{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,3]],"date-time":"2026-11-03T01:02:19Z","timestamp":1793667739114,"version":"4.5.1"},"reference-count":31,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,12,1]],"date-time":"2021-12-01T00:00:00Z","timestamp":1638316800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,12,18]],"date-time":"2021-12-18T00:00:00Z","timestamp":1639785600000},"content-version":"vor","delay-in-days":17,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100006275","name":"Friede Springer Stiftung","doi-asserted-by":"publisher","award":["131\/2019"],"award-info":[{"award-number":["131\/2019"]}],"id":[{"id":"10.13039\/501100006275","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Universit\u00e4tsklinikum Ulm"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Child Adolesc Psychiatry Ment Health"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>Attention-deficit hyperactivity disorder (ADHD) ranks top among neurodevelopmental disorders in children and adolescents. Due to a large number of unfavorable outcomes including psychiatric comorbidities, school problems, and lower socioeconomic status, early and effective treatment of ADHD is essential. Multimodal treatment has become the gold standard in ADHD management, comprising pharmacotherapy and psychosocial interventions, e.g., psychotherapy. Yet, little is known about the prevalence of multimodal treatment in routine care.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Based on German health claims data for the years 2009\u20132017, we identified children and adolescents aged 3\u201317\u00a0years diagnosed with ADHD and characterized them cross-sectionally (per calendar year) in terms of treatment status and psychiatric comorbidities. The detection of pharmacotherapy was based on dispensations of drugs to treat ADHD (e.g., methylphenidate); psychotherapeutic treatment was based on corresponding billing codes. Multimodal treatment was assumed if ADHD medication and psychotherapeutic treatment were coded within the same calendar year. Psychiatric comorbidities were based on outpatient and inpatient diagnoses. Prevalences of ADHD and proportions of different treatment options were calculated and standardized by age and sex.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>In 2017, 91,118 children met the study criteria for ADHD (prevalence: 42.8\/1000). Of these, 25.2% had no psychiatric comorbidity, 28.8% had one, 21.6% had two, and 24.5% had three or more. Regarding overall treatment status, 36.2% were treated only pharmacologically, 6.5% received multimodal treatment, and 6.8% were treated with psychotherapy only (neither treatment: 50.2%). With increasing numbers of psychiatric comorbidities, the proportions of patients with multimodal treatment increased from 2.2% (no psychiatric comorbidities) to 11.1% (three or more psychiatric comorbidities) while the proportions of untreated (from 56.8% to 42.7%) or only pharmacologically treated patients (38.4% to 35.0%) decreased. From 2009 to 2017, prevalences were stable and the proportion of patients with only pharmacotherapy decreased from 48% to 36.5%. Concurrently, the proportion of patients with neither pharmacotherapy nor psychotherapy increased from 40.5% to 50.2%. The fraction of patients with multimodal treatment ranged between 6.5% (2017) and 7.4% (2013).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Multimodal treatment, although recommended as the standard of treatment, is rather the exception than the rule. It is, however, increasingly common in ADHD patients with psychiatric comorbidities.<\/jats:p><\/jats:sec>","DOI":"10.1186\/s13034-021-00431-0","type":"journal-article","created":{"date-parts":[[2021,12,18]],"date-time":"2021-12-18T15:02:29Z","timestamp":1639839749000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Prevalence of multimodal treatment in children and adolescents with ADHD in Germany: a nationwide study based on health insurance data"],"prefix":"10.1186","volume":"15","author":[{"given":"Oliver","family":"Riedel","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simon","family":"Klau","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ingo","family":"Langner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7526-2660","authenticated-orcid":false,"given":"Christian","family":"Bachmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oliver","family":"Scholle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,12,18]]},"reference":[{"key":"431_CR1","doi-asserted-by":"publisher","first-page":"1151","DOI":"10.1007\/s00787-016-0831-8","volume":"25","author":"A Caye","year":"2016","unstructured":"Caye A, Spadini AV, Karam RG, et al. Predictors of persistence of ADHD into adulthood: a systematic review of the literature and meta-analysis. Eur Child Adolesc Psychiatry. 2016;25:1151\u20139.","journal-title":"Eur Child Adolesc Psychiatry"},{"key":"431_CR2","doi-asserted-by":"publisher","first-page":"942","DOI":"10.1176\/ajp.2007.164.6.942","volume":"164","author":"G Polanczyk","year":"2007","unstructured":"Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164:942\u20138.","journal-title":"Am J Psychiatry"},{"key":"431_CR3","doi-asserted-by":"publisher","first-page":"705","DOI":"10.1001\/jamapsychiatry.2016.0383","volume":"73","author":"A Caye","year":"2016","unstructured":"Caye A, Rocha TBM, Anselmi L, et al. Attention-deficit\/hyperactivity disorder trajectories from childhood to young adulthood evidence from a birth cohort supporting a late-onset syndrome. JAMA Psychiatry. 2016;73:705\u201312.","journal-title":"JAMA Psychiatry"},{"key":"431_CR4","doi-asserted-by":"publisher","first-page":"13","DOI":"10.3390\/jcm8101643","volume":"8","author":"S Kittel-Schneider","year":"2019","unstructured":"Kittel-Schneider S, Wolff S, Queiser K, et al. Prevalence of ADHD in accident victims: results of the PRADA study. J Clin Med. 2019;8:13.","journal-title":"J Clin Med"},{"key":"431_CR5","doi-asserted-by":"publisher","first-page":"303","DOI":"10.1111\/pcn.12393","volume":"70","author":"M Usami","year":"2016","unstructured":"Usami M. Functional consequences of attention-deficit hyperactivity disorder on children and their families. Psychiatry Clin Neurosci. 2016;70:303\u201317.","journal-title":"Psychiatry Clin Neurosci"},{"key":"431_CR6","doi-asserted-by":"publisher","first-page":"1145","DOI":"10.1001\/archpsyc.64.10.1145","volume":"64","author":"IJ Elkins","year":"2007","unstructured":"Elkins IJ, McGue M, Iacono WG. Prospective effects of attention-deficit\/hyperactivity disorder, conduct disorder, and sex on adolescent substance use and abuse. Arch Gen Psychiatry. 2007;64:1145\u201352.","journal-title":"Arch Gen Psychiatry"},{"key":"431_CR7","unstructured":"NICE. Attention deficit hyperactivity disorder: diagnosis and management. 2019."},{"key":"431_CR8","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1007\/s00787-004-1002-x","volume":"13","author":"E Taylor","year":"2004","unstructured":"Taylor E, Doepfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder\u2014first upgrade. Eur Child Adolesc Psychiatry. 2004;13:17\u201330.","journal-title":"Eur Child Adolesc Psychiatry"},{"key":"431_CR9","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1542\/peds.144.2MA1.25","volume":"144","author":"ML Wolraich","year":"2019","unstructured":"Wolraich ML, Hagan JF, Allan C, et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-feficit\/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144:25.","journal-title":"Pediatrics"},{"key":"431_CR10","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1177\/1087054718816172","volume":"24","author":"O Scholle","year":"2020","unstructured":"Scholle O, Fegert JM, Kollhorst B, Oeztuerk EE, Riedel O, Koelch M. Predictors for receiving medication and\/or psychotherapy in children newly diagnosed with ADHD: a longitudinal population-based cohort study. J Atten Disord. 2020;24:255\u201364.","journal-title":"J Atten Disord"},{"key":"431_CR11","volume-title":"Databases for pharmacoepidemiological research","author":"U Haug","year":"2021","unstructured":"Haug U, Schink T. German pharmacoepidemiological research database (GePaRD). In: Sturkenboom M, Schink T, editors. Databases for pharmacoepidemiological research. Cham: Springer; 2021."},{"key":"431_CR12","unstructured":"Herpertz SC, Herpertz S, Schaff C, Roth-Sackenheim C, Falkai P, Henningsen P, et al. Studie zur Versorgungsforschung: Spezifische Rolle der \u00c4rztlichen Psychotherapie [Health services research study: specific role of physician psychotherapy]. 2011. http:\/\/www.bundesaerztekammer.de\/fileadmin\/user_upload\/downloads\/aerztliche-psychotherapie-herpertz.pdf. Accessed 24 Apr 2020."},{"key":"431_CR13","doi-asserted-by":"publisher","unstructured":"Akmatov MK, Hering R, Steffen A, Holstiege J, Baetzing J. Aufmerksamkeitsdefizit-\/Hyperaktivit\u00e4tsst\u00f6rung bei Kindern und Jugendlichen in der ambulanten Versorgung in Deutschland. Teil 4 \u2013 Trends in der medikament\u00f6sen Versorgung im Zeitraum 2009 bis 2016 [Attention-deficit\/hyperactivity disorder in children and adolescents in outpatient care in Germany. Part 4 \u2013 Trends in medication use from 2009 to 2016]. Zentralinstitut f\u00fcr die kassenaerztliche Versorgung in Deutschland (Zi). Versorgungsatlas-Bericht Nr. 19\/02. Berlin. 2019. https:\/\/doi.org\/10.20364\/VA-19.02.","DOI":"10.20364\/VA-19.02"},{"key":"431_CR14","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0116407","author":"LE Arnold","year":"2015","unstructured":"Arnold LE, Hodgkins P, Caci H, Kahle J, Young S. Effect of treatment modality on long-term outcomes in attention-deficit\/hyperactivity disorder: a systematic review. PLoS ONE. 2015. https:\/\/doi.org\/10.1371\/journal.pone.0116407.","journal-title":"PLoS ONE"},{"key":"431_CR15","doi-asserted-by":"publisher","first-page":"753","DOI":"10.1177\/0269881111412095","volume":"26","author":"M Seixas","year":"2012","unstructured":"Seixas M, Weiss M, Muller U. Systematic review of national and international guidelines on attention-deficit hyperactivity disorder. J Psychopharmacol. 2012;26:753\u201365.","journal-title":"J Psychopharmacol"},{"key":"431_CR16","doi-asserted-by":"publisher","first-page":"663","DOI":"10.1111\/jcpp.12684","volume":"58","author":"JM Swanson","year":"2017","unstructured":"Swanson JM, Arnold LE, Molina BSG, et al. Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit\/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression. J Child Psychol Psychiatry. 2017;58:663\u201378.","journal-title":"J Child Psychol Psychiatry"},{"key":"431_CR17","doi-asserted-by":"publisher","first-page":"673","DOI":"10.1080\/15374416.2019.1630835","volume":"49","author":"EK Coles","year":"2020","unstructured":"Coles EK, Pelham WE, Fabiano GA, et al. Randomized trial of first-line behavioral intervention to reduce need for medication in children with ADHD. J Clin Child Adolesc Psychol. 2020;49:673\u201387.","journal-title":"J Clin Child Adolesc Psychol"},{"key":"431_CR18","doi-asserted-by":"publisher","first-page":"1201","DOI":"10.1007\/s00115-016-0168-z","volume":"87","author":"W Gaebel","year":"2016","unstructured":"Gaebel W, Zielasek J, Kowitz S. Utilization of outpatient psychotherapeutic treatment. A secondary data analysis. Nervenarzt. 2016;87:1201\u201310.","journal-title":"Nervenarzt"},{"key":"431_CR19","doi-asserted-by":"publisher","first-page":"98","DOI":"10.3389\/fpsyt.2016.00098","volume":"7","author":"U Altmann","year":"2016","unstructured":"Altmann U, Zimmermann A, Kirchmann HA, et al. Outpatient psychotherapy reduces health-care costs: a study of 22,294 insurants over 5 years. Front Psychiatry. 2016;7:98.","journal-title":"Front Psychiatry"},{"key":"431_CR20","doi-asserted-by":"publisher","first-page":"599","DOI":"10.1007\/s00115-020-00904-1","volume":"91","author":"A Haege","year":"2020","unstructured":"Haege A, Hohmann S, Millenet S, Banaschewski T. Attention deficit hyperactivity disorder in childhood and adolescence current state of research. Nervenarzt. 2020;91:599\u2013603.","journal-title":"Nervenarzt"},{"key":"431_CR21","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1055\/s-0044-102291","volume":"68","author":"A Bieda","year":"2018","unstructured":"Bieda A, Pflug V, Scholten S, et al. Unwanted side effects in children and youth psychotherapy\u2014introduction and recommendations. Psychother Psychosom Med Psychol. 2018;68:383\u201390.","journal-title":"Psychother Psychosom Med Psychol"},{"key":"431_CR22","doi-asserted-by":"publisher","first-page":"939","DOI":"10.1007\/s10198-012-0440-5","volume":"14","author":"S Braun","year":"2013","unstructured":"Braun S, Zeidler J, Linder R, Engel S, Verheyen F, Greiner W. Treatment costs of attention deficit hyperactivity disorder in Germany. Eur J Health Econ. 2013;14:939\u201345.","journal-title":"Eur J Health Econ"},{"key":"431_CR23","doi-asserted-by":"publisher","first-page":"58","DOI":"10.1089\/cap.2018.0060","volume":"29","author":"O Scholle","year":"2019","unstructured":"Scholle O, Jilani H, Riedel O, et al. Use of nutritional supplements in youth with medicated and unmedicated attention-deficit\/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2019;29:58\u201365.","journal-title":"J Child Adolesc Psychopharmacol"},{"key":"431_CR24","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1007\/s00115-016-0252-4","volume":"89","author":"W Schulz","year":"2018","unstructured":"Schulz W, Shin MA, Schmid-Ott G. Attitudes towards psychotherapy in South Korea and Germany. A cross-cultural comparative study. Nervenarzt. 2018;89:51\u20137.","journal-title":"Nervenarzt"},{"key":"431_CR25","doi-asserted-by":"publisher","first-page":"1074","DOI":"10.1001\/jamapediatrics.2014.1647","volume":"168","author":"WF Gellad","year":"2014","unstructured":"Gellad WF, Stein BD, Ruder T, et al. Geographic variation in receipt of psychotherapy in children receiving attention-deficit\/hyperactivity disorder medications. JAMA Pediatr. 2014;168:1074\u20136.","journal-title":"JAMA Pediatr"},{"key":"431_CR26","doi-asserted-by":"publisher","first-page":"1177","DOI":"10.1007\/s00115-019-0681-y","volume":"90","author":"J Nubel","year":"2019","unstructured":"Nubel J, Mullender S, Hapke U, Jacobi F. Epidemic of depression? Development of prevalence and help-seeking behaviour. Nervenarzt. 2019;90:1177\u201386.","journal-title":"Nervenarzt"},{"key":"431_CR27","first-page":"16","volume":"47","author":"B Martinez-Nunez","year":"2019","unstructured":"Martinez-Nunez B, Quintero J. Update the multimodal treatment of ADHD (MTA): twenty years of lessons. Actas Espanol Psiquiatr. 2019;47:16\u201322.","journal-title":"Actas Espanol Psiquiatr"},{"key":"431_CR28","doi-asserted-by":"publisher","first-page":"889","DOI":"10.1177\/1087054716671197","volume":"24","author":"MV Cherkasova","year":"2020","unstructured":"Cherkasova MV, French LR, Syer CA, et al. Efficacy of cognitive behavioral therapy with and without medication for adults with ADHD: a randomized clinical trial. J Atten Disord. 2020;24:889\u2013903.","journal-title":"J Atten Disord"},{"key":"431_CR29","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.4980","volume":"2","author":"AP Lam","year":"2019","unstructured":"Lam AP, Matthies S, Graf E, et al. Long-term effects of multimodal treatment on adult attention-deficit\/hyperactivity disorder symptoms follow-up analysis of the COMPAS trial. JAMA Netw Open. 2019;2: e194980.","journal-title":"JAMA Netw Open"},{"key":"431_CR30","doi-asserted-by":"publisher","first-page":"571","DOI":"10.3389\/fpsyt.2018.00571","volume":"9","author":"S Corbisiero","year":"2018","unstructured":"Corbisiero S, Bitto H, Newark P, et al. A comparison of cognitive-behavioral therapy and pharmacotherapy vs. pharmacotherapy alone in adults with attention-deficit\/hyperactivity disorder (ADHD)-a randomized controlled trial. Front Psychiatry. 2018;9:571.","journal-title":"Front Psychiatry"},{"key":"431_CR31","doi-asserted-by":"publisher","DOI":"10.1055\/a-1540-4958","author":"C Jaite","year":"2021","unstructured":"Jaite C, Hoffmann F, Seidel A, Mattejat F, Bachmann CJ. Outpatient psychological therapies in children and adolescents in Germany: status quo and time trends, 2009\u20132018. Psychiatr Praxis. 2021. https:\/\/doi.org\/10.1055\/a-1540-4958.","journal-title":"Psychiatr Praxis"}],"container-title":["Child and Adolescent Psychiatry and Mental Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13034-021-00431-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13034-021-00431-0\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13034-021-00431-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,14]],"date-time":"2023-11-14T13:01:47Z","timestamp":1699966907000},"score":1,"resource":{"primary":{"URL":"https:\/\/capmh.biomedcentral.com\/articles\/10.1186\/s13034-021-00431-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,12]]},"references-count":31,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2021,12]]}},"alternative-id":["431"],"URL":"https:\/\/doi.org\/10.1186\/s13034-021-00431-0","relation":{},"ISSN":["1753-2000"],"issn-type":[{"value":"1753-2000","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,12]]},"assertion":[{"value":"20 May 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 December 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 December 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"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, Women and Consumer Protection in Bremen as their responsible authorities approved the use of GePaRD data for this study.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Oliver Riedel, Oliver Scholle, Ingo Langner, and Simon Klau are working at an independent, non-profit research institute, the Leibniz Institute for Prevention Research and Epidemiology \u2013 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. Christian Bachmann reports no conflict of interest.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"76"}}