Utilization of Mental Health Care Services Among Children and Adolescents with ADHD in Germany: Treatment Satisfaction and Factors Influencing Access

Introduction

Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by symptoms of developmentally inappropriate inattentiveness, impulsivity, and/or hyperactivity. For an ADHD diagnosis, these symptoms must persist for at least 6 months and negatively impact academic, occupational, and social functioning (American Psychiatric Association, 2013; World Health Organization, 2004). ADHD is one of the most common mental disorders among children and adolescents, with meta-reviews estimating a global prevalence of 5% (Polanczyk et al., 2014). When properly diagnosed, ADHD is a highly treatable condition. However, it often remains undetected, which can lead to significant impairments in psychosocial, educational, and occupational functioning, as well as an increased risk of developing comorbid mental health disorders later in life (Rivas-Vazquez et al., 2023). This not only results in prolonged and unnecessary individual suffering but also imposes a substantial economic burden on society (Matza et al., 2005). Therefore, early diagnosis and continuous access to appropriate care are essential to prevent long-term adverse outcomes. To improve early identification and treatment, it is crucial to understand why a considerable number of young people remain undiagnosed or do not receive adequate ADHD treatment. While international—particularly U.S., Canadian, and British—research has addressed patterns of ADHD care utilization, cross-national differences in service structures, and sociocultural perceptions of ADHD make it difficult to generalize findings. Despite a growing body of evidence, there is still a lack of data on health care services utilization, treatment satisfaction, and factors influencing utilization among children and adolescents with ADHD in Germany.

In their recent international review of barriers to ADHD care, Baweja et al. (2021) highlighted that, although several evidence-based psychosocial and pharmacological ADHD treatments exist—and greater utilization of these services is associated with symptom improvement—treatments are often not used or are discontinued prematurely. They identified a variety of structural and attitudinal barriers, including treatment burden (such as cost, time, and travel), limited treatment availability, stigma, lack of parental knowledge, low child motivation, and low self-efficacy to implement change. In an earlier systematic international review, Wright et al. (2015) found that beliefs and perceptions regarding treatment efficacy and acceptable behavior influence help-seeking behavior. Sibley et al. (2022) conducted a mixed-method analysis of audio-recorded therapy sessions in the U.S. and found that common barriers to behavior therapy for adolescent ADHD included low adolescent desire (72.5%), parental failure to monitor skill application (69.4%), adolescent forgetfulness (60.3%), and adolescent belief that change is unnecessary (56.2%). Additional systemic barriers to care for youth with ADHD have also been identified. These include a lack of ADHD education among primary care physicians, which may lead to inadequate recognition and diagnosis and, consequently, low ADHD treatment rates (French et al., 2019; Gamma et al., 2017).

For Germany specifically, Döpfner et al. (2010) suggested that there is a lack of locally available behavioral therapy for ADHD patients. Additionally, therapy interruptions during the transition from adolescence to adulthood, due to a lack of continuity between pediatric and adult care in Germany, increase the risk of negative outcomes for ADHD patients (Bachmann et al., 2017; Libutzki et al., 2019). The decline in ADHD prevalence in adulthood likely results from under-recognition and limited specialized care (Bachmann et al., 2017; Philipsen & Döpfner, 2020). If ADHD remains untreated during childhood, adolescence, and adulthood, it can lead to a higher risk of poor academic performance, mental health and substance use disorders (e.g., depression), criminal behavior (e.g., arrests), and unemployment in adulthood (Erskine et al., 2016). Therefore, it is crucial to better understand the scope and determinants of health service utilization among children and adolescents with ADHD to develop effective interventions that improve the care and well-being of those affected.

With regard to sociodemographic factors associated with the utilization of mental health care services among children and adolescents with ADHD, Bussing et al. (1998) reported that girls had more unmet ADHD care needs than boys. In contrast, a study by Cuffe et al. (2009) found no gender difference in ADHD care utilization. Cuffe et al. (2009) also examined the impact of age on ADHD care utilization, finding that younger children between the ages of 9 and 13 were more likely to visit a medical professional than those aged 14 to 17. Studies on the association between socioeconomic status (SES) and mental health care utilization show mixed results: While Schlack et al. (2007) found that children with low SES were diagnosed with ADHD twice as often, they did not investigate health care utilization. A Canadian study by Brownell et al. (2006) found that SES was inversely related to medication use, whereas other studies found no association between SES and medication use (Russell et al., 2019). Additional studies found that lower SES was associated with less medication use (Froehlich et al., 2007) and lower engagement in and adherence to parental ADHD training (Chacko et al., 2016). Studies on the association between migration background and mental health care utilization indicate that in some countries, children with a migration background have lower rates of health care utilization than non-migrant children (Eiraldi et al., 2006; Yang et al., 2022). In the U.S., a recent review reported that medication use was particularly less frequent among Black, Hispanic, and Asian children (Baweja et al., 2021). However, results are mixed; for example, Cuffe et al. (2009) found no association between race and ADHD care utilization. For Germany, Schlack et al. (2007) found that children from families with a migration background were less likely to report an ADHD diagnosis, potentially due to migrant-specific underdiagnosis or differences in health care utilization between migrants and non-migrants. However, to date, there are no findings on whether migration background affects ADHD care utilization in Germany.

Regarding geographic factors, living in rural areas has found to be associated with a 30% higher likelihood of an ADHD diagnosis in children (Danielson et al., 2018) but with lower health care utilization compared to living in urban sites (Danielson et al., 2018; Howell & McFeeters, 2008; Janicke & Davis, 2011). Moreover, Sayal et al. (2015) found in the UK that the more ADHD symptoms a child exhibits, the more health care they receive. However, this has not yet been replicated for German youth. Finally, research indicates that parental mental health problems are associated with higher mental health service use for children with ADHD (Cuffe et al., 2009; Sayal et al., 2015).

In conclusion, despite growing international research, there is a substantial lack of representative data on how children and adolescents with ADHD in Germany access and experience mental health care. Specifically, little is known about how sociodemographic, geographic, health-related, and parental factors are associated with service utilization, and which barriers contribute to insufficient treatment. Addressing these gaps is essential to inform strategies that improve access, continuity, and effectiveness of ADHD care in the German health system.

Thus, the present study aims to enhance the understanding of ADHD-specific mental health care utilization in Germany by examining sociodemographic and health-related factors, using quantitative data from the consortium project INTEGRATE-ADHD. The consortium project INTEGRATE-ADHD was established to compare and integrate administrative and epidemiological ADHD diagnostic data for children and adolescents in Germany through clinical assessment. The aims of the present study are as follows:

Methods

Instruments

Current mental health care utilization, factors influencing utilization, treatment satisfaction, and belief in treatment efficacy were examined using established items from the KiGGS and BELLA studies. Current mental health care utilization was measured as a dichotomous variable, asking whether the child or adolescent was currently receiving psychological, psychotherapeutic, or psychiatric treatment for ADHD. This question was directed only to parents who had previously indicated that their child had an ADHD diagnosis. A filter-related missing in this variable (because the parents did not report an ADHD diagnosis for their child) was categorized as no current mental health care utilization. Among children and adolescents receiving mental health care, treatment satisfaction was assessed by asking parents to rate their satisfaction with the treatment on a 4-point Likert scale (“not at all” (1), “a little” (2), “fairly/quite” (3), “very” (4)). Parental belief in treatment efficacy was measured on a 4-point Likert scale, ranging from “not at all effective” (1) to “very effective” (4).

Factors influencing mental health care utilization were assessed using an established item from the BELLA study, asking about reasons for not seeking mental health care services. Multiple answers were allowed. This question was presented only to parents who had previously indicated that their child had an ADHD diagnosis but who did not report any use of mental health care services. The available response options are listed in Figure 1.

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Figure 1.

Factors influencing mental health care utilization (subsample not currently receiving mental health care; n = 1,591).

Sociodemographic information, including children’s and adolescents’ gender and age, as well as the families’ SES and migration background, was collected. SES was determined using the Comparative Analysis of Social Mobility in Industrial Nations (CASMIN) classification (Brauns et al., 2003), which categorizes SES based on parental education. Based on two items assessing the highest academic and vocational qualifications of both parents, parents were categorized into three groups reflecting low (primary education), medium (secondary education), and high (tertiary education) levels of education. Participants were identified as having a migration background if they had immigrated to Germany and had at least one parent born in a country other than Germany, or if both parents had immigrated to Germany or did not hold German citizenship (Schenk et al., 2006).

Geographic characteristics were defined using data from the Federal Institute for Research on Building, Urban Affairs and Spatial Development (referred to as INKAR data, “Indicators and Maps for Spatial and Urban Development”). Urban residential environments included medium-sized cities (more than 20,000 inhabitants) and large cities (over 100,000 inhabitants), while rural areas were classified as small towns (fewer than 20,000 inhabitants) and rural communities (Milbert & Porsche, 2022).

ADHD symptom severity was assessed using the parent-reported German ADHD Rating Scale (FBB-ADHS) (Döpfner & Görtz-Dorten, 2017). The scale consists of 20 items that correspond to the ADHD symptom criteria of the ICD-10 and DSM-V. Responses reflect the severity of ADHD symptoms and range from “not true” (0) to “especially true” (3). Erhart et al. (2008) found that the FBB-ADHS demonstrated good to excellent internal consistency (Cronbach’s α = .73–.90) as well as factorial validity (RMSEA = 0.06).

Parental psychopathology was measured using the short version of the multidimensional Symptom-Checklist 90-R (SCL-90-R) (Derogatis, 1977, 1992; Derogatis & Savitz, 1999; Franke, 1995, 2002)—the SCL-K-9 (Klaghofer & Brähler, 2001). Items measuring parental psychopathological symptoms were measured on a five-point Likert scale, ranging from “not at all” (0) to “very strongly” (4). The internal consistency of the short form has been reported with a Cronbach’s alpha of .87, indicating good reliability (Petrowski et al., 2019).

Results

Descriptive Statistics

An analysis of the sociodemographic characteristics of the sample revealed that the average age of the children and adolescents was 12 years. Among them, 75% were boys. The majority of the parents (60%) had a medium level of education and did not have a migration background (91%). Additionally, 63% of the children and adolescents resided in an urban area. Further details on the sociodemographic and psychosocial characteristics of the analyzed sample are presented in Table 1.

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Table 1.

Description of the Analyzed Sample of Children and Adolescents (N = 4,984).

	INTEGRATE-ADHD sample
Variable	n (%)	M (SD)
Age (7–17 years)	4,948	12.36 (2.71)
Gender
Male	3,707 (74.9)
Female	1,241 (25.1)
Parental education
Low	517 (10.4)
Medium	2,968 (60.0)
High	1,238 (25.0)
No information	225 (4.5)
Migration background
No	4,490 (90.7)
Yes	302 (6.1)
No information	156 (3.2)
Geographic region
Urban	3,122 (63.1)
Rural	1,756 (35.5)
No information	70 (1.4)
Mental health care utilization
Yes	1,994 (40.3)
No	2,954 (59.7)
Treatment satisfaction a
Not at all satisfied	82 (4.1)
A little satisfied	395 (19.8)
Quite satisfied	916 (45.9)
Very satisfied	600 (30.1)
Parental belief in treatment efficacy a
Not at all effective	46 (2.3)
Barely effective	225 (11.3)
Somewhat effective	988 (49.6)
Very effective	732 (36.8)
ADHD symptom severity	4,870	1.29 (0.68)
No information	78 (1.6)
Parental psychopathology	4,825	8.59 (6.81)
No information	123 (2.5)

Note. M = mean; SD = standard deviation.

a

This question was only presented to those parents who had previously indicated that their child had an ADHD diagnosis and was utilizing mental health care (n = 1,994).

Associations of Sociodemographic Factors, Geographic Characteristics, and Health-Related Factors With Current Mental Health Care Utilization and Treatment Satisfaction

Logistic regression analyses revealed that families with a migration background had a 0.64 lower likelihood of utilizing mental health care services. Children with more severe ADHD symptoms were nearly three times more likely to use mental health services (OR = 2.82) (see Table 2). In terms of treatment satisfaction, logistic regression analyses further revealed that parents of children with more severe ADHD symptoms were less likely to be satisfied with the mental health care their children received (OR = 0.57). Additionally, parents with higher levels of psychopathology were less likely to be satisfied with their child’s treatment; however, the OR was nearly 1 (0.96), indicating that this effect can be considered negligible (see Table 3).

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Table 2.

Results of Multivariate Logistic Regression Analyses on Factors Predicting Current Mental Health Care Utilization Among Children and Adolescents With ADHD (n = 4,582).

Variable	Estimate	SE	OR [CI]	p
Constant	−1.75	0.21	0.17	<.001
Predictor variables
Gender (reference: male)	−0.05	0.07	0.95 [0.82, 1.10]	.507
Age	0.00	0.01	1.00 [0.98, 1.03]	.873
Parental education (reference: low)
Medium	−0.01	0.11	0.99 [0.80, 1.21]	.904
High	0.10	<0.12	1.11 [0.89, 1.40]	.350
Migration background	−0.44	0.14	0.64 [0.49, 0.84]	.001
Geographic region (reference: rural)	0.70	0.07	1.07 [0.94, 1.22]	.291
ADHD symptom severity	1.04	0.05	2.82 [2.54, 3.13]	<.001
Parental psychopathology	0.00	0.01	1.00 [0.99, 1.01]	.938
Model fit	χ 2 (8) = 40.72, p < .001 Nagelkerke’s R 2  = .14

Note. SE = standard error; OR = odds ratio; CI = confidence interval.

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Table 3.

Results of Multivariate Logistic Regression Analyses on Factors Predicting Treatment Satisfaction (Subsample Currently Receiving Mental Health Care Services; n = 1,907).

Variable	Estimate	SE	OR [CI]	p
Constant	2.22	0.39	9.21	<.001
Predictor variables
Gender (reference: male)	0.01	0.13	1.01 [0.78, 1.31]	.920
Age	0.01	0.02	1.01 [0.97, 1.06]	.559
Parental education (reference: low)
Medium	0.16	0.18	1.17 [0.83, 1.66]	.369
High	−0.20	0.20	0.82 [0.56, 1.20]	.306
Migration background	−0.06	0.25	0.95 [0.56, 1.53]	.818
Geographic region (reference: rural)	0.30	0.12	1.03 [0.82, 1.30]	.782
ADHD symptom severity	−0.56	0.10	0.57 [0.47, 0.69]	<.001
Parental psychopathology	−0.04	0.01	0.96 [0.95, 0.98]	<.001
Model fit	χ 2 (8) = 9.43, p = .308 Nagelkerke’s R 2  = .07

Note. SE = standard error; OR = odds ratio; CI = confidence interval.

Discussion

The aim of the present study was to examine the utilization of mental health care services in a sample of children and adolescents with an administrative ADHD diagnosis, using data from the consortium project INTEGRATE-ADHD. In addition to treatment satisfaction and beliefs about treatment efficacy, the study also investigated factors associated with mental health care utilization and treatment satisfaction.

The study found that mental health care utilization among children and adolescents with ADHD was strongly associated with the severity of ADHD symptoms. Children with more severe symptoms were three times more likely to receive psychological, psychotherapeutic, or psychiatric treatment. This finding is intuitively understandable, as more severe ADHD symptoms are often linked to disruptive behaviors in the family or at school (e.g., attention shifts, impulsivity, and hyperactivity), which can lead to increased stress and burden for parents (Peasgood et al., 2021; Peñuelas-Calvo et al., 2021). Consequently, parents may seek additional support from mental health services. Additionally, more severe ADHD symptoms may be more readily recognized by pediatricians compared to less obvious or covert symptoms, potentially resulting in more referrals to mental health specialists. Furthermore, our findings indicated that families with a migration background were less likely to utilize mental health care. This may be due to various factors, such as language barriers, unfamiliarity with the German health care system, or discrimination against migrant families within that system. Although language proficiency was not assessed directly, limited German skills may have contributed to lower treatment engagement among some families. Future research should examine this factor more systematically, given the language demands of navigating mental health services. Our findings align with previous literature highlighting racial disparities in mental health service use and access to care among families with a migration background (Coker et al., 2016; Miller et al., 2009; Morgan et al., 2013; Shi et al., 2021).

Among families utilizing mental health care services, 76% of parents reported being satisfied with their child’s treatment. However, parents of children with more severe ADHD symptoms were less likely to be satisfied with the psychological treatment their child received. This may be related to parents having excessively high expectations for a rapid decrease in symptoms during treatment or to the possibility that the treatment was not yet effective, resulting in their child continuing to display severe symptoms. In this context, a study by Görtz-Dorten et al. (2011) found that ADHD symptoms are negatively correlated with treatment satisfaction, while symptom reduction is positively correlated with parental satisfaction with their child’s ADHD treatment.

Over 85% of parents believe that the ADHD treatment their child received was somewhat or very effective, highlighting the perceived benefits of the treatment among most parents. Generally, evidence indicates that treatment for ADHD—especially the combination of behavioral therapy and medication—is effective in improving various outcomes for children with ADHD (Brown et al., 2005). Beneficial treatment not only alleviates the suffering of children but also reduces stress in affected families, as the mental health of children and parents is closely intertwined (Theule et al., 2018).

In terms of factors influencing mental health care utilization, most families whose children were not currently receiving mental health care despite having an ADHD diagnosis indicated that treatment had already ended. This may be attributed to the timing of the consortium project INTEGRATE-ADHD, as there was a lag between the administrative data (indicating that the children had an administratively documented ADHD diagnosis in 2020) and the online survey data (collected between October 2021 and August 2022). Therefore, it can be assumed that some children had already completed treatment before the study began. Further, this raises the question of whether the treatment they received was sufficient or whether the appropriate resources for a necessary longer treatment were not available in the care system. Additionally, more severe ADHD symptoms may be associated with longer treatment durations, leading to higher rates of current (vs. completed) service utilization. Moreover, our findings show that about a quarter of children and adolescents were treated by a pediatrician or family doctor, rather than by ADHD specialists such as child and adolescent psychotherapists. Given that pediatricians in Germany are authorized to prescribe ADHD medication, it is likely that they are playing a key role in ADHD care—especially in pharmacological treatment. These results underline the importance of considering pediatric and general practitioners as an integral part of the ADHD care pathway in Germany. Other frequently reported barriers to seeking mental health care included a lack of providers in their area and excessive waiting times for appointments. This finding underscores the urgent need to expand mental health care availability in communities, such as by funding more mental health therapists specializing in ADHD for children. Additionally, 15% of families did not utilize mental health services due to low motivation among the youth, aligning with previous findings (Sibley, Link, et al., 2022). Sibley, Ortiz, et al. (2022) examined how patient and parent motivation and engagement in ADHD treatment, along with other barriers, could be addressed to improve the implementation and delivery of ADHD treatment. They concluded that training and educating professionals, increasing psychoeducation, digitizing treatment materials, applying motivational interviewing, and fostering relationships with children and parents could enhance motivation and implementation of ADHD treatment. Further recommendations for increasing engagement with ADHD care include integrating behavioral services into general medical settings and utilizing telehealth, which has been shown to reduce attitudinal and motivational barriers (Baweja et al., 2021). These measures appear worth applying to the German health care system. Moreover, our findings highlight that, especially during times of crisis (such as the COVID-19 pandemic), it is crucial to maintain mental health care for children who may suffer the most from crisis intervention measures. A recent meta-analysis found that children with ADHD (and their families) particularly suffered from pandemic restrictions and experienced symptom deterioration (Rogers & MacLean, 2023). This could be, among other factors, due to the restrictive pandemic measures (such as the closure of playgrounds) hindering children with ADHD from spending time outdoors, which may have helped alleviate stress and attention deficits.

INTEGRATE-ADHD is the first study in Germany to consolidate administrative, epidemiological, and clinical data. Its strengths include the large sample size of children and adolescents with an administrative ADHD diagnosis in Germany. Another strength is the use of established questionnaires and items to assess mental health care utilization, factors influencing utilization, ADHD symptom severity, and parental psychopathology. Limitations of the study include that INTEGRATE-ADHD is an observational study that only identifies associations and no cause-effect relationships. The variables included in our regression models explained 7% to 14% of the variance in current mental health care utilization and treatment satisfaction. This suggests that these outcomes may be associated with other important factors that were not considered in our models. Additionally, the present analyses focused on current mental health care utilization (including psychological, psychotherapeutic, and psychiatric treatment), so the results may not be comparable to the utilization of other health care services. Further, we did not differentiate between specific types of treatment (e.g., medication vs. psychotherapy), which limits conclusions about how particular modalities relate to treatment satisfaction or barriers to care. Moreover, the variables of interest were primarily assessed using single-item measures rather than validated multi-item scales, which may limit the reliability and depth of the assessments. In addition, the response rate of 21.5% may limit the generalizability of the findings due to potential selection bias. Although migration background was assessed and included in our analyses, no specific data on race, ethnicity, or primary language were collected. Future studies should consider including more detailed demographic variables to better examine potential disparities in ADHD care. Further, the sample was drawn exclusively from individuals insured with DAK-Gesundheit, a large statutory health insurance provider in Germany. Although DAK-Gesundheit covers a diverse and nationwide population, the findings may not be generalizable to individuals insured with other statutory or private health insurers, who may differ in terms of socioeconomic or regional characteristics. Lastly, the variable geographic region only categorizes areas into two groups: those with more or fewer than 20,000 inhabitants. This division does not allow for a nuanced understanding of the relationship between population size and mental health care utilization. A continuous metric variable could be beneficial in future studies to assess this relationship in a more detailed manner.

To conclude, our study provides important insights into specific treatment gaps and needs among children with ADHD and their families in Germany. Our findings indicate that symptom severity is a key driver of current mental health care utilization, yet also a risk factor for reduced parental treatment satisfaction. Additionally, families with a migration background showed lower service utilization, suggesting potential structural or cultural barriers to care. These results emphasize the need to better support families facing multiple challenges by expanding culturally sensitive services and systematically addressing barriers to access. Our recommendation to enhance interdisciplinary care structures is supported by Döpfner et al. (2010) and aligns with international evidence on the benefits of integrated service models for ADHD. To improve treatment effectiveness and satisfaction, care capacities must be increased, including more training for providers in culturally adapted and engagement-focused interventions. Better remuneration, especially for time-intensive diagnostic and therapeutic services, remains crucial to ensure sustainable improvements in ADHD care. Finally, ensuring access to evidence-based ADHD treatment is vital not only for immediate symptom management but also for preventing long-term risks such as psychiatric comorbidities, educational failure, and social exclusion. Our study thus highlights concrete starting points for improving ADHD care structures in Germany and contributes important epidemiological data to inform future service development and health policy.