ADHD in Children, Adolescents, and Adults

Incidence, Prevalence, and Treatment: Analysis of Routine Health Insurance Data

Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders in children and adolescents, with symptoms often persisting into adulthood. We studied epidemiology and health care provision for ADHD in Germany by analyzing recent billing data.

Methods: Anonymized billing data from 2017 to 2023 were examined. Patients with ≥ 2 outpatient or one inpatient ADHD diagnosis were included. Application of the inclusion and exclusion criteria yielded 78 919 ADHD cases for analysis.

Results: The administrative prevalence of ADHD in 2023 was 3.6% in children/adolescents and 0.6% in adults. In 2023, 40.9% of children and adolescents with ADHD received no treatment, 47.8% were treated with drugs alone, 4.2% were treated with psychotherapy alone, and 7.1% received multimodal therapy. 44.4% of adults with ADHD received no treatment, 38% were treated with drugs alone, 7.6% were treated with psychotherapy alone, and 10% received multimodal therapy. Over the period of observation, the prevalence of ADHD and the frequency of drug treatment, psychotherapy, and multimodal therapy rose slightly.

Conclusion: This secondary data analysis characterizes the care of ADHD in Germany. In 2023, the administrative prevalence was much lower in adults than in children and adolescents. Over the period of observation, there was a continuous rise in the provision of psychotherapeutic services—especially behavioral therapy—while the percentage of patients treated with neither drugs nor psychotherapy fell; yet overall rates of treatment are still low, particularly for psychotherapy.

Cite this as: Betzler F, Knop J, Grönig M, Timpel P, Višković V, Schöttle D: ADHD in children, adolescents, and adults: incidence, prevalence, and treatment. An analysis of routine health insurance data. Dtsch Arztebl Int 2026; 123: 275–80. DOI: 10.3238/arztebl.m2026.0032

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders. It begins in childhood or adolescence and persists into adulthood in a significant proportion of cases (1, 2).

Epidemiological studies report prevalence estimates of approximately 3–7% for children and adolescents (3, 4, 5). ADHD follows a heterogeneous course across the lifespan. Longitudinal studies show that the core symptoms persist into adolescence and adulthood in a proportion of those affected, while others experience partial remission or a change in clinical manifestations. Approximately 15–20% of children with ADHD continue to meet all diagnostic criteria in adulthood, while 40–60% exhibit partial remission with persistent functional impairments (6). The reported prevalence in adulthood varies between approximately 1 and 3%, with the range in prevalence estimates reflecting methodological differences, regional variability, and different diagnostic criteria (1, 2, 7, 8, 9). Diagnostic criteria also differ, for example, with regard to the age at which initial symptom onset must have occurred. While the “International Statistical Classification of Diseases and Related Health Problems” (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) stipulated symptom onset before age 7, the threshold in the DSM-5 has been raised to 12 years and adopted in the ICD-11. The ICD-11 also permits later symptom onset, thereby lowering the diagnostic threshold.

ADHD is characterized by persistent patterns of inattention, impulsivity, and hyperactivity that can lead to functional impairments in multiple areas of life (8). In addition to psychoeducation and drug treatment, the evidence-based, guideline-compliant treatment of ADHD is also based on a multimodal approach that comprises psychotherapy—in particular behavioral therapy (BT)—and psychosocial measures (10, 11, 12). While the American Academy of Pediatrics guideline recommends behavioral therapy as the first-line treatment in preschool children, a combination of stimulant medication (for example, methylphenidate; effect size: standardized mean difference [SMD] = −0.77; 95% confidence interval [CI], −0.90 to −0.64, based on teacher ratings) (13), behavioral therapy (effect size: SMD = 0.42; 95% CI, 0.33 to 0.51, based on parent ratings) (14), and school-based interventions is recommended from school age onward (15). The NICE guideline and the German clinical practice guideline confirm this approach and emphasize the importance of psychoeducation and parental training (10, 16, 17).

In adults, initial psychoeducation followed by drug treatment represents the standard approach. The effect sizes for drug treatments in adults with ADHD range between SMD = –0.35 and –0.66 [–0.94; –0.21] (18). These treatment options are supplemented by cognitive behavioral therapy, the effect size of which is SMD = –0.45. Treatment is tailored to symptom severity, comorbidities, and patient preference (17, 19, 20). Occupational therapy interventions, in particular structured programs such as the Cognitive-Functional (Cog-Fun) intervention in children with ADHD, show moderate to large improvements in executive and everyday functioning (21). In addition, international analyses and consensus statements suggest that occupational therapy in adults with ADHD, by focusing on everyday functioning, represents a useful component in the multimodal care context, the aim of which is to improve self-organization skills and participation in everyday life (22).

In light of this, the present study aims to use health insurance billing data to present administrative prevalence, incidence, and care indicators for ADHD among children, adolescents, and adults in Germany and to describe trends over time. The study focuses on the descriptive analysis of diagnosed cases and treatment services utilized within the statutory health insurance system.

Materials and methods

This retrospective cohort study was based on anonymized routine data from the statutory health insurance (SHI) obtained from the InGef Research Database (approximately 10 million insured individuals) for the period 2017–2023 (eMethods). The data are representative of the SHI population with regard to morbidity, mortality, and drug prescriptions and could be evaluated in the present secondary analysis in compliance with data protection regulations without additional ethics approval.

Insured individuals with at least one inpatient or two confirmed outpatient ADHD diagnoses (ICD-10-GM F90.0) in different quarters were included. Prevalence (2017–2023) and incidence cohorts (2018–2023, without a diagnosis in the previous year) were defined separately for children/adolescents (< 18 years) and adults (≥ 18 years).

The analysis was conducted on a yearly basis and descriptively. Treatment modalities, hospitalizations, and medical specialist groups were identified based on standardized billing and specialist group codes. To assess robustness, multiple sensitivity analyses were performed (eBox). Reporting was based on the STROSA-2-/STROBE recommendations (eChecklist).

eBox

Sensitivity analyses

Results

Description of the population

Of 7 758 093 patients in the database for 2023, 7 278 205 met the inclusion criteria of continuous insurance coverage throughout the entire observation year or of birth or death during this period. A further selection, based on continuous insurance coverage in the SHI during the observation year and the preceding year, reduced the sample to 6 941 858 insured individuals. The application of clinical inclusion criteria relating to the F90.0 diagnosis yielded a final study population of 78 919 insured individuals.

Prevalence and incidence

In 2023, the administrative prevalence of ADHD in Germany was 1.1% (children/adolescents and adults combined), corresponding to approximately 918 000 cases. In the under-18 age group, the prevalence was significantly higher at 3.6% compared to adult patients with ADHD (0.6%). Since 2017, the prevalence in the overall population has risen from 0.8% to 1.1%, which equates to a relative increase of more than 30%. This rise occurred alongside the growing prevalence among adults (+ 89.7%; Figure).

Figure

Trends in prevalence and incidence in patients with attention-deficit/hyperactivity disorder (ADHD), both overall and in the age categories < 18 years and ≥ 18 years for the period from 2017/2018 to 2023. The decline in prevalence and incidence in 2023 is due to methodological factors, since a second outpatient diagnosis was required in the following year. Data for 2024 were not available at the time of the analysis.

The incidence of ADHD remained largely stable during the study period and was 0.26% in 2023 (Figure). This corresponds to 217 000 cases in Germany. Since 2018, however, a slight increase in the overall incidence from 0.22% to 0.26% has been observed. This rise was observed primarily in adults, in whom the incidence steadily rose from 0.07% to 0.13% over the same period. In contrast, incidence rates among children and adolescents (< 18 years) fluctuated.

The decline in prevalence and incidence in 2023 can be attributed to methodological reasons, since a second outpatient diagnosis in the following calendar year served as an inclusion criterion. At the time of the analysis, the data for 2024 were not yet available (Figure).

Utilization of healthcare services

Hospitalization

In 2023, 42.7% of children/adolescents and 35.2% of adults with prevalent ADHD had at least one hospitalization (Table 1), regardless of the reason for treatment; cases did not need to be coded for ADHD, either as a main or as a secondary diagnosis, in order to be included. The hospitalization rate among patients with incident ADHD was higher: 53.4% among children/adolescents and 49.9% among adults. Overall hospitalization rates, as well as the rates of hospitalization due to somatic or psychiatric disorders, were also higher among patients with incident ADHD. The greatest difference was seen in hospitalizations for psychiatric disorders (22% versus 38% in 2023 among adults). The hospitalization rate increased slightly over time, while the length of hospital stay remained stable (Table 1).

Table 1

Hospitalizations and length of stay of patients with prevalent ADHD in 2023

Outpatient specialist visits

Most pediatric and adolescent ADHD patients had at least one visit to a pediatric and adolescent medicine specialist (79%), with the average being six visits. The number of visits to specialists in pediatric and adolescent psychiatry, psychosomatics, psychotherapy, and neurology was somewhat lower (57%, 12 visits). In adult ADHD patients, visits were primarily to specialists in general medicine/internal medicine (96%, nine visits), as well as to specialists in adult psychiatry, psychotherapy, and neurology (57%, 10 visits). eTable 8 provides a detailed analysis of visits to medical specialists in 2023.

Pharmacological and non-pharmacological treatment

The proportion of ADHD patients who received no treatment within an observation year increased with age—from 40.9% among children and adolescents to 44.4% among adults (Table 2). Pharmacological therapy was the most commonly utilized treatment modality across all age groups, accounting for 47.8% of children/adolescents and 38.0% of adults. Multimodal treatment (combined pharmacotherapy and psychotherapy), on the other hand, was more common in adults (10.0%) than in children/adolescents (7.1%). Psychotherapy alone was utilized more frequently in adults (7.6%) than in younger patients (4.2%). The proportion of patients who received psychotherapy alone was 5.8% across all ages. More than one in five children/adolescents received occupational therapy (22.4%) (Table 2). A breakdown of treatment groups (no therapy, pharmacotherapy, psychotherapy, multimodal therapy) across the observation period is shown in eFigure 1.

Table 2

Proportions of the various pharmacological and non-pharmacological treatments in patients with prevalent ADHD in 2023

eFigure 1

Proportion of patients with prevalent ADHD without treatment (no pharmacotherapy, no psychotherapy), with pharmacotherapy only (no psychotherapy), with multimodal therapy (*pharmacotherapy + psychotherapy), or with psychotherapy only (no pharmacotherapy).

eFigure 2

Selection of the study population

In 2023, 11% of children/adolescents with prevalent ADHD received at least one session of psychotherapy, whereas approximately 18% of adults with prevalent ADHD received psychotherapy (annual utilization of psychotherapy;

eTable 7

Proportion of patients with prevalent ADHD receiving treatment, as well as the mean annual number of sessions for PSY or BT by age group

eTable 7). Children/adolescents received an average of 14.8 psychotherapy sessions per year, while adults attended 13.8 sessions. A similar pattern was observed particularly for BT: approximately 6% of children/adolescents with prevalent ADHD attended at least one BT session, while this figure was 11% among prevalent adults. The average number of BT sessions in the two groups was 14.5 and 13.4, respectively. Overall, approximately 90% of all BT sessions were accounted for by individual therapy sessions, whereas only around 10% were conducted as group therapy (eTable 6).

eTable 6

Comparison of psychotherapy and behavioral therapy utilization by treatment context (individual vs. group) and age group (2023)

In the period from 2017 to 2023, there was a continuous rise in the proportion of ADHD patients receiving BT. Among children/adolescents, the proportion was still 5.1% in 2017, and among adults, 7.1% (eTable 7).

The proportion of pediatric/adolescent patients treated with psychotherapy (or BT) in the group of incident cases (11.2% psychotherapy [5.5% for BT]) was slightly lower than in the group of prevalent cases (11.3% [6.3%]). Among adults, in contrast, a higher proportion of incident cases received psychotherapy (26% for psychotherapy and 15% for BT, with an average of 14.0 and 14.2 sessions, respectively).

Discussion

This secondary data analysis studied the epidemiology and care of patients with ADHD in Germany based on billing data.

The administrative prevalence of ADHD in 2023 was 0.6% for adults and 3.6% for children/adolescents. The overall recorded administrative prevalence of 1.1% was lower than the 1.5% prevalence reported by Bachmann et al. (3) for 2014, but higher than the 0.68% prevalence reported by Libutzki et al. (23). These discrepancies can be explained by methodological factors, in particular differences in the ICD codes used. The stringent case definition (M2Q principle) increases specificity, but can lead to lower prevalence estimates. Sensitivity analyses show moderate robustness with consistent directionality compared to alternative case definitions (eBox).

While epidemiological studies report prevalence estimates of approximately 3–7% for children and adolescents (3, 4, 5), meta-analyses in adults in the general population point to a pooled prevalence of around 3.1% [2.60; 3.60] (I² = 98.9%), whereby, depending on the case definition, higher symptomatic prevalence rates have been described (for example, 2.58% [1.51; 4.45] for persistent ADHD versus 6.76% [4.31; 10.61] for symptomatic ADHD) (9, 24). A persistence rate into adulthood of 47% has also been reported (25). The administrative prevalence rates observed in the present analysis are within this spectrum for children but below it for adults. Administrative SHI billing data typically show lower ADHD prevalence rates (approximately 1–2%) than population-based survey and measurement studies (often around 2.5–5% or higher) (4, 9). This is partly due to the fact that register studies include the entire population as the reference group and therefore report systematically lower prevalence rates (approximately 1.6% [0.9; 3.0]) than survey studies (approximately 5.0% [2.9; 8.6]) or clinical studies (around 4.2–4.8%) (4). Moreover, differences may arise from differing data collection methods, given that billing data capture coded care cases, while population-based surveys include clinical or patient-reported measurements as well as individuals without a documented diagnosis (4, 26, 27). Results of the INTEGRATE-ADHD project also show that only 71.6% of parents report the administrative ADHD diagnosis of their child in surveys (28). Administrative ADHD prevalence rates derived from routine data can reflect the reality of diagnosis and care, but due to selective documentation and reporting effects, they can only be interpreted to a limited extent as direct epidemiological prevalence estimates (28, 29).

An analysis of nationwide outpatient billing data for adult SHI-insured individuals showed an increase in the cumulative incidence of AD(H)D diagnoses by 199% (from 8.6 to 25.7 per 10 000) between 2015 and 2024, particularly among younger individuals and even more so since 2021 (30). Therefore, the increase in incidence and prevalence observed in this analysis may be influenced by increased awareness of ADHD, changes in diagnostic practice, cohort effects, and structural changes in health care provision (31, 32, 33, 34). At the same time, potential upcoding needs to be taken into consideration in the context of administrative data, as the increase in documented diagnoses may also occur as a result of financial incentives and changes in the coding system, without necessarily reflecting an actual increase in the disorder (35). A clear distinction between real epidemiological changes and coding or system effects is not possible with billing data (36, 37).

The inpatient psychiatric treatment rate of 22% indicates that routine data tend to reflect patients with greater disease severity, comorbidities, and significant psychological distress.

In the present analysis, 42.5% of ADHD patients received no treatment in 2023 (adults, 44.4% and children/adolescents, 40.9%), with this proportion steadily declining since 2017. The increasing shares of pharmacologically treated children and adolescents are consistent with national (38, 39, 40) and international (31, e1) trends. European comparisons show marked inter-country variability in the utilization of behavioral therapy services (for example, 23–77% in the CAPPA survey), suggesting strongly context-dependent care pathways (e2, e3, e4). Possible explanations for this include clinical heterogeneity (1), lack of desire for treatment, completed or intermittent treatment courses, interventions not relevant for billing purposes (e5, e6), as well as age-related differences in access (2, 3).

For 2018, it was reported that 7.3% of children and adolescents with ADHD received psychotherapy (e7). Our study shows that in 2023, a total of 14.3% of patients received psychotherapy, with adults more likely to utilize psychotherapeutic services than children and adolescents. Riedel et al. (e8) report less than 14% multimodal or purely psychotherapeutic treatment among children, which is consistent with our results for 2023 (11.3% of children/adolescents receiving psychotherapy, 7.1% receiving multimodal therapy). In addition, the share of children and adolescents with at least one occupational therapy session (22.4%) was also higher than that among children without ADHD, confirming previous findings (17).

Strengths and limitations

This analysis is based on billing data, thereby enabling the analysis of data from almost 79 000 patients for 2023. The InGef research database is considered representative of the German population covered by statutory health insurance with regard to morbidity, mortality, and drug prescribing (e9, e10); however, it does not contain information on disease severity or indications for pharmacological or psychotherapeutic treatments. The inclusion of ADHD patients based, among other criteria, on the presence of a total of two outpatient diagnoses in two quarters of an observation year may have led to a slight underestimation of patient numbers. At the same time, case projections for 2023 are underestimated due to right-censoring (cases diagnosed in 2024 fell outside the observation period).

Summary

The administrative prevalence of ADHD was lower among adults in 2023 than among children and adolescents. Over the 2017–2023 period, changes were observed in the documented forms of care, including a declining share of individuals without billed pharmacological or psychotherapeutic treatment, as well as an increase in psychotherapeutic services. Behavioral therapy, in particular, became more important. Overall, however, almost half of patients with ADHD in adulthood received no treatment, and only one in five received psychotherapy.

Acknowledgments

The authors would like to thank Roman Spelsberg for his critical review of the manuscript and his valuable comments on the interpretation of the results.

Funding

The study was funded by Takeda Pharma Vertrieb GmbH & Co. KG.

Conflict of interest statement

FB has received speaker’s and/or consultancy fees and/or study funding from Takeda, Medice, and MiNDNET. He is a member of the Advisory Board and has received brochures and other materials from Takeda and Medice.

JK and MG are employed by Takeda.

PT has received speaker’s and/or consultancy honoraria from Takeda.

VV is employed by the InGef Institute, which conducted the data analysis for Takeda.

DS has received speaker’s and/or consultancy fees and/or reimbursement of travel expenses/conference fees and/or study support (third-party funding) and/or is a member of the Steering Boards of Otsuka, Lundbeck, Boehringer Ingelheim, Roche, Janssen Cilag, ROVI, Recordati, Medice, Takeda, and Mindnet. He has received author’s fees from Elsevier, Thieme, Kohlhammer, and Penguin Books.

Manuscript submitted on 24 August 2025, revised version accepted on 20 February 2026.

Translated from the original German by Christine Rye.

Corresponding author
PD Dr. med. Felix Betzler

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