing physician, documentation of an ADHD diagnosis, psychiatric hospitalization, psychiatric comorbidities, and history of other psychopharmacological drugs at first-time use.Results: The study population comprised 18,703 pediatric first-time users of ADHD medication. Of these, 9.8% had no documented ADHD diagnosis. Most of the ADHD drug users received first-line ADHD pharmacotherapy , whereas 2.6% were prescribed second-line ADHD medication  as first drug. Overall, 1.2% of first-time users were aged below 6 years. A total of 12.7% of the study population met any off-label criterion.Conclusions: About 13% of pediatric first-time users of ADHD medication in Germany received an off-label pharmacotherapy at first-time use. Prescribing ADHD medication without a confirmed ADHD diagnosis was the most common of the three assessed off-label criteria. Off-label prescribing regarding drug choice and age of patients only occurred in a small percentage of initial pharmacological ADHD treatment. Our results suggest the need for improvement in rational prescribing, especially with regard to diagnostic requirements. With a worldwide community prevalence between 2 and 7%, attention-deficit hyperactivity disorder (ADHD) is one of the most common mental disorders among children and adolescents , 2. The Before initiating medication, the prescriber must ensure that the patient has a confirmed diagnosis of ADHD. Current clinical guidelines recommend a full clinical interview including structured and comprehensive assessments for the ADHD diagnosis , 9. In aAlthough the evidence base is the same, the approval status and guideline recommendations differ between countries in North America and Europe, particularly regarding LDX. In Germany—as in other European countries—only MPH and atomoxetine (ATX) are approved as the initial—i.e., first-time—pharmacological ADHD treatment without restriction and—in contrast to the approval in, e.g., the US and Canada—LDX (available since June 2013) and dexamfetamine (DEX) require insufficient response to previous MPH treatment. Similarly, guanfacine  may be indicated only if stimulants such as MPH are not suitable. In its recommendations, the German guideline on ADHD points out that the approval status of the medication should be taken into account .All mentioned drugs are not approved for children aged below 6 years, i.e., preschool children in Germany. Guidelines do not preclude pharmacological treatment for preschool children but emphasize that psychosocial interventions should be considered first. Medication should only be prescribed to children with residual symptoms and after an individual risk-benefit assessment.Little is known about adherence to guidelines for ADHD medication prescribed to children and adolescents in routine care. Especially recent drug utilization studies from Europe and including all available ADHD medication are lacking. These are, however, important since LDX and GUA have only been available for a relatively short time in European countries. Early monitoring and identification of characteristics associated with off-label prescribing of these newer drugs is crucial as the safety of newer drugs in routine care is generally not well-understood.Therefore, this study aimed to evaluate off-label prescribing in first-time users of ADHD medication among children and adolescents in Germany based on three criteria: (i) lack of a documented ADHD diagnosis; (ii) first-time pharmacological treatment with a second-line drug; and (iii) patient age below 6 years.This study used data from the German Pharmacoepidemiological Research Database (GePaRD) . GePaRD In addition to demographic data, GePaRD contains information on reimbursable drug dispensations as well as outpatient  and inpatient services and diagnoses. Drug dispensations are identifiable via the German modification of WHO Anatomical Therapeutic Chemical (ATC) classification codes. Diagnoses are coded according to the German Modification of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD).We included children and adolescents aged 0–17 years with a dispensation of any ADHD medication between January 1, 2015 and December 31, 2017 and with health insurance coverage on the earliest dispensation date in that period. ADHD medication included all drugs approved to treat ADHD in Germany at the time, which were identified based on ATC codes: MPH (N06BA04), ATX (N06BA09), LDX (N06BA12), DEX (N06BA02), or GUA .Individuals were excluded if they did not have a minimum pre-observation time  of 4 years before the earliest dispensation date; those aged 4 years or younger were required to have a pre-observation time since the year of birth. Next, we excluded all individuals with a dispensation date of any ADHD medication in the pre-observation period .The final study population can therefore be considered as first-time users of any ADHD medication. Depending on the ADHD medication(s) dispensed on the day of first-time use, each individual was assigned to one of six mutually exclusive groups of users: MPH; ATX; LDX; DEX; GUA; or users of more than one of these drugs.Characteristics assessed for each individual of the study population included year of first-time use, sex, and age. We examined whether ADHD (ICD-10 codes F90/F98.8) and/or narcolepsy  had been coded in the 2 years before and including the day (inpatient data) or quarter (outpatient data) of first use. The specialty of the prescribing physician was derived from the prescription. Psychiatric hospitalizations were identified based on hospital admissions with at least one ICD-10 code F00–F99 as main or secondary discharge diagnosis in the year before and including the day of first use. Psychiatric comorbidities were assessed from inpatient data in the year before and including the day of first use; in outpatient data—as outpatient diagnoses are recorded quarterly—psychiatric comorbidities were assessed in the quarter of the day of first use and in the three preceding quarters. History of other psychopharmacological drugs—antipsychotics (ATC codes starting with N05C), anxiolytics (N05B), hypnotics and sedatives (N05C), and antidepressants (N06A)—was assessed in the year before (not including) the day of first use of ADHD medication.Descriptive analyses were conducted in first-time users overall and stratified by (i) whether or not there was a lack of a documented ADHD diagnosis, (ii) whether or not second-line ADHD medication was dispensed on the day of first use, and (iii) whether or not the age was below 6 years.We additionally evaluated characteristics associated with (off-label) prescribing of a second-line pharmacological treatment as the first ADHD medication. Multivariable logistic regression was used to obtain odds ratios (OR) and corresponding 95% confidence intervals (CI) for the association between the characteristics described above and the prescribed line of treatment, comparing first-time users of second-line drugs  with those of first-line drugs (MPH or ATX). We did not include all psychiatric comorbidities as independent variables but rather selected those deemed clinically relevant for the decision-making process regarding the prescription of ADHD medication.The study population comprised 18,703 pediatric first-time users of ADHD medication . OverallMore than half of all users received the first prescription from a child and adolescent psychiatrist and almost one quarter received the prescription from a pediatrician. The most frequent psychiatric comorbidities were conduct disorders and emotional disorders in childhood or anxiety; about 80% had at least one comorbidity. With regard to history of other psychopharmacological drugs, antipsychotics were most frequently prescribed.Psychiatric hospitalizations occurred less often in first-time users without than in those with a documented ADHD diagnosis , 10% (n = 22) were aged 3 years or younger.In patients aged below 6 years, second-line ADHD medication use was more prevalent . They alThis study evaluated adherence to prescribing guidelines in first-time users of ADHD medication among children and adolescents in routine care in Germany based on three key off-label criteria. Our main finding is that prescribing ADHD medication without a confirmed ADHD diagnosis was relatively common, while rather few first users received prescriptions of a second-line ADHD medication, and only a small percentage of users was aged below 6 years.During the study period, ADHD and narcolepsy were the only licensed indications for each of the ADHD medications assessed in this study . As expeA prior study on LDX used data on prescriptions and diagnoses of ADHD from eight European countries . The maiGiven that current clinical guidelines consistently recommend a structured, comprehensive ADHD assessment , 9 and tThe characteristics of patients with a lack of a documented ADHD diagnosis do not indicate that they were more severe cases warranting immediate drug treatment. Characteristics such as psychiatric hospitalizations as well as comorbidities that would indicate a more complex psychopathology  were even less frequent in first-time users of ADHD drugs with a lack of a documented ADHD diagnosis as compared to those with a diagnosis of ADHD.We conclude that prescribing ADHD medication to children and adolescents without a clinically confirmed ADHD diagnosis was relatively common. Assuming that in these cases diagnostic requirements were not met, our results indicate irrational prescribing with possible associated consequences such as exposing the patient to unnecessary risks of side effects.In our study, characteristics of patients who used second-line as compared to those who used first-line drugs as the first ADHD medication differed markedly. These characteristics—higher prevalence of prior psychiatric hospitalization and of antipsychotic prescription, conduct disorders, mental retardation, tic disorders, and pervasive developmental disorders—indicate a more complex and extensive psychopathology in these patients. In the multivariable regression, these characteristics were positively associated with receiving a second-line drug.In addition to the above-mentioned characteristics indicating a more complex clinical presentation, both children below 6 years as well as those receiving the prescription from a pediatrician were also more likely to be prescribed a second-line drug as their first ADHD medication.Regarding potential reasons for starting ADHD treatment with second-line medication, prescribing based on trial data ahead of formal licensing might be a potential cause. Nevertheless, clinical data on efficacy do not support the superiority of LDX, DEX, or GUA  over MPH or ATX  for patients with the above-mentioned conditions . ConsideThe fact that children aged below 6 years were more likely to receive a second-line drug as the first ADHD medication was especially surprising. A possible reason might be that prescribers estimate the risk of adverse events of second-line ADHD drugs as less than MPH. Yet, such an attitude is not supported by current evidence: To date, there are only few studies assessing safety and efficacy of ADHD medication in children younger than 6 years. This is particularly true for the second-line drugs assessed in this study . It is expected that the evidence base on ADHD medication for children younger than 6 years will improve soon as numerous randomized controlled trials are planned or currently running . HoweverSurprisingly—even when adjusted for age and characteristics indicating the complexity of ADHD cases—patients were more likely to receive a second-line drug as the first ADHD medication when the prescription was made by a pediatrician. This is particularly remarkable as more severe ADHD cases are usually pharmacologically treated by specialized child and adolescent psychiatrists, as was suggested by a previous study . FurtherOne study based on UK data found that in a sample of individuals aged below 16 years, 4% of ADHD medication users were aged below 6 years. This percentage is somewhat higher than in our study. Notably, the study was limited to the years 1992–2013, and the more recently approved drugs LDX and GUA were not included . Two othOne explanation for not finding recorded diagnoses might be concerns of physicians and/or parents regarding a potential stigmatization of children with ADHD . This coIn patients aged below 6 years as compared with older patients, prescribers were less often specialists and more often pediatricians. However, these results do not allow conclusions about the prescribers' specialty or their preferences regarding prescribing off-label to children younger than 6 years as the proportion of individuals with contact to specialists for mental health disorders might be much smaller for younger patients. This was shown for pediatric patients diagnosed with autism spectrum disorders in Germany . HoweverThe German guideline on ADHD —similar Similar to recipients of second-line drugs, first-time users aged below 6 years more often had psychiatric hospitalizations, conduct disorders, pervasive developmental disorders, and history of antipsychotics, i.e., characteristics indicating more complex clinical presentations. Guidelines do not preclude off-label prescribing to children aged below 6 years in severe cases and after individual risk-benefit assessment. In fact, the guidelines from the UK National Institute for Health and Care Excellence (NICE) differentiate between the age groups below 5 years and older . AgainstIn routine care in Germany, adherence to prescribing guidelines is suboptimal in a substantial proportion of children and adolescents initiating medication to treat ADHD. Physicians should follow current guideline recommendations on ADHD to optimize rational prescribing and avoid adverse events such as insomnia, seizures, tics, loss of appetite, and possible growth deficits. This holds especially true for some pediatricians, who appear to be susceptible to non-adherence to guidelines or label requirements—at least with regard to prescribing second-line drugs as first ADHD medication.Due to potential side effects and frequent use of drugs to treat ADHD, future research should continue to monitor their off-label use in children and adolescents. Evaluating prescribing behavior following the release of the new German ADHD guidelines in 2018 will provide information for further measures aimed at implementing evidence-based recommendations in routine care.The main strength of this study is that the underlying routinely collected prescription data are not prone to both, non-responder and recall bias. This is particularly important as it cannot be assumed that prescribers would admit if they did not adhere to prescribing guidelines. In addition, we used a large statutory health insurance database covering about one fifth of the German population. Among children and adolescents in Germany, prevalence of drug use does not differ substantially between different types of statutory health insurance providers . We therA general limitation of claims data is that the validity of outpatient diagnoses is suboptimal; also, ADHD in children might be overdiagnosed in Germany . This, hOur findings show that in more than 10% of pediatric first-time ADHD medication users, prescribers did not adhere to prescribing guidelines. Initiating ADHD drugs without a confirmed ADHD diagnosis was the most common of the three studied off-label criteria. We found off-label use in terms of drug choice and age of patients in a small percentage of pediatric first-time users of drugs to treat ADHD. Since ADHD medication is prescribed frequently in children and adolescents, improving rational prescribing in this area is of high relevance for public health.scholle@leibniz-bips.de.As we are not the owners of the data, we are not legally entitled to grant access to the data of the German Pharmacoepidemiological Research Database. In accordance with German data protection regulations, access to the data is granted only to BIPS employees on the BIPS premises and in the context of approved research projects. Third parties may only access the data in co-operation with BIPS and after signing an agreement for guest researchers at BIPS. Requests to access the datasets should be directed to OS, In Germany, the utilization of health insurance data for scientific research is regulated by the Code of Social Law. All involved health insurance providers as well as the German Federal Office for Social Security and the Senator for Health, and Women and Consumer Protection in Bremen as their responsible authorities approved the use of GePaRD data for this study. Informed consent for studies based on claims data is required by law unless obtaining consent appears unacceptable and would bias results, which was the case in this study. According to the Ethics Committee of the University of Bremen, studies based on GePaRD are exempt from institutional review board review.OS and CB conceptualized the research question. OS wrote the first draft of the manuscript. BK, OR, and CB revised it critically for important intellectual content and approved the final version to be published. All authors designed the study and participated in the discussion and interpretation of the results.OS, BK, and OR are working at an independent, non-profit research institute, the Leibniz Institute for Prevention Research and Epidemiology – BIPS. Unrelated to this study, BIPS occasionally conducts studies financed by the pharmaceutical industry. Almost exclusively, these are post-authorization safety studies (PASS) requested by health authorities. The design and conduct of these studies as well as the interpretation and publication are not influenced by the pharmaceutical industry. The study presented was not funded by the pharmaceutical industry. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.