ADHD EU Survey-2020-FINAL

Diagnosis and
Treatment of
ADHD in Europe
SURVEY 2020
Carola Stivala MA
Board Member & Chair, Research Committee
Copyright ADHD-Europe AISBL 2021

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Europe AISBL.
TABLE OF CONTENTS
Executive Summary ........................................................................................................................................... 1
Introduction............................................................................................................................................................ 2
Survey Results 2020.......................................................................................................................................... 4
Conclusion ............................................................................................................................................................. 16
Appendix 1: Survey 2020 Questions ....................................................................................................... 17
Appendix 2: Country Profiles...................................................................................................................... 19
Table of Figures:
Figure 1: National Guideline Pie Chart .................................................................................................. 4

Figure 2: Standard ADHD procedures in health services .......................................................... 5
Figure 3: National Health Services............................................................................................................ 6
Figure 4: Private Health Services .............................................................................................................. 6
Figure 5: Child diagnosis of ADHD ........................................................................................................... 7
Figure 6: Adult diagnosis of ADHD .......................................................................................................... 7
Figure 7: Diagnostic tests for ADHD in children............................................................................. 8
Figure 8: Diagnostic tests for ADHD in adults ................................................................................. 8
Figure 9: Medication prescription........................................................................................................... 12
Figure 10: Medication complaint procedure.................................................................................... 13
Figure 11: Medication availability.............................................................................................................. 15

Europe AISBL.
EXECUTIVE SUMMARY
The ADHD-Europe Survey 2020 (answered by 22 member organisations from 19
countries) reflects some positive changes over the last decade, compared to the
previous surveys, namely:
1) the number of countries with national guidelines for ADHD have increased
2) more medication brands are available
3) increased specialist awareness of ‘ADHD in adults’ as well as the ‘lifelong
condition of ADHD’
Unfortunately, there remain circumstances that are in dire need of improvement:
1) Continued long waiting lists for children to access diagnostic services in

most member countries; (contrary to the early intervention advice of the
NICE ‘gold’ standard).
2) Continued inadequate provision of health services for adults in many
countries (while research shows that untreated ADHD can lead to
increased risk self-medication or drug addiction, unemployment, increased
traffic accidents, etc) and lack of family clinics where child AND parent can
be treated simultaneously (as ADHD is a heritable trait).
3) ‘Generic’ medication brands. Some members report increased medication
side-effects for minors using generics, others report positive effects. This
urgently warrants unbiased research, including research into comparative
medication efficacy and treatment adherence with branded and generic
medication. National medicine procurement systems may take mainly
price into consideration whilst lacking specialist and patient feedback
mechanisms (except for extreme physical side-effects). In addition, ‘out of
stock’ situations jeopardise especially youths during examination times.
4) Lack of access to specialists and lack of medication options. National and
regional discrepancies exist (especially in rural areas of large countries,
island (countries) and Eastern European countries) which are often due to
inadequate national funding for mental health services.
5) Continued cultural “stigma” about ADHD amongst specialists, in the media
and the general public. Some member countries even mention that
dominant professionals apply a psychoanalytic approach only instead of a
multi-modal treatment approach for children and adults with ADHD. There
are different viewpoints on ADHD as a disorder and on its medication in
society.
The survey shows that despite positive developments, the ideal situation, in
which an individual with ADHD can access the same standard of care and
medication wherever they are in the EU, is still very far from reality.
It is evident that research, support and contact between members of ADHD-

Europe is beneficial to the European ADHD community.

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Europe AISBL.
INTRODUCTION
ADHD-Europe
ADHD-Europe (2008) was set up in Belgium by 13 founding member organisations.

ADHD Europe represents the voices of national and regional ADHD organisations
from across Europe. Our members are made up of Non-Governmental
Organisations, Charities, Family Support Groups, and other grass roots
organisations, who share similar aims and agendas. Its mission is to advance the
rights and dignities, and advocate for, all those affected by Attention Deficit
Hyperactive Disorder (ADHD) and co-existing conditions across Europe. It currently
represents the voices of 29 member organisations in 22 countries in the European
geographical area and beyond. Our website is www.adhdeurope.eu
ADHD-Europe has a vision for an inclusive European community, where people

affected by ADHD can experience well-being, achieve their full potential, and
contribute to their community and society.
Attention Deficit Hyperactive Disorder (ADHD)
ADHD is a neurodevelopmental disorder of the brain, categorised as a mental

health disorder and a disability. It is described and classified in the Diagnostic and
Statistical Manual of Mental Disorders (USA, DSM 5, 2013), and in the World Health
Organisation International Classification of Diseases 11th Revision (ICD-11, 2018) as:
“Attention deficit hyperactivity disorder is characterized by a persistent pattern (at

least 6 months) of inattention and/or hyperactivity-impulsivity, with onset during
the developmental period, typically early to mid-childhood. The degree of
inattention and hyperactivity-impulsivity is outside the limits of normal variation
expected for age and level of intellectual functioning and significantly interferes
with academic, occupational, or social functioning. Inattention refers to
significant difficulty in sustaining attention to tasks that do not provide a high
level of stimulation or frequent rewards, distractibility, and problems with
organization. Hyperactivity refers to excessive motor activity and difficulties with
remaining still, most evident in structured situations that require behavioural self-
control. Impulsivity is a tendency to act in response to immediate stimuli, without
deliberation or consideration of the risks and consequences. The relative balance
and the specific manifestations of inattentive and hyperactive-impulsive
characteristics varies across individuals and may change over the course of
development. In order for a diagnosis of disorder the behaviour pattern must be
clearly observable in more than one setting.” (source: https://icd.who.int/en)
History of the “Diagnosis and Treatment of ADHD in Europe” Survey
The initial survey (2009) was an opportunity for the ADHD-Europe member
organisations to learn about each other’s work and common challenges such as
the lack of national health policies addressing ADHD, the lack of specialised
professionals for the provision of diagnosis, medication and treatment, limited

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educational support measures for children with ADHD and lack of awareness of
adult ADHD in the 19 member countries in the European area.
In 2011, the survey was updated by 22 member countries, and additional topics
such as ADHD prevalence, national policies, coaching and adults in the workplace
were discussed. Conclusions drawn included: some countries now had ADHD
national health policies in place, however, there was room for improvement
within the educational sphere as well as regarding the waiting lists for services;
also limited access to ADHD medication amongst the member countries was
noted. The ‘gold’ standard of ADHD care described in the NICE guidelines (UK)
provided hope and inspiration for the European ADHD community. The results of
these previous surveys are available on the ADHD-Europe website.
In 2020, the survey was answered by 22 organisations from 19 member countries.

It reflects the current context with the revised global medical manuals DSM 5 (2013)
and ICD-11 (2018). The 2011 survey questions were re-evaluated and updated with
the topic of generic medication. The survey layout was re-designed to include
some colourful visual summary pie charts, graphs, and internet links.
Methodology of the Survey:
The survey questions were re-drafted and approved by the Board and Professional
Board, after which they were sent out by email. The survey was compiled in both
‘word’ documents and later all transferred to an online ‘google form’ format to
facilitate the members. Some questions could be responded to in descriptive form,
others were multiple choice to enhance quantitative data collection. Some
respondents were very elaborate with their descriptive answers, others provided
less (maybe due to language barriers). This may have influenced the results. For
future reference, providing ‘translated’ versions of the forms may elicit more
qualitative data, however the survey should also include quantitative data to
facilitate visualisation and comparison (keeping in mind above limitations).
Continuous constructive re-evaluation of the survey, addition of current topics and
considering the purpose of the data is recommended as well as keeping the survey
easy for the members to engage with.
The intent for regular survey updates and increased collaboration on important
topics (such as collecting negative feedback to generic medication and lobbying
for incorporation of patient feedback into the medication procurement system)
has been an indirect result of the update of this survey for the Board and members.
The survey report was written incorporating qualitative and quantitative data in a
new format including colourful pie diagrams and some statistics for enhanced
visual interpretation. The descriptive overview of each country’s response was
retained by adding these to the appendix for reference.

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SURVEY RESULTS 2020
Participant ADHD-Europe Member organisations:
The twenty-two members representing nineteen countries that contributed to

the survey are the following and have provided the below information, (in some
countries multiple member organisations replied): Belgium, Croatia, Cyprus,
Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy,
Luxembourg, Malta, Slovenia, Spain, Sweden, The Netherlands (2 organisations),
and the United Kingdom (3 organisations). The Board would like to express their
gratitude to these participants.
National Policies
In 2008, the National Institute for Health and Clinical Excellence (NICE) published
guidelines for the diagnosis and treatment of ADHD in the United Kingdom.
These guidelines have come to be regarded as a ‘gold’ standard in Europe
(nevertheless, in the absence of supportive funding in the UK they remain just
guidelines). It’s recommendations were updated in 2018:
https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-
behavioural-conditions/attention-deficit-disorder
In the summary chart below, members replied that 10 countries (59 %) now do
have a national policy for ADHD (or equivalent), in 1 (Sweden) the policy is in the
making and in 8 countries (36%) namely Italy, Greece, Croatia, Luxembourg,
Malta, Hungary, Cyprus and Slovenia there is no national government health
policy yet.
Figure 1: National Guideline Pie Chart
Compared to the previous surveys, there has been a marked increase in ADHD
national guideline policies by the governments, although in some cases it is
administrated at a regional level (UK, Spain, Belgium) or in an alternative form of
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a national medical consensus basis or registry by the professionals instead
(Greece, Italy). Some policies are still limited to children below 18 years of age
instead of reflecting the fact that ADHD is a lifetime condition and including
adults (France, Italy, Luxembourg, and Cyprus). According to the Luxembourg
association, this may be partially due to the pharmaceutical company
registrations limits to 17 years of age which hinders a change of government and
insurance policies for those diagnosed after 18 years of age.
Figure 2: Standard ADHD procedures in health services
For the countries that do not have a national guideline policy, the majority replied
that there is no standard of care for ADHD patients and they receive mixed
feedback from their members regarding access to services, diagnosis, and
treatment.
National Health Services
The members replied that in most countries there are national health services for
ADHD; however, as mentioned above, France, Italy, Luxembourg and Cyprus note
that these services are limited to those who have been diagnosed as children
before reaching their 18th birthday.

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Figure 3: National Health Services
Figure 4: Private Health Services
Diagnosis and Treatment
The NICE ‘gold’ standard recommendation is for assessment, diagnosis, and

treatment by a multidisciplinary team. In most member countries, specialised
medical doctors (psychiatrists, paediatricians, neurologists, etc) work together
with psychologists on assessment procedures with subsequent diagnosis and
treatment. Some, however, work as a ‘chain’: starting with a medical doctor who
refers a patient to the psychologist who then refers to specialists for multimodal
treatment (which may often include medication). Others (Greece and Hungary)
restrict diagnosis and treatment in the public health service to a few recognised
medical professionals or hospitals. This can be detrimental for national access to
services, especially for patients in rural areas or islands. In the UK, Sweden and
The Netherlands, specialised prescribing nurses take over the routine care for the

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ADHD patient which reduces the need to visit the specialist or ‘shared care’
doctor for a repeat prescription.
From the charts below, it is clear that many more specialists are permitted to
diagnose children compared to adults.
Figure 5: Child diagnosis of ADHD
Figure 6: Adult diagnosis of ADHD
The diagnostic tests which are most often used for children are: Conners Scales,
Wisc, Clinical Personal Interview & history (CPI), ADOS (autism), ADHD-rating
scale DSM-5, Vanderbilt scales, Snap scales, Young Diva-5 and others. These may
be used in conjunction. The scales assessments are often not expensive, and they
can be used for re-testing after a period of treatment to see improvements or at
an interval of 2 years for review.

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Europe AISBL.
Figure 7: Diagnostic tests for ADHD in children
The most frequently used diagnostic tests for adults are the Clinical Personal
Interview and History together with the Diva-5, ADULT ADHD SELF-REPORT
SCALE (ASRS-V1.1), ADHD Rating Scale DSM-5, Adult ADHD Self-reporting
screening scales and others.
Figure 8: Diagnostic tests for ADHD in adults

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The ADHD diagnostic process
In summary, most members described the diagnostic process through the

national health services by the mechanism of a ‘chain’ of referrals from family
doctor to specialists. Most mentioned that the services are subject to waiting lists.
The diagnosis for both children and adults commonly consists of an intake
appointment with clinical personal and family history and disorder-specific
questionnaires (self-ratings and informant-ratings) resulting in a written
psychological report and followed-up by treatment advice from further
specialists.
In Hungary, the national health service provides a 1–2 week stay in a psychiatric
hospital to diagnose and initiate medication treatment for children. Several
members mention specialised children’s health service centres (France, Malta,
UK, and NL). Only Slovenia, Hungary, The Netherlands, and Iceland specifically
mentioned a multi-disciplinary team collaboration for children’s diagnosis and
treatment.
The length of the diagnostic process can take up to 18 months (with Ireland
having the longest process mentioned). In many countries, check-up
appointments with specialists are held at 3 – 6 months intervals during
treatment. In some countries, the monthly medication prescription is under
supervision of the family doctor.
Regarding the adult national health services, overall, there is much less
availability. Especially noted are that France, Hungary, Slovenia, and Luxembourg
has very few services, even in the private sector. In these countries, the support
organisations assist to find the qualified specialists. In the UK, specialised ADHD
clinic services are mentioned, however, they are characterised by waiting lists of 2
years. In Denmark, average waiting lists of 1.5 years are mentioned, due to lack of
capacity. In Greece, there are only 2 national clinics available for adults for
providing diagnosis and medication prescription, these provide no therapy,
however.
The adult diagnostic assessment consists of self-rating disorder-specific

questionnaires and checklists integrated with a personal clinical history, family
and third-party and evaluation of co-morbid symptoms. Not all tests are available
in many foreign languages. Additional tests are mentioned in the individual
country surveys.
The ADHD diagnostic process by private health services
In most member countries, people can self-refer or get a referral from their family
doctor for private health services. They are also affected by waiting lists, however,
an initial appointment and beginning diagnosis assessment will be undertaken
on average within 3 – 6 months. This is fast compared to the waiting lists ranging

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between 1- 3 years in the national health services of the different member
countries.
The NICE ‘gold’ standard recommendation of “early intervention” is affected by

these long waiting lists for specialists, and in those countries where the private
services are not covered by private health insurance, only those with sufficient
financial means can opt to obtain private services (if available).
The costs of these private services are not known exactly (however, a range
between €300- €1000 per diagnosis and depending on the tests performed has
been suggested). In some countries, costs are (partially) refunded by the health
insurance. However, for many (especially adults) it is at personal expense.
In Cyprus, no national health services for adults exist, only private services are
available. In Italy, all private services are at private cost. In Hungary, appointments
for private services are with only approximately 1 month waiting time. In the UK, a
private specialist can still refer a patient for subsidised government medication
on the national NHS system. In France, an adult paying for private health services
will be partially reimbursed.
Advantages of private health services
The ‘fast track’ time advantage is the most frequently mentioned reason why
someone would opt for private health services. Both the shorter waiting time for
the initial appointment as well as the faster diagnosis process and initiation of a
treatment plan were noted.
Access to (highly) specialised professionals regarding ADHD was another

important advantage, providing an optimal diagnosis and treatment plan,
especially for adults in member countries where national services for ADHD are
limited or non-existent.
Partial or full reimbursement for the financial costs for private health insurance
were noted by some; however, others emphasised the expense was at personal
cost.
In Ireland, Spain, Italy, Luxembourg, Malta and Cyprus, adults have to make use of
private services as virtually no national services exist. In Denmark, private services
have 1.5 years waiting list as only ‘ADHD with co-morbidities’ are tackled by the
national health service and the rest is requested to make use of private services.
In Malta, public health services for children are only available until approximately
2pm (during school hours) after which some specialists then work at private
clinics serving children and adults at private cost.

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Europe AISBL.
How are the ADHD diagnostic costs for children and adults covered?
Most member countries cover or partially refund the national services for ADHD
diagnostic cost for children and adults, many also mention the (partial) refund of
private services through the (compulsory) private insurances for children. In
Belgium, The Netherlands, Cyprus, Malta, and Iceland, adults are not refunded for
any private services regarding ADHD unless their private insurance covers it while
in Luxembourg there is a partial refund.
Some members mention ADHD disability allowance (France), a monthly amount

paid to parents to cover unreimbursed treatments; however, these are not in
place in all countries.
The administrative process of getting ADHD medication (for a child or for an

adult), once prescribed by the professional
In most member countries, the initial medication treatment for children or adults
can be only prescribed and monitored by the psychiatrist (or paediatrician / other
specialist). Children must have a six-month follow-up appointment with their
specialist and adults an annual visit. In the Netherlands, the specialist will remain
in contact by email or phone. In some countries, the specialist prescribes for 3
months and in others the family doctor provides ‘shared care’ and prescribes
medication. In the UK, Sweden and the Netherlands, specialised prescribing
nurses may also be involved.
In Finland, Denmark, Sweden and The Netherlands, this process is completely

electronic, and prescriptions are sent directly to the local pharmacy for collection
(for up to 3 months’ supply). In Greece and Belgium, electronic prescriptions are
also used by specialists. In Malta, there are 5 documents (permit letter, white
control card, POYC registration card, identity card and a pre-organised valid
monthly doctor’s prescription) that must be presented in order to collect
medication.
In Italy, the psychiatrist releases the child’s therapeutic plan, however, the
prescription must be collected from the pediatrician and the medication from
the pharmacy. Many member countries have special national permits for ADHD
medication (to monitor and control the use of narcotic and psychotropic drugs as
stipulated by law) and a national pharmacy of our choice scheme (POYC).
Most medication is prescribed for 1 month, 28 days (France), or 3 months

(Luxembourg); however, in Hungary only a 4-day medicine supply is provided. In
France and Italy, methylphenidate treatment may continue to be refunded into
adulthood (until approximately 24 years of age) if an ADHD diagnosis is made
before the age of 18 years. In a few countries, some medication has to be
collected from special hospitals (Atomoxetine - France, Atomoxetine &
dexamphetamine - Belgium) or from across the border (guanfacine imported
from Germany – as it is not available in Luxembourg yet).

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Is ADHD medication for children and adults prescribed based on "best
medication for the patient " or a standard public health medication brand
(private and national services)?
The most common response to this survey question was that the standard
national health medication is chosen as first treatment in Slovenia, Belgium,
Finland, Malta, UK, Cyprus, Luxembourg, Sweden and Spain. The ‘best medicine
for the patient’ was mentioned by Iceland (although the pharmacy offers the
lowest price medication), Ireland and The Netherlands (price refund depends on
insurance).
Regarding private services, specialists prescribing the "best medication for the
patient" was noted by Spain, Cyprus, and the UK.
Greece, France, Luxembourg, Italy and Hungary mention reluctance in

prescription of medication by specialists due to a history of psycho-analytic
psychiatry and the cultural stigma of ADHD.
Figure 9: Medication prescription
Many countries do have access to different brands and generic medications as

standard national health medication in the national health system. Some countries
are very limited in their medication stock: Luxembourg has only methylphenidate
for children; adults in Luxembourg are prescribed off-label and Belgium too; in The
Netherlands, all stimulant medication for adults is also prescribed ‘off label’. Italy
has 2 medications only: methylphenidate and atomoxetine, and they are
sometimes ‘out of stock’. Malta has only 3 national generic brands (and 2 brands at
pharmacy/private cost, often ‘out of stock’) and Greece only 3 branded medications

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(Ritalin, Concerta and Strattera). The dosage range of these medications are often
also limited. This limits the ‘toolbox’ of the specialists for the optimal ‘best medicine
for the patient’ within the ‘gold standard’ multi-modal treatment plan. It is a clear
indication that within Europe, there is no uniform medical treatment for a child or
adult with ADHD.
Figure 10: Medication complaint procedure
In most countries, complaints about medication are registered with the family
doctor or specialist or directly to the national agency. Full details on this point can
be found in the country profile appendix.
Any additional comments regarding ADHD diagnosis and medication

prescription:
Some members commented on the lack of access to trained and prescribing

specialists (Belgium, Slovenia, the Netherlands, France). In general, most
members mention the long waiting lists: Iceland, Cyprus, Malta, Ireland, Italy, The
Netherlands, and Spain.
Generic medication complaints (Iceland, UK, Cyprus) and lack of access to variety
of medication (Luxembourg) have also been noted.
Religious and societal ‘stigma’ related to ADHD and medication (Hungary,

France) and psycho-analytic psychiatry (Greece, France) were given as comments
by some countries.
For additional comments, see the country form in the appendix.

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How are the ADHD medication costs (for children and adults) covered for the
patient?
The only member country that does not refund any ADHD medication costs is
Cyprus. The Irish health system refunds medication in full until 16 years of age
only, Italy until 18 years. Free of cost medication is provided in Slovenia and Malta
(no age limit). In Finland, medication is free up to a maximum amount after
which a fee is charged. In Greece, the €50 monthly prescription cost of the
psychiatrist is not refunded, whilst 75% of the medication cost is covered by the
national system. The remainder of the member countries have different medicine
cost patient contributions (‘prescription charge’ (UK / NHS) or free after an ‘own
risk’ sum (The Netherlands), and unique national health systems with compulsory
or voluntary private insurances, which cannot be compared to each other (see
individual country appendix for details).
If ADHD medication costs for children and adults are completely covered by the
national public health system, is there any insight into the cost? If yes, provide
further information.
Insight into the national health services costs regarding ADHD medication is
available in some countries, such as The Netherlands, UK, Sweden, Denmark and
France; this can give an indication of the use of the different ADHD medications
and the national budget allocated.
Are there any significant differences between national citizens and EU

citizens for the use of the national public health system and medication cost
reimbursement?
Most EU and EEA member countries replied that anyone registered with the local
social security system would have access to the same standard of care and
reimbursement as locals. Due to Brexit, the situation in the UK is to be clarified.
Any additional comments regarding ADHD medication and cost

reimbursement:
Recurrent ‘out of stock’ of ADHD medication is an important problem mentioned

by Iceland, Greece, Cyprus, Italy, Malta, and The Netherlands, which warrants
urgent investigation and tackling by the national authorities.
Secondly, the change from “brand” to “generic” ADHD medication labels is

problematic. Many complaints have been received by the organisations on behalf
on their members which are substantiated by professionals. This warrants review
by the national authorities and indicates a need for patient and professional
feedback to be incorporated in the national medication purchasing procedure.
Thirdly, the lack of access to a variety of medication options was mentioned by

Italy, Hungary, Malta, Greece and Iceland, which means that there is no ‘best
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medication for the patient’ policy. Europeans moving from one country to
another cannot continue to take their medication ‘brand’ if it is not available in
the country they moved to. Previously, a lack of access to specialists was also
mentioned, especially in rural areas. Additional comments can be found in the
appendix of country profiles.
Figure 11: Medication availability

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CONCLUSION
In conclusion, the following points can be made which reflect some positive
changes amongst the member countries over the last decade: the increased
availability of national guidelines for ADHD, the increased number of medication
brands available to the patients, and the increased awareness about adult ADHD
as well as the lifelong condition of ADHD by specialists.
Unfortunately, there are also some problematic issues that remain visible in most
countries, such as the continued long waiting lists for national health services for
children (contrary to the advice of early intervention in the NICE ‘gold’ standard)
and the lack of adequate national health services and multi-modal treatment,
including medication for adults. This, while research shows that unmedicated
ADHD treatment can lead to increased chance of self-medication or drug
addiction, unemployment, increased traffic accidents, etc.
There are many reports of the less effective ‘generic’ ADHD medications
throughout Europe, which should be investigated by the national authorities. This
includes increased reporting of negative medication side-effects with minors and
overall, less efficacy (which in turn may lead to less treatment adherence or
increased use of multiple medications and increased need for professional advice
visits negating the cost-effectiveness) which national medication purchasing
authorities may not be aware of due to lack of patient/doctor feedback
mechanisms. Some positive feedback regarding generics has also been noted,
unbiased research is necessary.
National and regional discrepancies remain: a lack of access to specialists and a

lack of a variety of medication for the ADHD patient (especially in the smaller
countries, rural areas, islands, and Eastern European countries), due to
inadequate national funding for mental health services.
Lastly, “stigma” (negative presumptions and prejudices) in the media and society
about ADHD is still highly prevalent.
The survey shows that the ideal situation, in which an individual with ADHD can
access the same standard of care and medication wherever they are in the EU, is
still very far from reality.
It is, however, very evident that research, support and contact between members
of ADHD-Europe is beneficial in order to exchange information, collaborate and
lobby on behalf of the European ADHD community.

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APPENDIX 1: SURVEY 2020 QUESTIONS
Organisation name and country: …………………………………………………………………………………………….
Q 1: Does your country have a national guideline for ADHD Diagnosis, medication
and treatment for children and adults?
Q1A: internet link of National ADHD Guideline (if available).
Q2: If your country does not have a national guideline: is there any standard
procedure for ADHD diagnosis, medication and treatment in the national and
private health services?
Q3: Does your country have national health services for ADHD Diagnosis,
medication and treatment for children and adults?
Q4: Does your country have private health services for ADHD Diagnosis,
medication and treatment for children and adults?
Q5: Who can diagnose a child?
Q6: Who can diagnose an adult?
Q7A: which diagnostic tests/tools are used for children?
Q7B: which diagnostic tests/tools are used for adults?
Q8: Explain briefly the ADHD Diagnostic process in your country (for a child and
an adult) by the NATIONAL health services.
Q9: Explain briefly the ADHD diagnostic process in your country (for a child and
an adult) by the PRIVATE health services, especially if there are any differences
from the national health services.
Q10: Explain why an ADHD patient and their family would choose to use private
health services instead of national health services, or not.
Q11: How are the ADHD diagnostic costs for children and adults covered?
Q12: Which professionals can prescribe ADHD medication for children? (multiple
answers accepted)
Q13: Which professionals can prescribe ADHD medication for adults?
Q14: Describe the administrative process of getting ADHD medication (for a child
or for an adult), once prescribed by the professional.
Q15: Is ADHD Medication for children and adults prescribed based on "best
medication for the patient " or a standard public health medication brands by
private and national health service professionals?

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Q16: Are there any significant differences reported between private and national
health service professionals' prescriptions of ADHD medicine for children and
adults?
Q17: Is there a medicine complaints procedure for side-effects to the patient's

health in the national public health system?
Q17A: internet link of national medication complaints system (if available).
Additional comments regarding ADHD diagnosis and medication prescription in

your country?
Q18: How are the ADHD medication costs (for children and adults) covered for the
patient?
Q19: If ADHD medication costs for children and adults are completely covered by
the national public health system, is there any insight into the cost? If yes, provide
further information.
Q20: Are there any significant differences between national citizens and EU
citizens for the use of the national public health system and medication cost
reimbursement?
Additional comments regarding ADHD medication / cost reimbursement?
MEDICATION AVAILABILITY ( tick which ones are available)
• Methylphenidate short-release "Ritalin"

• Methylphenidate short -release generic
• Methylphenidate long-release Concerta
• Methylphenidate long-release generic
• Methylphenidate long-release Medikinet
• Methylphenidate long-release generic Sandoz
• Methylphenidate long-release generic Mylan
• Methylphenidate long-release generic Equasym XL
• Dexamphetamine
• Lisdexamphetamine
• Dextroamphetamine Amfexa
• Dextroamphetamine Attentin
• Atomoxetin Strattera
• Atomoxetin generic
• Guanfacin
• Risperdal / Risperdone (comorbid)
• Other
• no medication prices / details supplied
Other medications

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APPENDIX 2: COUNTRY PROFILES
Organisation name and country: ADHD, ASC & LD Belgium ASBL, Belgium
(BE)
Q 1: Yes
Q1A: (BE) Yes, since 2013 and the information was partly updated in 2018 in
Belgium. https://www.trajet-tdah.be and www.css-hgr.be
Q2: not applicable
Q3: Yes
Q4: Yes
Q5: Psychiatrist (dpm), Neurologist (N), Psychologist (Psy), other. Q6:

Psychiatrist (dpm), Neurologist (N).
Q7A: Conners Scales (parent and teachers), Wechsler Intelligence Scale for
Children (WISC), Clinical Personal Interview & history, Autism Diagnostic
Observation Schedule (ADOS), ADHD-rating scale DSM-5, other.
Q7B: DIVA, Clinical Personal Interview & history, Adult ADHD Self-Report Scale
(ASR-v1.1), other.
Q8: (BE) Note: According to the Belgian National Guidelines, only a Child
Psychiatrist or a Neuro-pediatrician can diagnose ADHD (which means these
are the two types of professionals who can prescribe medication). In reality, a
psychologist or a neurologist can do the pre-diagnosis if they are experts on
ADHD, but they have to work closely with a psychiatrist in order for their
patients to get medication prescribed for them after the diagnosis. This can
mean an extra cost for the patient. Once a psychiatrist has authorized the use
of ADHD medication for a child or adolescent, s/he is required to monitor the
patient during the first 3-6 months in order to titrate the dosage to what has
the most benefit with the fewest side effects. If stimulant medication does not
bring any improvement or the side effects are too severe, the attending
psychiatrist can prescribe either Atomexitine (Strattera) or Guanfacine, the only
non-stimulant options available in Belgium as per the Guidelines. For pre-
evaluation, notification to parent and only referred to testing with parental
approval; scheduled for medical exam, hearing test, vision test, executive
function assessment, “logopède” evaluation (OT/speech & Lang), cognitive
exam, IQ test, sometimes Vision Therapy; if the suspicion is still there of ADHD,
the child is referred to a Child Psychiatrist or Neuro-pediatrician in the public
health services, which can take as long as 1-2 years. From patient feedback not
all these diagnostic processes were offered for every child. Child: Parents
usually initiate the process, sometimes because of unfavourable school
feedback. Very often, they contact our organization as the first step to finding
out how to find a suitable Child Psychiatrist to test their child.
Psychoeducational testing is almost always done first by a psychologist,
followed by an Occupational Therapist and a behavioural opthomologist’s
evaluation (Centrum Beter Zien). When there are still problems, the parents
make an appointment with a Child Psychiatrist, a Neuro-pediatrician, or a Child

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Europe AISBL.
Psychologist who collaborates with a Child Psychiatrist or Neuro-pediatrician to
get a diagnosis, a detailed report for the school and - if needed - a prescription
for ADHD medication. The process is much shorter when the parents can
access private health services. The psychoeducational report highlights the
child’s strengths and weaknesses and is very useful for the identification of
discrepancies between the child’s innate abilities and one or more areas where
he struggles. It may also point to possible comorbidities. ADHD ASC, and LD
Belgium works closely with the parents and families at this phase to help them
understand the report better. This includes finding out which interventions are
most needed to improve the situation for the child / adolescent. These range
from Cognitive Behaviour therapy, social skills training, ADHD coaching to help
improve executive functioning, to finding a suitable subject and/or a homework
tutor for the pupil. Normally these services will be carried out by English
speaking professionals that are known to the ADHD ASC & LD Belgium
network.
Q9: (BE) Flanders = Dutch speaking part of Belgium run under Flemish
Government Walloon = French speaking part of Belgium under French
speaking Government ADHD Diagnoses depends on the doctors or medical
professional as there are reported cases of years of medical exams before the
ADHD diagnoses is given. Adult: The first step is an extensive medical exam to
preclude physical causes for the person’s problems; after this, they are put on a
list for referral to a Psychiatrist who specializes in adult ADHD (if lucky). Testing
includes completion of self-reported questionnaire, inventory of any struggles
experienced at school and /or at work, a psych analysis follows for any
comorbidities. The whole process of diagnoses could take quite a long time
because of waiting lists (hospitals). ~Explained more below. Generally, this is the
route that is taken when an adult is at-risk of losing their job due to
undiagnosed ADHD and possible comorbidities and it begins with a referral to
the National Health services. (The route is checking for medical/physical
problems then going to the psychiatrist) Otherwise, we have found that adults
contact ADHD ASC and LD Belgium (English), TDAH Belgique (French) or
Centrum Zitstil (Dutch), if they suspect that ADHD might be their problem and
if it is our organization, they often go through the private health services
because of the waiting periods and English is easier to understand. Adult:
Adults who have never been identified as having ADHD in their childhood
usually look online for assistance when their symptoms make life difficult for
them. Very often, they begin with ADHD ASC and LD Belgium whether they are
French or Dutch speaking and especially if they use English as the language of
communication. We help them understand their symptoms and if they want to
get tested, point them in the right direction. They must go through rigorous
medical exams to rule out other reasons for their symptoms and if they have
cardiovascular problems, this is taken into account if they need medication. In
the private health system, the process is much quicker than the Public Health
Services but costs more. As there is more awareness now about adult ADHD in
Belgium, it is possible to get diagnosed and treated through the National
Health system, but the waiting lists are long because there are fewer doctors
specializing in adult ADHD. Anyone can go for private diagnose, which is a
higher service charge than the National Health system charge. As a rule, only
adults who are in danger of losing their employment because of undiagnosed
ADHD are referred to adult ADHD clinics to begin the process of diagnosis and
treatment. The company could refer the employee to a specialist but not

20
Europe AISBL.
necessarily an ADHD coach. Being diagnosed won’t necessarily solve the
problem but problems can be solved by a sympathetic Human Resource
department by looking into workplace accommodations. Many only want to
understand themselves better and to learn as much as possible about the
condition. They may have already had to face some challenging situations at
work or in personal relationships before seeking help for ADHD; in the case of
high achieving women, this tends to be burnout. During the recovery period
when they are on sick leave, they begin to realize that ADHD might be the
underlying reason for their situation. These are the people who also begin
attending our adult support group for people with neurodiverse brains. Our
organisations helps adults with all learning differences/disorders such as
Autism Spectrum Conditions, Aspergers, Dyslexia, Dyspraxia, Dyscalculia - other
Learning Disorders.
Q10: (BE) Child: One reason would be to get a quicker diagnosis and report for
the school so that the child can access school services and accommodations.
Secondly, if the child does not speak either French or Dutch because the family
is newly arrived in Belgium (it happens very often) and they use English as their
language of communication in Belgium, they need to find English-speaking
specialists (first a Child Psychologist to conduct a psycho-educational
evaluation and a Child Psychiatrist to do further testing for ADHD. Adult: As for
children, adults who decide to use private services do so because of language
reasons or to speed up the diagnosis process. Generally, for both children and
adults, there are long waiting periods for a diagnose in hospitals, but private
services are more expensive than those done by the Public Health system.
Q11: (BE) Children: Neuro-pediatrician or psychiatrist visits are payable at the

time of each visit and the parents are refunded according to their medical
insurance. Psychiatrist visits (diagnosis, monitoring treatment, etc.) are 95%
reimbursed for children who are under 18 years of age. In the case of visits to
their general practitioner, children can be part of the global medical system
whereby visits are automatically refunded. Diagnosis counts as a normal visit to
a doctor, Neuro-pediatrician or Child Psychiatrist and is refunded accordingly.
Adults: Doctor or psychiatrist visits are payable up front and the patient is
refunded according to their medical insurance. The reimbursement depends
on the medication and the pharmacies follow the INAMI guidelines. No
automatic refunds are available for adults. They pay at the time of each visit
and submit the documentation to their insurance provider in order to receive a
partial refund. Diagnosis usually counts as a doctor or psychiatrist visit in terms
of what is refunded.
Q12: Psychiatrist (dpm).
Q13: Psychiatrist (dpm).
Q14: (BE) Children: Monthly prescriptions are required from the attending Child
Psychiatrist and providing the ADHD medication is on the list of available
ADHD medications available in any pharmacy, the prescription is filled and
payment taken upfront. Parents then submit the pharmacy receipts to their
medical insurance provider in order to get reimbursed. If the pharmacist is
satisfied that the medication was prescribed by a psychiatrist, s/he fills the
prescription. There are no special permits required. In the case of
Dexamphetamine and Atomexetine (Straterra), these medications cannot be

21
Europe AISBL.
filled at any pharmacy, but in a hospital. Adults: Monthly prescriptions are
required from a Psychiatrist for the ADHD medication best suited to the
patient. Once an adult has received a diagnosis from a psychiatrist and s/he has
written the first prescription, a person’s general physician (GP) can prescribe
the ADHD medication afterwards as long as the patient continues to see the
psychiatrist to review the medication and the side-effects from time to time.
This is, however, not written in the Belgium Guidelines. The visits are refunded
but not the medication.
Q15: (BE) Children: Initially, each child is prescribed the standard public health
medication brands by both the National Health and the private health provider;
only after the attending specialist can show that this medication does not work
for the child – usually after 3-6 months of monitoring – can a different brand
medication be prescribed. Therefore, it is not “the best medication for the
patient” until everything else fails. Adults have more flexibility provided they are
prepared to pay for the medication of their choice – provided it is registered
Belgium.
Q16: No
Q17: Yes.
Q17A: (BE) The Belgian National Guidelines have very detailed

recommendations about what psychiatrists should do to help their patients
manage side effects of ADHD medication. If they follow these Guidelines
exactly, they have the backing of the National Health authorities and can make
a good case for a change of medication. https://www.trajet-tdah.be and
www.css-hgr.be Parents and adult patients can contact the FEDERAL AGENCY
FOR MEDICINAL PRODUCTS AND HEALTH PRODUCTS (FAMHP) to report any
grievance they might have concerning an ADHD medication they have been
prescribed, how it was prescribed and/or about the side-effects they are
experiencing as a result of this medication. Visit the website: www.afmps.be or
send an email to adversedrugreactions@fagg-afmps.be. The Patient advises
the doctor who reports on their 'yellow card':
https://www.famhp.be/sites/default/files/downloads/fiche-jaune-FR-2009-03-
24.pdf

prescription in your country:
(BE) As per the Belgian National ADHD Guidelines, only a Child Psychiatrist or
Neuro-pediatrician can diagnose a child with ADHD but this really means that
these are the only two specialists who can prescribe ADHD medication. There
are some ADHD specialised Child Psychologists and Neuro-psychologists in
Belgium who are very well able to diagnose ADHD in children and adolescents
but they must ask their clients to see a Child Psychiatrist with whom they
collaborate to prescribe the necessary medication and to continue to monitor
them while they are medicated.
Extra Diagnostic Tests: Adult: CAARS short version: Conners Adult scales;
DAWBA (for adult and child); ADHD Rating Scale DSM-5 ACE (NL) (Kooij)
Diagnostic interview for children w/ADHD CAPA K-SADS Child/Ado Psy Ass.
Affective disorders; ADEXI CHEXI (children) TEXI (teenagers) Stroop Test TEA-CH

22
Europe AISBL.
(6-16 yrs.) WCST Test. The Belgian Guidelines are detailed and thorough and
have continually been updated. However, they must be implemented to be
truly effective, which is not always the case.
Q18: (BE) ADHD medication costs for children and adults are mentioned below.
However, a patient takes their prescription to the pharmacy, pays full price, and
then needs to forward the receipt to be claimed back from the Belgian Public
Health system, which is run by several different private insurance companies
following the health system called INAMI. Persons working at the EU
Commission have a different process. Children: Every citizen in Belgium is
required to have a health insurance provider (Mutuelle), which they can
supplement with private insurance if needed. 75% of the total cost of Rilatine
short acting and Rilatine MR is reimbursed for children up to 18 years of age.
They must submit their receipts for this medication to their health insurance
provider each month to get reimbursed. Adults: ADHD medication for adults
(18+) is not reimbursed in Belgium. However, if a citizen (Belgian born or from
an EU state) is unable to pay the monthly fee for the health insurance provider
because of losing their job, or through illness, etc., the Belgian Social Security
authority waives the monthly charge for such a person and allows them to
keep their health coverage with a co-payment for medication, etc. It is not clear
at this point if this would include ADHD medication.
Q19: (BE) -
Q20: (BE) In Belgium, all residents, no matter from which country they hail, can
make use of the National Public Health Service and have access to medication.
The reimbursement, however, is only for specified medicines, as approved by
INAMI (Belgian National Public System), and residents who have private
medical insurance can get a reimbursement. Belgium Public Health services
does not operate like its counterpart in France, for example, where you are
automatically reimbursed via the Social Security System. The Belgian patient or
parent needs to submit their documentation to the insurance who reimburses
according to the INAMI guidelines for the specific medication. In the case of
ADHD medications for children up to 18 years of age, there is no difference
between the reimbursement procedure for National and EU citizens. No ADHD
medication is reimbursed for adults, whether they are Belgian nationals or from
other EU countries. If an EU citizen arrives in Belgium, they can produce their
EU medical card and their proof of ADHD treatment reference letter and they
are able to get a prescription from a doctor or psychiatrist for said medication
(providing it is available in Belgium). An ADHD patient does not need to be a
registered resident in Belgium to get access to medicines from a pharmacy.
The policy and healthcare system in their Member State from will automatically
approve the reimbursement of the ADHD medication needed as well as the
necessity of visiting a doctor or psychiatrist while outside their own country.
Having an EU medical card in their possession makes the process run
smoothly.
Any additional comments regarding ADHD medication / cost reimbursement:

(BE) Yes! Private purchases of ADHD medication is allowed with a prescription
as per the availability of the medicines. Different ADHD patients have different
needs so some patients do not see their psychiatrist every month to get a
prescription, but every three to six months. In January 2020, Belgium converted
from paper to barcoded prescriptions, which means that one piece of paper
23
Europe AISBL.
authorizes either three or six refills. Doctor or psychiatrist visits are payable
upfront, and the patient is refunded according to their medical insurance. For
psychiatrist visits, children (under 18 years of age) are 95% refunded. Adults are
generally given a 60% reimbursement for doctor/psychiatrist visits. In the case
of adults who have low income, they get a higher reimbursement and Social
Security contributions are waived.
MEDICATION AVAILABILITY

• Methylphenidate short-release generic
• Dexamphetamine
• Guanfacin
• Other
Other medications: (BE) Clonidine, Wellbrutin, Provigil and Venlaffaxazine

24
Europe AISBL.
Organisation name and country: Udruga Budenje, Croatia (CR)
Q1: No
Q1A: (CR) –
Q2: Mixed feedback from service-users.
Q3: Yes
Q4: Yes. Q5: Psychiatrist (dpm), Psychologist (Psy), Child Psychologist (CPsy)
Q6: Psychiatrist (dpm), Psychologist (Psy).
Q7A: Wechsler Intelligence Scale for Children (WISC), Vanderbilt Assessment

Scales, DIVA young, Clinical Personal Interview & history, Autism Diagnostic
Observation Schedule (ADOS), ADHD-rating scale DSM-5, Snap- IV.
(ASR-v1.1), Adult ADHD Self-Report screening scale for DSM-5, ADHD Rating
scale DSM-5.
Q8: (CR) Child: psychological, psychiatric assessment, pediatrician, neuro-

pediatrician if needed. Adult: psychological, psychiatric assessment, family
doctor, neurologist if needed.
Q9: (CR) –
Q10: (CR)-
Q11: (CR) Both: national public health system or at private costs.
Q12: Psychiatrist (dpm)
Q14: (CR) –
Q15: (CR)-
Q16: Not known.
Q17: Yes.
Q17A: http://www.halmed.hr/en/Lijekovi/Za-pacijente/Kako-prijaviti-sumnju-na-
nuspojavu-lijeka/

25
Europe AISBL.
prescription in your country: (CR)-
Q18: (CR) Information about medication: http://www.halmed.hr/Lijekovi/Baza-

lijekova/
Q19: (CR)-
Q20: (CR) -

(CR) -

• Other
No medication prices / details supplied
Other medications: (CR) -
Editor's note- Concerta 18 & 36 mg (methylphenidatum):

https://mediately.co/hr/drugs http://www.halmed.hr/Lijekovi/Baza-lijekova/.
Only Concerta, Risperidone, Olanzapine prescribed in Croatia - source:
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30178-
0/fulltext

26
Europe AISBL.
Organisation name and country: ADHD CYPUS, Cyprus (CY)
Q 1: No.
Q1A: (CY) - Assessment is done through the Ministry of Education for

accommodations in schools. Diagnosis is done through Child-psychiatrist/
Psychiatrist and medication prescribed if appropriate.
Q2: No.
Q3: Children only until 18 yrs
Q4: Yes. Q5: Psychiatrist (dpm), Child Medical Doctor/ Pediatrician(CMD),

Neurologist (N), Educational Psychologist (EPsy)
Q6: Psychiatrist (dpm), Neurologist (N), Educational Psychologist (EPsy).
Children (WISC), Vanderbilt Assessment Scales, Clinical Personal Interview &
history, ADHD-rating scale DSM-5.
Q7B: Clinical Personal Interview & history, Adult ADHD Self-Report Scale (ASR-
v1.1), Adult ADHD Self-Report screening scale for DSM-5, ADHD Rating scale
DSM-5, Snap- IV, other.
Q8: (CY) Assessment is done through the Ministry of Education for

accommodations in schools.
Q9: (CY) Child: Diagnosis is done through Child Psychiatrist/Psychiatrist and

medication prescribed if appropriate. Adult : nothing available in public health
service.
Q10: (CY) Child: Long waiting times for appointments. Adult: Nothing available
in the public health sector.
Q11: (CY) Children: Free or low cost in public sector and circa 400 euros in
private sector Adults: circa €400 in private sector.
Q12: Psychiatrist (dpm), Child Medical Doctor/ Pediatrician(CMD), Neurologist

(N).
Q13: General Practitioner (GP), Psychiatrist (dpm), Neurologist (N).
Q14: (CY) Both: Prescription is taken to general hospital pharmacy or private

pharmacy and medication is purchased.
Q15: (CY) Child: Standard public health medication. Adult: At discretion of

practitioner.
Q16: No.
Q17: N0.
Q17A: (CY) Not that we are aware of. The patient is referred back to the
physician.

27
Europe AISBL.
prescription in your country: (CY) Yes. government health services have waiting
lists - private diagnosis expensive but faster - changes in medication (brands vs
generic).
Q18: (CY) Both: Not covered by public health insurance. Q19: (CY) Not known.
Public Health System is in process of changing.
Q20: (CY) No, if they are registered in the public system. Any additional
comments regarding ADHD medication / cost reimbursement: (CY) frequent
out of stock medicine - changes from brand to generic medication - limited
medicines available.
MEDICATION AVAILABILITY:

• Risperdal / Risperdone (comorbid )
Other medications: (CY) –

28
Europe AISBL.
Organisation name and country: ADHD-Foreningen, Denmark (DK)
Q1: Yes
Q1A: (DK) https://www.sst.dk/da/udgivelser/2018/nkr-adhd-hos-boern-og-unge ,

https://www.sst.dk/da/udgivelser/2015/nkr-adhd-hos-voksne
Q2: not applicable
Q3: Yes
Q4: Yes

(N),Psychologist (Psy), Child Psychologist (CPsy). Q6: Psychiatrist (dpm),
Neurologist (N), Psychologist (Psy).
Children (WISC), ADHD-rating scale DSM-5.
scale DSM-5.
Q8: Both: need a referral from your GP for private medical specialist services.
Only private services available at the moment due to lack of capacity national
health system. Waiting list for private care is still aprox. 1.5 yrs.
Q9: (DK) A referral from your GP for private specialist medical services. Waiting
list. Diagnostic tests and clinical interview by psychologists who refers to
psychiatrist for case advice and medication.
Q10: (DK) At the moment, ADHD patients are forced to use private services if
they "only" are in for ADHD. That means that if the papers only describe ADHD,
and not any comorbidity, ADHD patients are declined from public services and
referred to private services. These have waiting time for up to 1,5 years.
Q11: (DK) Refunded / free of cost, if assessment and diagnosis is from public
hospital. Also if referred to private services by doctor.
Q12: Psychiatrist (dpm), Child Medical Doctor/ Pediatrician(CMD). Q13:

Psychiatrist (dpm)
Q14: (DK) - Professional (psychiatrist) prescribes and monitors. Electronic health

records system.
Q15: (DK) Mostly "standard" medication prescription, but we do see more of

prescriptions that refer to "best for patient".
Q16: Do not know.
Q17: Yes.
Q17A: (DK)
https://blanket.laegemiddelstyrelsen.dk/forms/mopform/reporter/?style=borger

29
Europe AISBL.
prescription in your country: (DK) -
Q18: (DK) Part refunded: see https://www.medicinpriser.dk/ for medicine.
Q19: (DK) No. For pharmacy medication cost prices, see:

https://www.medicinpriser.dk/
Q20: (DK) No. Any additional comments regarding ADHD medication / cost
reimbursement: (DK)-

• Dexamphetamine
• Guanfacin
Other medications: (DK) Denmark has many brands of medication, see

https://www.medicinpriser.dk/ where one can check the brand, price, price
fluctuations and alternative brands as well as patient re-imbursement.

30
Europe AISBL.
Organisation name and country: TDAH PACA, France (FR)
Q 1: Yes. Q1A: (FR) YES However, these “recommendations for good practice” are
not guidelines strictly speaking and pertain to children and adolescents only.
No effort was made to implement these recommendations and update them
after 5 years, for example. https://www.has-
sante.fr/upload/docs/application/pdf/2015-02/tdah_argumentaire.pdf
Q2: not applicable Q3: Yes Q4: Yes
Q5: Psychiatrist (dpm), Neurologist (N), other. Q6: Psychiatrist (dpm),

Neurologist (N), other.
Children (WISC), Clinical Personal Interview & history.
Q7B: DIVA, Clinical Personal Interview & history, ADHD Rating scale DSM-5,
other.
Regarding the tests: Some are not available translated into French. No norms
for scores in French speaking population… Often downloaded from the Internet.
DIVA-5 recently available in France. ADHD Rating Scale DSM-5 not translated
into French. However, the ADHD-RS DSM-IV was translated and disseminated.
Wender Utah Rating Scale translated into French for adults.
Q8: (FR) Child: No specific national service. Reference centers for learning
disorders and/or ASD exist in each administrative department and may
diagnose ADHD. There are some pediatric services or CAP services developing
ADHD diagnosis and treatment. Parents can reach (or any MD may refer the
child to) the public CAP services but professionals there are mostly under
influence of psychoanalytic theories. Child may consult speech therapists
(reimbursed by Social Security) or psychologists (not reimbursed by Social
Security) who may suspect the diagnosis and ask a specialist for confirmation.
So called “platforms for neurodevelopmental disorders under the age of 7” have
been promoted by the government. The concept shall be extended to children
up to 12 years old. Parent support associations often help finding the right
specialist. Adult: Adults: No specific national services. There are some reference
centers for bipolar disorders, addiction services or psychiatric services offering
ADHD diagnosis and treatment. Some psychologists and psychiatrists here and
there, mostly addiction or sleep specialists can be reached in hospitals. No
national registry exists! Parent support associations often help finding the right
specialist.
Q9: (FR) Same as above. Child: In France, parents can access directly to
psychiatrists (and be partly reimbursed by the Social Security) without the
obligation to be referred by their GP. Adult: Same as Q8. In France, adult can
access directly to psychiatrists (and be partly reimbursed by the Social Security)
without the obligation to be referred by their GP.
Q10: (FR) Child: Shorter waiting lists, predominance of psychoanalysis theories

among CAP psychologists and psychiatrists. Adult: Shorter waiting lists.
Q11: (FR) Children: Consultation with any MD are reimbursed (some private
specialists may ask for a higher amount of money), speech therapists are

31
Europe AISBL.
reimbursed (some private therapists may ask for a higher amount of money).
Parents are charged for all other costs (e.g. psychological assessments, other
therapies) unless performed in the public health system when available. When
the child’s disability is recognized by the “Maison Départementale de la
Personne Handicapée” (MDPH), an amount of money is given monthly to the
parents to pay for unreimbursed treatments. The amount depends on the
burden/impairment and may be up to 500€ per month. Adults: Same as above
except that adults can be given a monthly amount of money by the MDPH for
their treatment. Other social aids exist however, not specifically to cover ADHD
diagnostic costs.
Q14: (FR) Children: Methylphenidate is available in in-town pharmacies.

Treatment for 28 consecutive days can be given at once. The prescription by
the specialist at the public hospital / private clinic is valid for one year and shall
be renewed every 28 days by any MD (public or private regardless of his
specialty). There are concerns about a generic brand of Concerta® that appears
to be less effective than the princeps. Since the 1st of January 2020, there is a
mandatory generic substitution with a number of issues. Patients are obliged
to pay for their treatment or be switched to another brand (i.e. Ritalin®,
Medikinet® or Quasym®). Atomoxetine is only available in hospital pharmacies.
The doctor (who doesn’t need to be a specialist) requests on-line the
authorization to the “Agence Nationale de la Sécurité du Médicament et des
Produits de Santé” (ANSM). This is called a Temporary Use Authorization (ATU in
French). The treatment is delivered at no cost to the patient. Amphetamines
(Attentin®) are available in France under the process of ATU for a very limited
number of patients, mostly those with narcolepsy or foreigners who were
previously treated in their countries and come living in France. Guanfacine is
not available in France at all. Adults: Methylphenidate immediate release is
licensed for adults with narcolepsy, all other forms of methylphenidate are not
licensed for ADHD in adults. However, the Social Security tolerates that the
doctor do not write “off label” on the prescription. The Social Security
recognizes that ADHD may persist at adulthood and reimburses
methylphenidate only if first prescribed before age of 18. Atomoxetine can be
obtained via the ATU process (see above) Amphetamine (Attentin®) can be
obtained via the ATU process (see above) Guanfacine is not available at all.
Q15: (FR) Not known. Q16: Not known. Q17: Yes Q17A: (FR) Yes. Any MD has the
legal obligation to declare any adverse effect of any treatment to the “Centre
Régional de Pharmacovigilance” (e.g. https://ansm.sante.fr/Declarer-un-effet-
indesirable/Pharmacovigilance/Centres-regionaux-de-
pharmacovigilance/(offset)/4), one in every university hospital. There is no legal
obligation to declare ineffectiveness, but it is not forbidden. The doctor or the
patient himself fills a form on-line. The information is checked, and databases
searched, and a written answer is returned. If validated, the declaration is
entered in the national and international databases for adverse events. For
example, this is the issue with regard to the generic brand of Concerta®.

prescription in your country: (FR) Lack of specialists: - students in medicine

32
Europe AISBL.
didn’t have any courses on ADHD since two years ago) - vast majority of
psychology students are forced to apply psychoanalytic theories in the first
three years of their cursus. Time for diagnosing ADHD is underpaid so doctors
in public hospitals are not encouraged to proceed by the hospital directors
(“Time is money”) Teachers are not trained to spot neurodevelopmental
disorders and it is not rare they refuse to rate the child’s behaviour pretending
they don’t want to be involved in a diagnosis process that would lead to
prescribe a drug… Lack of awareness and Stigma.
Q18: (FR) See above.
Q19: (FR) YES, but no update since 2014.

https://ansm.sante.fr/content/download/105139/1331877/version/1/file/Rapport+m
%C3%A9thylph%C3%A9nidate+-+VF.pdf
Q20: (FR) No, if they are resident with access to the Social Security system.

(FR) We need amphetamine to be labelled in France. Mylan’s generic of
Concerta® is concerning. Dexamphetamine and Atomoxetine are only available
in France under the regimen of Autorisation Temporaire d’Utilisation (ATU =
Temporary Authorization for Use) delivered by the Health Ministry. Patients can
get the product for free at the declared hospital pharmacy. The ATU procedure
pertains to products that do not have a label. However, the vast majority of
patients treated by dexamphetamine in France have narcolepsy or diurnal
hypersomnia. Risperidone is not a treatment for ADHD, although available in
France.

• Other
• no medication prices / details supplied.
Other medications: -

33
Europe AISBL.
Organisation name and country: ADHD-liittory ADHD Association, Finland (Fi)
Q 1: Yes 1A: (Fi) https://www.kaypahoito.fi/hoi50061 Q2: not applicable Q3: Yes

Q4: Yes
Q5: General Practitioner (GP), Psychiatrist (dpm), Neurologist (N). Q6:

Psychiatrist (dpm)
Observation Schedule (ADOS), ADHD-rating scale DSM-5, Snap- IV, other.
scale DSM-5, Snap- IV, other.
8: (Fi) Diagnosis by school doctor or childcare centre doctor with referral to

special healthcare if needed. For adults: referral from the general practitioner
/occupational health doctor to psychiatrist.
Q9: (Fi) Parents/ child or adults can book private health service appointment
with a psychiatrist.
Q10: (Fi) Waiting time can be long in public healthcare. Q11: (Fi) Costs are
covered by the national public health service for children and adults. Q12:
General Practitioner (GP), Psychiatrist (dpm), Neurologist (N).
Q13: Psychiatrist (dpm). Q14: (Fi) Both have electronic patient records and
prescriptions.
Q15: (Fi) for both: methylphenidate is first prescribed medication.
Q16: No Q17: Yes Q17A:

https://www.fimea.fi/web/en/pharmaceutical_safety_and_information/pharmac
eutical_safety/reporting_adverse_reactions

(Fi) Additional diagnostic tests/tools are for children "Kesky" and for adults
"WURS" and "BADDS". The school doctor can also prescribe ADHD medication
for child. Private diagnosis is expensive but faster. There are changes in the
medication (brands vs generic).

34
Europe AISBL.
Q18: (Fi) Both are partly covered by the national public health service up to
€572 cost, then after only €2,50 per prescription.
Q19: (Fi) No Q20: (Fi) If EU citizen lives or works in Finland, heath service and
medication will be covered by public health system. Temporary stay (excluding
acute emergency treatment) is not covered.
Any additional comments regarding ADHD medication / cost reimbursement :

(Fi) No.

• Dexamphetamine
• Guanfacin
Other medications: (Fi) -

35
Europe AISBL.
Organisation name and country: ADHS-Deutschland, Germany (DE)
Q 1: Yes Q1A: https://www.awmf.org/uploads/tx_szleitlinien/028-

045l_S3_ADHS_2018-06.pdf
Q2: not applicable. Q3: Yes Q4: Yes. Q5: General Practitioner (GP), Psychiatrist
(dpm), Child Medical Doctor/ Pediatrician(CMD), Neurologist (N), Psychologist
(Psy), Child Psychologist (CPsy), Educational Psychologist (EPsy).
Q6: Psychiatrist (dpm), Neurologist (N), Psychologist (Psy).
Children (WISC), VanderBilt Assessment Scales, Clinical Personal Interview &
history, Autism Diagnostic Observation Schedule (ADOS), ADHD-rating scale
DSM-5. Q7B: DIVA, Clinical Personal Interview & history, Adult ADHD Self-Report
Scale (ASR-v1.1), Adult ADHD Self-Report screening scale for DSM-5.
Q8: (DE) Child: The diagnosis integrates information from a detailed

developmental anamnesis and family history, psychodiagnosis as well as
physical diagnostics and differential diagnostics. The assessment of the current
clinical symptoms and their severity is based on the exploration of the parents
and other caregivers, e.g., teachers. The exploration should always integrate
information from multiple raters and take into account different areas of life.
Structured or semi-structured interviews and checklists are used as well as
disorder-specific questionnaires (parent- and teacher ratings) Adult: The
diagnosis integrates information from a detailed developmental anamnesis
and family history, psychodiagnosis as well as physical diagnostics and
differential diagnostics. In adulthood, diagnosis is mostly based on the
exploration of the patient, taking into account information by relatives or third
parties (for example school certificates). Structured or semi-structured
interviews and checklists are used as well as disorder-specific questionnaires
(self-ratings and informant-ratings).
Q9: (DE) Same. Waiting lists for government health services. Private diagnosis
expensive. Q10: (DE) Private services is faster but expensive. Q11: Relevant
diagnostic procedures are covered by health insurance (only extra procedures
depend on the status of the insurance)
Q12: (DE) All medical doctors but the recommendation is that ADHD
medication should be started and prescribed by specialists only: General
Practitioner (GP), Psychiatrist (dpm), Child Medical Doctor/ Pediatrician(CMD),
Neurologist (N), Psychologist (Psy), Child Psychologist (CPsy), Educational
Psychologist (EPsy). Q13: Psychiatrist (dpm), Neurologist (N), Psychologist (Psy).
Q14: All medical doctors but the recommendation is that ADHD medication
should be started and prescribed by specialists only.
Q15: Usually along the guideline algorithm which does not imply that all
medications are tested but also not that "one brand fits all". All medical doctors
can prescribe but the recommendation is that ADHD medication should be
started and prescribed by specialists only.
Q16: No Q17: Yes Q17A: (DE) If serious new side effects occur these should be
reported to the Federal Ministry

36
Europe AISBL.
https://www.bfarm.de/DE/Arzneimittel/Pharmakovigilanz/RisikenMelden/Nebe
nwirkungsmeldungBuerger/_node.html

prescription in your country: (DE) Yes, approval status differs but stimulants are
first-line medication for children and adults.
Q18: (DE) Most medication is covered by insurance companies, some medicine

has additional costs for patient.
Q19: No. Q20: (DE) All approved medications will be reimbursed but pricing is
fixed by the Federal Joint Committee (G-BA) which is the highest decision-
making body of the joint self-government of physicians, dentists, hospitals and
health insurance funds in Germany. If companies sell for higher prices the
additional costs need to be covered by the patients. Any additional comments
regarding ADHD medication / cost reimbursement: -

• Methylphenidate short -release Medikinet
• Dexamphetamine
• Guanfacin
Other medications: Elvanse, Intuniv

37
Europe AISBL.
Organisation name and country: ADHD Hellas & National Kapodistrian
University of Athens, Medical school, Dept. of Psychiatry, Greece (GR)
Q 1: No Q1A: - Q2: No Q3: Yes Q4: Yes Q5: Psychiatrist (dpm),, Child Medical
Doctor/ Pediatrician(CMD), Neurologist (N)
Q6: Psychiatrist (dpm), Neurologist (N), Psychologist (Psy)
Q7A: Conners Scales (parent and teachers), Clinical Personal Interview & history,
Autism Diagnostic Observation Schedule (ADOS), other.
(ASR-v1.1), other.
Q8: (GR) Child: There are national health services for ADHD diagnosis and
medication but not for treatment. Many remote areas and islands do not have
access to national or private services. Regarding diagnosis- the use of
standardised tests like SDQ, Dupaul and Achenbach are widely used. Many
services complete a full psycho-educational assessment, including WISC III or V,
learning assessment and occupational assessment. This is in addition to a
developmental history and a clinical interview. In Greece, there are only two
national clinics for ADHD adult diagnosis (Athens and Heraclio, Crete) and
medication. None for treatment. There is no standard procedure. It largely
depends on how each clinic works. Nevertheless, regarding treatment the
standard approach is that of occupational therapy, individual psycho-therapy,
family work and individualised education plan (at least in theory). Medication is
under-used, reserved mainly for severe cases of hyperactivity and conduct
problems. The Athens University Psychiatric Clinic and the Hellenic Psychiatric
Association (section for neuro-developmental disorders across the lifespan)
have agreed for a standard procedure for adult ADHD diagnosis.
Q9: Child: the same as national services. Adult: Largely unknown. Only very few
adult psychiatrists deal with that. There are very few child psychiatrists and
psychologists able to perform a comprehensive adult assessment, including (on
top of a clinical interview) executive functioning testing (CPT, STROOP, ATRAIL).
Q10: Child: More expertise, short waiting list, provision of treatment options,
liaison work with school and continuity of care. Adult: more expertise (although
still limited).
Q11: Child: If assessed in NHS, the cost is covered by public insurance. If assessed
privately, the cost is covered privately.
Q12: Psychiatrist (dpm) Q13: Psychiatrist (dpm)
Q14: Both: Patient is issued with an electronic prescription, supervised and

governed by a service which is under the Ministry of Health.
Q15: Best medication for the patient by both health services. Note that: Ritalin,
Concerta and Strattera are the only medications available (only brands, no
generics) Risperdone/Risperdal for aggression.
Q16: yes Q17: yes Q17A: Medication complaints should be directed to

psychiatrist and for side effects a report can be made :

38
Europe AISBL.
prescription in your country: *
(GR) Additionally:1) the Dupaul, SDQ, Achenbach tests are used for children.
2)National health services have long waiting lists (1-2 years). Private diagnosis is
expensive (€250-€500) but faster. 3) National services are very guarded to
prescribe medication because of a very long history of prominent social and
psycho-analytic psychiatry in Greece but this is slowly changing. The difference
in national /private services depends on who runs the service.
Q18: Both: Public insurance covers 75% of the national health service costs.
Q19: No. Q20: Same for resident EU citizens who have national insurance.
Any additional comments regarding ADHD medication / cost reimbursement :
(GR) Private purchase is allowed if the medication is not a controlled substance.

If medication is a controlled substance, the doctor has to issue an electronic
prescription only. Monthly prescription by the psychiatrist is a cost (€50) which
is not refunded. Limited medicines available. "Concerta" medication is
frequently out of stock.


39
Europe AISBL.
Organisation name and country: ADHD Hungary (HU)
Q 1: No Q1A: - Q2: Yes Q3: Yes Q4: Yes Q5: Psychiatrist (dpm) Q6: Psychiatrist
(dpm)
Observation Schedule (ADOS), ADHD-rating scale DSM-5.
scale DSM-5.
Q8: There are no local community health services for ADHD. Psychiatric
hospitals have developed protocol for examination. Child: All examinations are
carried out over 1-2 weeks at the psychiatric hospital with a doctor, psychiatrist,
psychologist and special education teacher. Medication is tested too. Adult: the
clinical personal interview and DIVA questionnaire are used.
Q9: Private appointments are done within 1 month. No reimbursement of cost.

In Hungary, children with ADHD are not accepted, there is no proper education,
healthcare/leisure programs. Therapies are expensive, not supported and there
are few specialised professionals.
Q10: Both: There is no national service where you do not pay. The waiting list is
for 2 -3 years.
Q11: Both: social insurance covers part and rest at private costs. Limited
locations only.
Q12: Psychiatrist (dpm) Q13: Psychiatrist (dpm)
Q14: Both: Psychiatrist can only prescribe medication. Ritalin prescription only
double after ordering the full price without rebate. Strattera medication is price
sponsored.
Q15: Not known. Q16: No Q17: No Q17A: Not known. For medication complains,
patients will need to speak to their psychiatrist. For other complaints, ADHD
patient organisations can help patient.
Any additional comments regarding adhd diagnosis and medication

prescription in your country: (HU) Medication is not given when parents object.

40
Europe AISBL.
The 'scientology' religious movement has an influence, it does not
acknowledge the existence of mental health disorders.
Q18: Hungary’s healthcare system is financed through the Health Insurance

Fund (HIF), which is primarily responsible for recurrent health care costs.
Patients make co-payments on certain services, including pharmaceuticals.
Q19: No. Q20: Foreigners have to pay the full price for the diagnosis, tests, and
medication.

There are only 2 medications: 'Ritalin' and 'Strattera'. There are no state
pharmacies anymore. ADHD medications are always on prescription with strict
conditions.
Other medication: -

41
Europe AISBL.
Organisation name and country: ADHD Samtokin (The ADHD Association),
Iceland (IS)
Q 1: Yes. Q1A: (IS) https://www.landlaeknir.is/gaedi-og-

eftirlit/heilbrigdisstarfsfolk/klininskar-
leidbeiningar/leidbeiningar/item14931/ADHD---vinnulag-vid-greiningu-og-
medferd Original document from 2012:
https://www.landlaeknir.is/servlet/file/store93/item14259/ADHD-
7.%20mars%202012.pdf Update from 2014 to accommodate DSM-5 and other
matters:https://www.landlaeknir.is/servlet/file/store93/item23317/ADHD%20loka
útgáfa_2014_lagad_2017.pdf
Q2: not applicable. Q3: Yes Q4: Yes Q5: Psychiatrist (dpm), Child Medical Doctor/
Pediatrician(CMD), Neurologist (N), Psychologist (Psy), Child Psychologist
(CPsy). Q6: Psychiatrist (dpm), Neurologist (N), Psychologist (Psy).
Observation Schedule (ADOS), ADHD-rating scale DSM-5, other.
Q7B: DIVA, Clinical Personal Interview & history, ADHD Rating scale DSM-5,
other.
Q8: (IS) Child: A team consisting of CMD, DPM and CPsy lead the work, but
consult with parents, teachers and school health staff and other parties that
may have relevant information. Adult: A team of DPM’s and Psy’s conduct
interviews, tests and discuss the outcome. Additional tests are: 1. SDQ 2. K‐SADS
3. WPPSI‐R, WISC‐ IV 4.ASEBA 5.CAPALETTI 6. CPT 7. TEACH 8. TOVA 9. NEPSY-II
10. Rey Complex Figure Test 11.FAS 12. Rey Auditory Verbal Learning Test 13.ABC-
II 14. TOLD 15.SRS 16.SCQ. Instead of ADOS, ASSQ is used. Some of these tests
are not used for adults. TEACH is used in relation to autism not ADHD
diagnosis. TOLD is used once ADHD diagnosis is being considered, not as part
of diagnosis.
Q9: (IS) Child: A child is usually diagnosed by a CMD or referred to a Cpsy/Psy,

which may then refer the child to a CMD after diagnosing Note: According to
the clinical guidelines it is preferable this work is done by a team – in case of
children that usually includes a number of specialists. Adult: DPM can diagnose
– either alone or in co-operation with a Psy. It is common the individual starts
our with a Psy and then has to seek out a DPM, specifically if the intention is to
try drug therapy. Note: According to the clinical guidelines it is preferable this
work is done by a team – for example 1 DPM and one Psy – most DPM’s
probably prefer to do so where possible.
Q10: (IS) The national diagnostic team has a growing waiting list – approx..12-18
months per child – many parents are forced to go through the private sector.
Adult: The waiting list is 30-36 months • Note: In both cases this comes boAth
down to public finance as well as the simple fact that more qualified DPM’s are
needed in Iceland.
Q11: (IS) Children: In theory most or all health care for children should be free of
charge. The reality however is that in many cases parents will suffer some cost –
not the least when choosing the private sector. Government will only cover part
42
Europe AISBL.
of that cost via the Icelandic Health Insurance. Private health insurance is not
common and usually exclude ADHD, Adults: Going through the public health
ADHD team an individual will pay minimum amount – maybe +/- €205 in total.
Most DPM’s have a contract with the Icelandic Health Insurance. Individual will
pay <€100 per interview and are reimbursed for some of the rest. Consulting a
Psy is rarely covered by the Icelandic Health Insurance and an individual is
likely to pay €500-€1200 for ADHD diagnosing.
Q12: General Practitioner (GP), Psychiatrist (dpm), Child Medical Doctor/

Pediatrician(CMD), Neurologist (N).

Pediatrician(CMD),Neurologist (N).
Q14: (IS) Note in addition to Q12 & Q13 :Child: * GP can only prescribe ADHD
medicine when a CMD/N/DPM has started treatment – mainly though as a
backup option. Adult: ** GP can only prescribe ADHD medicine when a CMD
has started treatment – mainly though as a backup option or later on when
regular CMD consultation is no longer needed. This mainly applies to
medication based on methylphenidate or amphetamine related ingredients.
GP’s can prescribe medication based on Atomoxetine as well as some other
medication accepted for off-label use for ADHD. Administrative process for
both: Doctor applies for a special national permit covering a specific type of
medication (brand or generic. The process may take 2-4 working days
(occasionally longer). Without this a chemist is not allowed to fill a prescription
(for example a ‘valid’ EU prescription), nor would the National Health Insurance
subsidise the cost.
Q15: (IS) For both child & adult: It is up to the specialist to choose a medication.
Unless a prescription stipulates a specific make (brand or generic), the chemist
is supposed to offer a lower cost alternative. But it is up to the parent to choose.
National Health Insurance will however only subsidise the cost according to the
lowest cost alternative (if generic is available). If an individual can not tolerate
generic medication, a special permit can be granted in order to get the brand
name original fully subsidised.
Q16: No Q17: yes Q17A: (IS) https://www.ima.is Icelandic Medicines Agency.

Doctor and/or patient can (and preferably both should) report side effects etc. If
the intention is to get a brand name medicine fully subsidised the doctor will
follow up with new application for a special permit. How long this process takes
really depends on the severity of side effects and how thoroughly the doctor
presents the case. Apart from that the IMA works in conjunction with all sister
institutions in EU/EEC and aims to provide similar service. The IMA director has
though recently voiced that Icelandic health professionals [and individuals for
that matter] could and should be more active in reporting such issues. The
implication being that statistics for reporting in Iceland is somewhat lower that
elsewhere in Europe.

(IS) Waiting lists are counting in multiple years and this has to be addressed by
Icelandic authorities – not the least in regard to children, even 6-12 months wait

43
Europe AISBL.
is utterly unacceptable at a young age when a child is developing fast, both
mentally, physically and socially. Going the private route – Psy work for adults is
not subsidised and thus cost of diagnosing can easily go well past €1000. Same
can actually apply to children since ‘jumping the cue’ often means paying full
price without being able to apply for a government refund. Brand vs. generic …
Generic alternatives should be and probably mostly are fully acceptable
alternative to brand names. The government does offer the possibility of
proving a generic option does not work and thus get a brand medicine fully
subsidised. However – regarding the current alternatives to Concerta, it looks to
us unacceptable to accept some of them as real generic alternatives. This
applies not the least to Methylphenidate Sandoz, which seems to generate
complaints going well above 50%. MS was tested and accepted by the Danish
MA (thus for all EU/EES countries) – even re-screened and given a green light
again. Complaining to the IMA only results in the institution point out this fact.
This particular example really points out that we may need a way to address
such complaints simultaneously with all the EU/EES MA institutions. Additional
note to Q16: Well … not really. The government argument may be that to many
are diagnosing and thus over-prescribing medication – but the reality is that
neither children or adult health service ADHD team are coping with the
workload. If looking specifically towards the adult group Iceland has probably
had more than a fair share of rouge doctors prescribing ADHD medication
without cause (some due to wrong diagnosing and some due to drug misuse) –
but with stricter control systems this problem seems to have fallen sharply in
the past 1-2 year.
Q18: (IS) Children: National public health system and private cost. For the most
part children health cost should be covered by the national public health
system. For medication there is a “cost roof” [separate from other health cost]
where parents/ adult patients will carry 100% of the first ca. €200p/y. Then
lowering in steps to 15%, 7,5% and after ca. €500 it’s down to 0%. For children
this “cost roof” covers all children in family combined. Note: Unless a special
permit is granted this will only apply to the lowest cost of a generic alternative –
meaning that if you choose a brand name without a special permit then you
carry the price difference.
Q19: (IS) No. Q20: (IS) No. Any additional comments regarding adhd medication /
cost reimbursement:
(IS) 1) frequent out of stock medicine. Iceland, just like the rest of Europe has
been experiencing frequent out of stock issues for medication. This partly
comes down to BREXIT related issues – but also looks like big pharmas are
looking at some European market sections as to small to really bother
sometimes to keep stock available – this may in some instances even apply to
Europe as a whole. Part of this problem also relates to EU/EES regulations that
stipulates the “drug information leaflet” has to be provided in a printed form.
By allowing for the leaflet to be only provided in a digital format it will be far
easier for countries to purchase drugs as 'one big entity' and thus help battling
this situation. 2) changes from brand to generic medication. So far generic
substitution is only available for Concerta and Strattera. For the most part the
generics are an acceptable choice – but lately we have seen repeated stock
problems for generic drugs. However, one generic drug stands out in terms of
complaints regarding how it seems to differ from the original brand – in this

44
Europe AISBL.
case is Concerta. Multiple complaints have been made about Methylphenidate
Sandoz – far to many to be acceptable – and some (informal) research seems to
indicate the generic MS released the methylphenidate irregularly and/or to fast.
One possibly factor may be type of food consumed. MS was qualified by the
Danish Medicines Agency – which later on saw reason to look again into the
matter – but eventually came to the same conclusion. Serious irregularities
were found during the original testing – and this matter should be looked at by
an independent party. 3) limited medicines available. The number of brands
(original and generics) on offer in Iceland is very limited compared to for
example the rest of Scandinavia – for example only two amfetamin related
stimulants where allowed some 2-3 years ago (Attentin and Elvanse) and to this
day no drug based on guanfacine is on offer. The Icelandic Medicine Agency
works closely with its counterparts within the EU/EES – which indicates this
may largely come down to lack of interest from importers rather than official
limitations.

• Dexamphetamine
Other medications: (IS) Multiple generic Methylphenidate long-release; multiple
generic Atomoxetin

45
Europe AISBL.
Organisation name and country: ADHD Ireland (IR)
Q1: Yes.
Q1A: (IR) These are for children (Nice Guidelines from the UK are used but not
official)
https://www.hse.ie/eng/services/list/4/mental-health-
services/camhs/camhssop.pdf
Q2: mixed feedback from service -users Q3: Yes. Q4: Yes.
Q5: General Practitioner (GP), Psychiatrist (dpm), Psychologist (Psy), Child

Psychologist (CPsy), Educational Psychologist (EPsy)
Q6: General Practitioner (GP), Psychiatrist (dpm), Psychologist (Psy).
Children (WISC), other.
Q7B: DIVA, Clinical Personal Interview & history, other.
Q8: (IR) Referral from GP, initial assessment within 3 months but could be 18
months for ADHD assessment is done.
Q9: (IR) Private clinicians will diagnose a child earlier, national service only from
6 years. Multi-disciplinary model from national service but not with private
clinician. Very little available service in either public or private for adults.
Q10: (IR) Cost, the only advantage to going private is speed of access (18 months
for children and virtually no services for adults in the public sector)
Q11: (IR) In public service, all is funded by the State, in private all is paid by the
parent or adult.
Q12: General Practitioner (GP), Psychiatrist (dpm).
Q14: (IR) In either case you simply bring the prescription to the pharmacy.
Q15: (IR) "best medication for the patient ". Q16: No. Q17: No. Q17A: n/a

(IR) It’s too slow for children and little available for adults
Q18: (IR) State will pay up to 16 years all that you pay (unless you can show
hardship etc).
Q19: (IR) n/a.
Q20: (IR) No, we are members of the EU so equal access for all EU citizens

(IR) No

46
Europe AISBL.
No medication prices / details supplied.
Editor’s note: https://www.hpra.ie/homepage/medicines/medicines: Ritalin,

Concerta, Tyvense and Strattera available.

47
Europe AISBL.
Organisation name and country: AIFA ODV, Italy (IT)
Q 1: No Q1A: (IT) - There are some standard procedures written on a national

diagnostic protocol but they are not followed by all centres due to time and
diagnostic tests availability.
Q2: No Q3: Yes Q4: Yes Q5: Psychiatrist (dpm), Child Medical Doctor/
Pediatrician(CMD), Psychologist (Psy).
Q6: Psychiatrist (dpm), Psychologist (Psy).
Q7A: Conners Scales (parent and teachers), Wechsler Intellegence Scale for
Observation Schedule (ADOS).
scale DSM-5.
Q8: (IT) Neuro-psychiatrist first assesses the child. Tests are submitted by
psychologists. speech therapists and psychomotricists. Adult: psychiatrist visit
first the patient. Tests are submitted by psychologists.
Q9: (IT) There are private centers affiliated with the public health service that
can make diagnosis and psychological therapy but cannot prescribe
medication. Private health service is very expensive and completely charged at
private costs to the patient/ families.
Q10: (IT) Child: Poorly trained doctors and long waiting lists in the public health
oblige to use private services Adult: There are few public treatment centres in
Italy and the number of diagnosis is tiny compared to estimation. Patient often
emigrate to other Italian cities where diagnosis and psychotherapeutic
treatments are available on private basis, nevertheless pharmacological
treatments can be prescribed only by psychiatrists listed by the Region Health
Administration.
Q11: (IT) Children: The National Health System does not charge children’s
diagnosis Private centre’s cost is entirely charged to families. Adults: There are
few centers. Diagnosis and treatments have a different cost decided by the
Regional Health System.
Q12: Psychiatrist (dpm). Q13: Psychiatrist (dpm)
Q14: (IT) Children: Therapeutic plan is released by the child neuro-psychiatrist,

you than ask the pediatrician for a prescription. You can show the prescription
to the pharmacist to withdraw the medication which is free. Adults:
Therapeutic plan is released by the psychiatrist to present to your general
family doctor to get a prescription and withdraw the medication in the
pharmacy. Medications are free if therapeutic plan was made before eighteen
years of age.
Q15: (IT) Children and adult: we have only two medication in Italy
methylphenidate and atomoxetine prescribed in different dosages, distributed
by the pharmaceutical company approved by the drug agency. We have do not

48
Europe AISBL.
have many medication brands for ADHD. Sometimes during the year, the
medicines are out of stock.
Q16: yes
Q17: yes Q17A: (IT) - Every citizen can report a suspected adverse reaction
through an appropriate "Template form for citizens reporting side effects",
which can be downloaded from the website of the Agenzia Italiana del
Farmaco - Italian Medicines Agency (AIFA) at the following address:
http://www.agenziafarmaco.gov.it/en/content/reporting-adverse-reaction

(IT) Private diagnosis is expensive (€300 - €600 aprox.). The minimum waiting
time for a first visit in the national health system is at least 6 months or more. In
some areas, such as Campinia region, service-users feedback is that it takes 8
months to 1 year before the first visit.
Q18: (IT) Children: free of charge under the national public health system.
Adults: at private cost/ private services only, if after 18 years of age.
Q19: (IT) No. Q20: (IT) Resident EU citizens get the same use.

(IT) No private purchase for ADHD medication is allowed without a prescription.
Sometimes the medicine is out of stock which can be very problematic for
school/work.

Other medications: (IT) -

49
Europe AISBL.
Organisation name and country: Treffpunkt ADHS, Luxembourg (LU)
Q 1: No Q1A: (LU) - Q2: mixed feedback from service -users Q3: Children only until
18 yrs Q4: Yes

(N), Psychologist (Psy), Child Psychologist (CPsy)

(N), Psychologist (Psy), Child Psychologist (CPsy).
Q7A: Conners Scales (parent and teachers), Wechsler Intellegence Scale for
Children (WISC), DIVA junior, Clinical Personal Interview & history, Autism
Diagnostic Observation Schedule (ADOS), ADHD-rating scale DSM-5.
scale DSM-5.
Q8: (LU) Children who have been treated before 18yrs will have medication
reimbursement. Child diagnosis consists of multi-diagnosis tests, blood, OTO,
EEG, otorhinolaryngologist, psychomotor specialist, psychologist,
ophthalmologist and orthoptist.
Q9: (LU) same as above
Q10: (LU) Child: services and waiting time are the same, no difference.
Q11: (LU) Child CNS national public health system and optional private
insurance will cover costs. Per 3 months prescription.

Q14: (LU) Child on CNS need a special prescription (carnet de stupefiants, which
is valid for 3 months) and then pay only 20% of medication cost.
Q15: (LU) Children only methylphenidate available. Adults private prescriptions

can be for methylphenidate, ATMX, and guanfacin.
Q16: don’t know Q17: yes Q17A: (LU)

https://guichet.public.lu/en/entreprises/sectoriel/sante/medecins/notification-
effets-indesirables-medicaments.html
Any additional comments regarding adhd diagnosis and medication

(LU) For children only Ritalin, Medikinet and Concerta are available. For Adults
'off-label' prescriptions of Methylphenidate, Atomoxetine (Strattera) a non-
stimulant medication, and (imported) guanfacin can be prescribed and might
be (partially) refunded by private insurance.
Q18: (LU) Children are covered by the national health insurance and private
insurance. Adults reimbursed only by private insurance.

50
Europe AISBL.
Q19: (LU) No Q20: (LU) If registered with the CCSS and CNS, no difference.

(LU) -

• Lisdexamphetamine correction
• Guanfacin (imported)
Other medications:-

51
Europe AISBL.
Organisation name and country: ADHD Malta, Malta (MT)
Q 1: No Q1A: A draft national guideline is being developed by the Ministry of

Health & CYPS.
Q2: mixed feedback from service-users Q3: Yes Q4: Yes.
Q5: Psychiatrist (dpm), Child Psychologist (CPsy), Educational Psychologist

(EPsy). Q6: Psychiatrist (dpm), Psychologist (Psy).
Children (WISC), Vanderbilt Assessment Scales, Clinical Personal Interview &
history, Autism Diagnostic Observation Schedule (ADOS).
Q7B: Clinical Personal Interview & history, Adult ADHD Self-Report Scale (ASR-
v1.1), Adult ADHD Self-Report screening scale for DSM-5, ADHD Rating scale
DSM-5.
Q8: Child: GP doctor refers patient to Child/Youth Psychological Services (CYPS),

after intake and diagnostic tests by a psychologist, a diagnosis and treatment
plan with medication is prescribed by the psychiatrist and every 6 months a
check-up appointment is made. Adult: Doctor refers patient to Psychological
Out Patient (POP) at the national hospital Mater Dei, an appointment / intake
/diagnosis will be made by the psychologist after which a treatment
plan/medication will be made and every 6 months a check-up appointment is
made.
Q9:Child: parents take the child to the psychologist, the diagnosis tests are
often made in summer, they are quite expensive and subject to waiting list and
the report can take up to 3 months to be finished, a treatment plan is
suggested and educational support suggestions are made in the report which
the school has to provide ( such as apply for learning assistant in the
classroom). The parents can opt to visit a psychiatrist to check if medication will
be prescribed as art of the treatment plan, several visits will be needed to
optimise the medication and follow-up appointments have to be initiated by
the parents. All costs are at private cost (diagnosis might be partially covered if
they have private insurance) including medication, unless the parent requests
the psychiatrist to apply for the Permit, white control card and POYC system.
Adult: Patient can initiate a visit to psychologist or psychiatrist to ask for
diagnosis of complaints, the specialist will diagnose or refer, and all
appointments are paid by the patient and follow up appointments are made
upon their initiative.
Q10: Child: waiting lists at CYPS are aprox 1 year. Depending on the severity of
the complaints and their financial situation, the parents often opt to pay for
private services. Appointments with private psychologists are fast (no waiting
list), however the diagnostic tests are expensive and often take part in summer
with the report taking 3 months to be produced. The procedure within the
national health services however takes longer as diagnostic procedures
depends on the internal waiting list for services and appointments are only
available during school hours which means that the child misses school and
the parent has to take leave from work. Services are not provided after 1pm
daily. Some of the specialists working at CYPS provide the same services

52
Europe AISBL.
privately in the afternoon. From the feedback of parents joining ADHD Malta
complaints regarding the high private costs and copying of reports, lack of
expertise on ADHD and bias against medication use from psychologists has
been noted. Lack of accountability by these medical professionals makes
parents attempt to combine government and private services as best as
possible to get their child help. Adult: National POP waiting list are aprox 1 year
for the first appointment and upto six months between appointments. Private
appointments with psychiatrists and psychologists are often within a week (no
waiting lists) and cost between 35 – 75 euro per visit. Diagnosis, treatment, and
medication plan can often be accomplished within a few visits. From the
feedback of adults joining ADHD Malta indicate complaints regarding varying
specialists’ expertise on ADHD and treatment /medication issues. All expenses
are borne by the patient unless requests the psychiatrist to apply for the
Permit, white control card and POYC system. Lack of accountability by these
medical professionals makes patients attempt to combine government and
private services as best as possible to get help. Within the local mental health
professional community ADHD is often dismissed as a relatively benign
condition whilst only patients in crisis and self-harm situations are treated in an
accountable manner within the national health system.
Q11: (MT) Child & Adult: National Diagnostic health services are completely
covered by government health system. Private services are completely at
private cost (unless the patient has a private health insurance coverage for
which approval must be requested).
Q12: General Practitioner (GP), Psychiatrist (dpm). Q13: General Practitioner

(GP),Psychiatrist (dpm).
Q14: (MT) Child: once the psychiatrist prescribes a medication, three papers
need to be filled: a permit application, a control card (for medications collected)
and a POYC application to collect medicine from your local pharmacy. These
papers all have different validity dates and need to be renewed periodically
with updated application papers from the psychiatrist. Each month the family
doctor has to be asked to write a new monthly prescription at private cost (€ 5
– 10) in order to request the POYC medicine. Adults: once the psychiatrist
prescribes a medication, three papers need to be filled: a permit application, a
control card (for medications collected) and a POYC application to collect
medicine from your local pharmacy. These papers all have different validity
dates and need to be renewed periodically with updated application papers
from the psychiatrist. Each month the family doctor has to be asked to write a
new monthly prescription at private cost (€5 – 10) in order to request the POYC
medicine.
Q15: Children & Adults : national health service specialists will always prescribe
the standard generic brands as provided by POYC unless the patient
experiences severe side-effect (self-harm/etc) then a special application can be
made for a different medication on a ‘named basis’ (after a board reviews the
complaint and gives permission). Private specialists often prescribe on a ‘best
medication for the patient’ basis as the patient will buy the ‘brand’ medication
at their own cost (government medication is not for private purchase) however
the patient can be registered for POYC /generic medication too. In 2018 the
national medication system switched to generic brands as part of an EU-wide
health cost cutting process.
53
Europe AISBL.
Q16: Yes. Q17: Yes. Q17A: (MT) Yes, both the family doctor has to register a
complaint as well as the patient (or parent) regarding side-effects for an
application for a different medication to be considered ‘on a named basis’. The
patient complaint should be registered online:
http://www.medicinesauthority.gov.mt/complaints.The current experience is
that the complaint and review board process takes at least 6 months during
which time the patient will have to buy medication at private costs while the
process takes place.

prescription in your country: (MT) - government health services have long
waiting lists of aprox 1 year – this is not acceptable for parents as they are often
in a crisis situation with their child at home and at school and thus private
services are sought and paid. Parents point out that the government health
staff only provide morning services and have no incentive to improve the
waiting lists as they provide private practise services in the afternoon. -
Government medication was changed in 2018 from ‘brand’ which was very
effective to ‘generic’ which is much less effective for many patients – this lack of
effective medication and the deterrent of the high private cost undermines the
optimal treatment plan for patients. - Within the ADHD Malta group many
more complaints of self-harm and suicide danger have been reported in the
adolescent age group after the introduction of ‘generic’ medication. A national
strategy for ADHD, effective services and ‘best medication for the patient' seem
far away.
Q18: (MT) Children & adults: national health medication is ‘generic’ brand and at
no cost to Maltese residents. Private prescriptions are ‘brand’ label and
expensive and not refunded by national or private insurance at all.
Q19: (MT) No, the costs price of the national medications is not public.
Q20: (MT) Yes, national citizens have free health care and medication whilst EU
citizens have to show payslips and EHIC card and may be subject to additional
charges.

(MT) Only few ADHD medications available and unfortunately ‘out of stock’ of
the brand medications Ritalin and Concerta happens on average 2 -3 times per
year, sometimes at exam time (such as Feb 2020 at the start of final secondary
school exams). In 2019, the POYC medication was not out of stock however the
lack of effectiveness of the ‘generic’ medication is a source of stress to the
ADHD community who claim much less effective treatment plan & more side-
effects have been registered. A review Board (national health service) was set
up to deal with the aprox 50 families that requested to change from generic
medication (back) to brand medication and have been approved but it takes
time. Several patients have notified ADHD MALTA that medication period of 3
months not refunded at the beginning of the medication treatment of the
Concerta brand as it is more expensive for POYC (national pharmacy system).
The system is not completely electronic yet and often the parent/adult patient
has to supervise at least 3 documents renewal dates besides the monthly
prescription papers which have to be requested from their GP ( at €5-€15 euro
per prescription), namely medication letter from psychiatrist , white control
card, POYC card/yellow access letter.

54
Europe AISBL.

Other - no medication prices / details supplied (some unknown)

55
Europe AISBL.
Organisation name and country: Impuls & Woordblind, The Netherlands (NL)
Q 1: (NL)Yes Q1A: (NL)

https://www.ggzstandaarden.nl/zorgstandaarden/adhd/samenvatting
Q2: (NL) Not applicable. Q3: (NL) Yes Q4: (NL) Yes
Q5: (NL) General Practitioner (GP), Psychiatrist (dpm), Child Medical Doctor/
(CPsy), Educational Psychologist (EPsy)
Q6: (NL) General Practitioner (GP), Psychiatrist (dpm), Psychologist (Psy)
Observation Schedule (ADOS).
(ASR-v1.1), Adult ADHD Self-Report screening scale for DSM-5
Q8: (NL) Child: clinical interview, questionnaires (sometimes physical

examination, IQ test, QB test, MOXO test or other neurological test if required).
Adult: clinical interview, DIVA questionnaire, sometimes QB test, rarely physical
examination.
Q9: (NL) same as national health service.
Q10: (NL) Depends on the waiting lists (which both services have) and on
financing by national and compulsory private insurance.
Q11: (NL) Children are covered by the locality (limited yearly budget), in the
private sector it depends on your compulsory private insurance which
percentage (70 - 100%) you get refunded. Adults are covered in the national
public health system; in the private sector it depends on your compulsory
health insurance regulations (70-100%).
Pediatrician(CMD), Neurologist (N)
Pediatrician(CMD), Neurologist (N)
Q14: (NL) Both: medication prescribed for 3 months by professionals, entered

into electronic database, collection at local pharmacy.
Q15: (NL) Both: professionals will prescribe according to 'best medication'

however this is influenced by availability and preference of insurance
companies (this influences the reimbursement for patient)
Q16: (NL) No. Q17: (NL) Yes. Q17A: (NL) national pharmacovigilance centre
LAREB: https://www.lareb.nl/en/


56
Europe AISBL.
(NL) GP to be contacted for effectiveness complaints, for side - effects there are
the national pharmacovigilance centre LAREB and Poisoning Centre UMC
Utrecht.
Q18: (NL) In the Netherlands everyone is covered by national public health

system together with a compulsory private insurance company policy for
additional services, chosen by the patient. Children costs will be annual €250
euro 'own risk' of compulsory private insurance maximum. Adults have €385
euro 'own risk' and €250 contribution, after which all medication is free of cost.
Q19: (NL) Yes, the costs are publicly available: www.medicijnkosten.nl
Q20: (NL) No.

(NL) Three medications (Amfexa, Inttuniv and Elvanse) are very expensive and
not prescribed much - the pharmaceutical industry with a special regulation.
Medications are more frequent 'out of stock' leading to substitution of own
medication for another brand.

• Dexamphetamine
• Guanfacin
• Risperdal / Risperdone (co-morbid)
• Other
Other medications:(NL) Local manufacture of medication by Pharmacy
Regenboog. Additional medications: Bupropion, Aripiprazol, Pipamperone. Out
of stock problems occur.

57
Europe AISBL.
Organisation name and country: Radboud University and Karakter facility
(highly specialised for most complicated ADHD patients), the Netherlands
(NL2)
Q 1: Yes. Q1A: (NL2) (NL)

https://www.ggzstandaarden.nl/zorgstandaarden/adhd/samenvatting and for
adults: https://www.nvvp.net/website/nieuws/2015/monodisciplinaire-richtlijn-
adhd-bij-volwassenen-fase-1-gepubliceerd
Q2: Not applicable. Q3: Yes. Q4: Yes. Q5: General Practitioner (GP), Psychiatrist
(dpm), Child Medical Doctor/ Pediatrician(CMD), Neurologist (N), Child
Psychologist (CPsy). Q6: General Practitioner (GP), Psychiatrist (dpm),
Neurologist (N), Psychologist (Psy).
Observation Schedule (ADOS), ADHD-rating scale DSM-5, other. Q7B: DIVA,
Clinical Personal Interview & history, Adult ADHD Self-Report Scale (ASR-v1.1),
Adult ADHD Self-Report screening scale for DSM-5, ADHD Rating scale DSM-5,
other.
Q8: (NL2) Child: Step 1: a child is referred for clinical evaluation by the GP or
community service centre. At that point, the decision is made based on the
complexities of the problems to refer the child for specialized or generic
diagnostics and treatment. Step 2: Through parent and teacher questionnaires
information is summarized on the main points of concern, pre/perinatal
circumstances, developmental milestones, somatic wellbeing, social/family
circumstances, major life events, results of prior clinical evaluations and
treatment and school results. Internalizing and externalizing behaviour
(including ADHD) is compared to age and sex corrected norms. Step 3: a visit to
the clinic takes place that takes around 2.5 hours and always includes two
health care professionals, usually a medical specialist (psychiatrist, clinical
psychologist, clinical neuropsychologist) and generalist (GZ-psychologist). The
child and parents are interviewed together and separately. An observation of
the child takes place during a child psychiatric observation. Initial hypotheses
regarding what is explaining the problems are discussed with the parents (and
child if above 12 years old). In some cases, the diagnostic process is finished and
treatment plans are discussed. In most cases, step 4 takes place. Step 4:
additional diagnostic information is gathered, such as: family diagnostic
observation (in case familial relationships seem to contribute largely to the
problems of the child), ADOS (in case ASD is suspected), IQ (if TIQ <85 or > 115 is
suspected), neuro-psychological testing (in case information processing
difficulties are suspected, such as specific learning disorders), classroom
observation (in case parent and teachers ratings widely differ), specialized
somatic investigations (child neurologist, clinical geneticist, child paediatrician
etc in case somatic co-morbidity is suspected). Step 5: all information is
collected and diagnosis/diagnoses are made and a treatment plan is discussed
and started. During treatment, evaluations take place roughly every three
months. Adult:
https://richtlijnendatabase.nl/richtlijn/adhd_bij_volwassenen/diagnostiek_adhd
_bij_volwassenen.html

58
Europe AISBL.
Q9: (NL2) Not known as only few private services available. Q10: (NL2) Both: High
socioeconomic status/high income families may seek private health care to
avoid waiting lists (minority of patients).
Q11: (NL2) Child: the local authority / municipality covers costs. Adults: partly
national public health system (which includes a compulsory private insurance)
and maybe a small part at private cost.

(CPsy), Educational Psychologist (EPsy).
Q13: General Practitioner (GP), Psychiatrist (dpm), Neurologist (N), Psychologist

(Psy), Child Psychologist (CPsy), Educational Psychologist (EPsy).
Q14: (NL2) Both: after a formal diagnosis, if/when medication is prescribed &
sent to local pharmacy for collection on a 3 monthly basis after which the
patient/nurse practitioner /team of nurse-GP-professional are in contact and re-
new the prescription. Only those with a 'BIG' licence are allowed to diagnose
and prescribe for children and adults according to the following criteria:
https://english.bigregister.nl/
Q15: (NL2) Child: Based on treatment guidelines, intervention with medication

start with methylphenidate or dexamphetamine and only when not effective,
atomoxetine or guanfacine are used. Professionals have the freedom to
prescribe the medication brands they think is best helping the patient using
the guidelines. Not all brands are available in NL.
https://www.farmacotherapeutischkompas.nl/bladeren/indicatieteksten/adhd_
bij_kinderen See flowchart: https://www.kenniscentrum-
kjp.nl/professionals/adhd/ Adult:
https://www.ggzstandaarden.nl/zorgstandaarden/adhd/herstel-participatie-en-
re-integratie
Q16: No. Q17: Yes. Q17A: (NL2) Yes: https://www.lareb.nl/en If the patient is
experiencing side effects and is not helped with the medication, change in type
of medication is no problem.

prescription in your country: (NL2) Only professionals who have a 'BIG'
registration may treat children and adults. Nurse practitioner may also be
involved. GP refers case to 'GZ'-psychologist or clinical (neuro) psychologist
(http://english.bigregister.nl/). 2) Test such as SDQ, CBCL/TRF and semi-
standardised behavioural observation at school or in the clinic. It differs per
clinic which scales are used, but standardized questionnaires are always part of
the diagnostic procedures. Cognitive assessment other than intelligence
(attention, executive functions, memory, etc) becoming increasingly part of
standard diagnostic procedures. 3)Health services have long waiting lists,
largely due to a sharp reduction in finances during the past years to both
health care services and primary/secondary education. Increasing numbers of
children are referred for clinical evaluation.
Q18: (NL2) For both: Short working methylphenidate is reimbursed by the

national public health system, long acting methylphenidate, dexamphetamine
and atomoxetine/guanfacine is partly paid by parents/adult patient.
59
Europe AISBL.
Q19: (NL2) No. However, for the patient's medication costs, there is a website:
https://www.medicijnkosten.nl.
Q20: (NL2) No. Any additional comments regarding ADHD medication / cost
reimbursement: (NL2) Long-acting stimulants are sometimes out of stock, the
same for guanfacine 20mg.
MEDICATION AVAILABILITY: -

60
Europe AISBL.
Organisation name and country: Eternia - Rainbow Warriors ADHD Slovenia
(SL)
Q 1: No. Q1A: (SL) Only one publication is available, with Slovenian government
co-financing
https://www.scoms-lj.si/files/Biti%20stars%CC%8C%20otroku%20z%20ADHD.pdf
This is general Guideline for reformatory institutions, but not specific for ADHD.
Q2: Mixed feedback from service-users Q3: Children only until 18 yrs. Q4: Yes.
Q5: Psychiatrist (dpm), Neurologist (N), Psychologist (Psy), Child Psychologist

(CPsy).
Q7A: Conners Scales (parent and teachers), other.
Q7B: other
Q8: (SL) Diagnostic process for children happens on parents or Educational

Psychologist initiative. The diagnostic process happens in the (Pediatric)
psychiatry. The diagnostic process is hardly available for adults, as it isn't
standardised, and it mostly depends on doctor's personal opinion regarding
ADHD.
Q9: (SL): Generally private psychiatric clinics have concessions for Public health
service, so all expenses are covered by National PH fund. Adults might find
better chance for constructive support regarding ADHD in concession clinic.
Q10: (SL) The diagnostic process is not standardised; therefore some private
health services might present more organised approach towards ADHD
diagnosis.
Q11: (SL) The national diagnostic process for children is covered from Slovenian
public health fund.
Q12: Psychiatrist (dpm), Neurologist (N), Psychologist (Psy), Child Psychologist

(CPsy).
Q14: (SL) Medication is generally available in pharmacies, also covered by

national healthcare fund.
Q15: (SL) By our knowledge standard public health medication brands are
promoted.
Q16: Not known. Q17: No Q17A: (SL) University Clinical Centre of Ljubljana, capital
city provides such link along with some Pharmaceutical stores
https://kf.kclj.si/NUZ/landing.xhtml The national complains system exist only for
vaccination.

prescription in your country: (SL) Due to poor standardisation of diagnostics

61
Europe AISBL.
process it largely depends on professional's opinion and viewpoint over the
ADHD status. Confirmed diagnoses are therefore unevenly distributed over
different clinics.
Q18: (SL) Public health system covers all regular medication costs.
Q19: (SL) We don't have those insights at our disposal.
Q20: (SL) By my kowledge national citizens and EU citizens are treated equally
in the public health system, however we are not sure regarding accessibility of
such medication for foreign citizens over our Public Health System.

(SL)-

no medication prices / details supplied.
Other medications: (SL) Nature & meditation :)

62
Europe AISBL.
Organisation name and country: Adana Foundation, Spain (ES)
Q 1: Yes Q1A: https://portal.guiasalud.es/wp-

content/uploads/2018/12/GPC_574_TDAH_IACS_compl.pdf (2017)
Q2: not applicable Q3: Yes. Q4: Yes. Q5: Psychiatrist (dpm),Child Medical Doctor/
(CPsy), Educational Psychologist (EPsy).
Children (WISC), Vanderbilt Assessment Scales, DIVA young, Clinical Personal
Interview & history, Autism Diagnostic Observation Schedule (ADOS), ADHD-
rating scale DSM-5, Snap- IV, other. Q7B: DIVA, Clinical Personal Interview &
history, Adult ADHD Self-Report Scale (ASR-v1.1), Adult ADHD Self-Report
screening scale for DSM-5, ADHD Rating scale DSM-5.
Q8: (ES) Child: Good anamnesis (medical overview) information from parents,
family, and teachers. Recommended to study physical condition as well as
comorbid or confusing symptoms through psycho-pedagogical test and
explore other possible learning problems and IQ as well as depressive/anxiety
issues. Adult: Good anamnesis with information from childhood from family
and others, diagnostic tests, and evaluation of co-morbid symptoms.
Q9: (ES) For both: Same process. Can be complete depending on tests done.
Q10: (ES) Child: In many cases parents prefer private services because they don't
have to wait for more than 1 year to get the diagnosis and because they also
look for additional treatment, not only medication, such as psycho-pedagogical
support, social skills and parent training. Adult: In the public health services
there are not many services for ADHD, mainly medication in extreme cases.
Many adults want coaching services, psycho-education or psychological help
which are not given by the national health services.
Q11: (ES) Free of charge by the national health system. Some private insurance
companies refund the diagnosis and psychological services.

(N). Q13: Psychiatrist (dpm), Neurologist (N).
Q14: (ES) Child: A prescription is required. Methylphenidate, atomoxetine, lis-

dexamfetamine and guanfacine are indicated for the disorder. Adult: A
prescription is required. Methylphenidate and atomoxetine are indicated for
the disorder. In the case of lis-dexamfetamine, if the patient was already taking
this medication during childhood or does not respond to other medications.
Q15: (ES) For both the 'best medication for the patient' is chosen by the
professional although in the national health service the standard cheapest
medication is often prescribed while the private service professionals will chose
the optimal medication for the individual needs.
Q16: No. Q17: No. Q17A: (ES) - https://www.notificaram.es/Pages/CCAA.aspx#no-

back-button

63
Europe AISBL.
prescription in your country: (ES) Public health services may have a waiting list
of 1 year or more. Private diagnosis can be expensive but is faster. Medication
prescribed by the public health services are often the generic cheap brands
while private prescription is more patient-oriented / brands. No public psycho-
pedagogical treatment or social skills, few parent and school training. The
national health system is decentralised and in each autonomic community
there may be different rules such as that some ADHD medications require a
permit, excluding Atomoxetine, Rubifen retard, generics and Medikinet which
are approved in all areas. Other medications may require a permit or the
medication's use in childhood due to problems with other prescriptions.
Q18: (ES) Both: medication costs min. 40% or more depending on their income.
Private insurance often doesn't include medication cost reimbursement.
Q19: (ES) No. Q20: (ES) If EU citizen works in Spain and has registered at the
TGSS, they will be provided with a health card (tarjeta sanitaria individual or TSI)
which is the same as nationals.

(ES) Reimbursement for national health service medication prescriptions only.

• Guanfacin
Other medications:-

64
Europe AISBL.
Organisation name and country: RF ATTENTION, Sweden (SE)
Q1: in progress. Q1A:(SE) - Q2: (SE) Yes. Q3: (SE) Yes. Q4: (SE) Yes.
Q5: Psychiatrist (dpm), Psychologist (Psy)
Q6: Psychiatrist (dpm), Psychologist (Psy)
Q7A: Wechsler Intelligence Scale for Children (WISC), Clinical Personal

Interview & history, ADHD-rating scale DSM-5, Snap- IV.
Q7B: Clinical Personal Interview & history, ADHD Rating scale DSM-5.
Q8: (SE) Child and parents or adult visit psychologist for diagnostic services.
Q9: (SE) Same as above.
Q10: (SE) Faster (shorter waiting period)
Q11: (SE) national public health system
Q12: (SE) Psychiatrist (dpm)
Q13: (SE) Psychiatrist (dpm)
Q14: (SE) For both: a nurse compiles the information and recommends
adjustments if needed with neurologist/Psychiatrist, who decides and puts into
electronic journal and sends an electronic prescription to pharmacy for
collection.
Q15: (SE) According to the recommendations of the National Board of Health.
Q16: (SE) Do not know
Q17: (SE) yes
Q17A: (SE) https://busa.registercentrum.se/

prescription in your country: * (SE) Private diagnosis expensive (approx. 20 000
SEK) but usually faster
Q18: (SE) Children are covered by the national public health system, adults are
subsidized
Q19:(SE) Only on national basis. The pharmacy also offers cheaper generica.
Q20: (SE) If prescription is made in Sweden, no difference.

(SE) no


65
Europe AISBL.
• Dexamphetamine
• Guanfacin
• Risperdal / Risperdone (co-morbid)
No medication prices / details supplied.
Other medications: (SE)-

66
Europe AISBL.
Organisation name and country: Oxford ADHD & Autism Centre, UK (UK 1)
Q 1: Yes Q1A: (UK1) https://www.nice.org.uk/guidance/ng87 Q2: not applicable

Q3: Yes Q4: Yes
Q5: Psychiatrist (dpm), Child Medical Doctor/ Pediatrician(CMD), Psychologist

(Psy), Child Psychologist (CPsy
Q6: Psychiatrist (dpm), Psychologist (Psy) Q7A: Conners Scales (parent and
teachers), Wechsler Intellegence Scale for Children (WISC), VanderBilt
Assessment Scales, Clinical Personal Interview & history, other.
scale DSM-5, other.
Q8: (UK1) Varies according to different areas but screening questionnaire to

school & home/child, psychiatric interview and in some areas QB check. For
adults: Varies according to different areas: some centres do a DIVA plus
psychiatric interview and some just use a psychiatric interview alone.
Q9: (UK1) At our private centre, for children we use Conner's screening
questionnaires, QB check, WISC-V and Psychiatric/developmental interview.
For adult: at our private centre, we use Barkley 's questionnaires, DIVA and
Psychiatric interview.
Q10: (UK1) For children: Private health services have shorter waiting times. For
adults: private health services have shorter waiting times or the lack of NHS
services in most cases.
Q11: (UK1) NHS covers costs for all. Q12: General Practitioner (GP), Psychiatrist
(dpm), Child Medical Doctor/ Pediatrician(CMD). Q13: General Practitioner (GP),
Psychiatrist (dpm).
Q14: (UK 1) For children and adults: the GP takes over the monthly prescribing
task under "shared care arrangement" with the specialist. Children must have a
6-month follow-up appointment with their specialist and adults’ annual visit.
Q15: (UK1) Children and adults are normally prescribed the best medication but
the cheapest brand.
Q16: Don’t know. Q17: Yes Q17A: (UK1) https://www.nice.org.uk/bnf-uk-only

prescription in your country: (UK 1) Nurse prescriber is another professional
which can prescribe ADHD medication for children and adults. BNF 'yellow
card ' system for reporting adverse effects of medication. Q18: (UK1) Both by
NHS
Q19: (UK1) Yes, the local clinical commissioning groups review costs and give
advice to primary and secondary care.
Q20: (UK 1) Don't think so.

67
Europe AISBL.
No.
Other medications: - (UK1)

68
Europe AISBL.
Organisation name and country: ADHD Solutions CIC, UK (UK2)
Q 1: Yes Q1A: (UK2) https://www.nice.org.uk/guidance/ng87 Q2: not applicable

Q3: Yes. Q4: Yes.

(N), Child Psychologist (CPsy).
Q6: Psychiatrist (dpm). Q7A: Conners Scales (parent and teachers), Wechsler
Intellegence Scale for Children (WISC), Vanderbilt Assessment Scales, Clinical
Personal Interview & history, other.
scale DSM-5, Snap- IV.
Q8: (UK2) In our area, GP refers to single point of access for referral into
Community Paediatrics (under 12 yrs) or CAHMS (over 12yrs), acceptance is low
and waiting lists very long. Reports collected and rating scales completed at
home and at school, assessed for ADHD and ASD, some children have QB Test.
For an adult: GP referral into Adult Mental Health Services for assessment then
refer on to ADHD Clinic if ADHD is suspected. Waiting lists are very long aprox 2
years min.
Q9: (UK2) Both: GP or self-referral to private Clinician for assessment and

treatment- assessment varies according to Clinician.
Q10: (UK2) National health services are patchy and long waiting lists. However
private services are expensive and nor reimbursed.
Q11: (UK2) Both: public services covered by national health system (NHS) and
private services are at your own costs (maybe covered by private insurance).

Pediatrician(CMD).
Q14: (UK 2) Both: monthly prescriptions are available from GP or clinic as shared
care protocols are in place. Specialists nurses are also allowed to assist with
medication. Some medications are not available in some areas.
Q15: (UK2) Standard generic brands normally prescribed on NHS. Medication

changes can be discussed with specialist nurse or GP. Service users’ feedback
that private services are more likely to prescribe 'best medication for the
patient'.
Q16: Don’t know. Q17: Yes Q17A: (UK2) ADHD medication complaints are
directed to GP. National complains: https://yellowcard.mhra.gov.uk/the-yellow-
card-scheme/

prescription in your country: (UK2) National health care advantages: Specialist
nurse able to assist diagnosis & prescribe medication. GP has shared care
agreement with Clinician. Unfortunately, NHS waiting times are long and

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Europe AISBL.
threshold for referral is high, generic medication brands are not as effective.
Private care is expensive, and quality differs.
Q18: (UK2) Child: NHS - no charge; private prescriptions are very expensive.
Adult: NHS prescription charges apply; private prescriptions are very expensive.
Q19: (UK2) Indications:

https://www.nice.org.uk/advice/esnm19/chapter/Estimated-impact-for-the-NHS
Q20: (UK2) No. Any additional comments regarding ADHD medication / cost
reimbursement : (UK2) No.
Other medications:-

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Europe AISBL.
Organisation name and country: ADDISS (UK3)
Q 1: Yes Q1A: (UK3) https://www.nice.org.uk/guidance/ng87
Q2: not applicable. Q3: Yes. Q4: Yes

(N).
Q7A: Conners Scales (parent and teachers), Clinical Personal Interview & history,
ADHD-rating scale DSM-5, Snap- IV.
scale DSM-5, other,
Q8: (UK3) Parent will request the GP makes a referral to CAMHS, sometimes at
the request of the school, another agency but mostly because the parent
knows there is an issue and seeks the referral themselves. Adults will need to
be referred to an adult service by the GP and cannot self-refer to an Adult
ADHD NHS service.
Q9: (UK3) Most people will self-refer to a private service, though the private
doctor will insist on writing a follow up to the GP. This is because after the
patient is settled on medication the GP can take over the role of prescribing on
a shared care basis. This means the patient can then receive NHS prescription.
Prescriptions are free for children and adults on benefits. Adults would
normally pay no more than around £9 for an NHS prescription.
Q10: (UK3) Patients will choose a private service if the waiting list in their area is
more than three months. The process on the NHS for children can take
anything up to a year. Children are first triaged and if they think the likely
outcome of an assessment will be ADHD they are asked to come back several
months later for a full assessment and treatment. During this time they are
often sent on a parenting course. Sometimes there is no service in an area and
this again is another reason to go privately. Finally some families have no
confidence in their local NHS service and have been failed by their service for
failing to recognise inattentive symptoms as being impairing.
Q11: (UK3) The NHS covers everything for children and adults.


Q14: (UK3) Take your prescription direct to the chemist, or GPs can send direct
to the chemist of your choice. Prescriptions for controlled drugs are only issued
for a month at a time.
Q15: (UK3) Private doctors can prescribe anything, even medications that are
not licenced in the UK. The NHS is different in each trust and recommended

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Europe AISBL.
medications are very much a postcode lottery. Patients are advised by patient
organisations to demand the medication that is best for you and not for the
budget of your trust.
Q16: No. Q17: Yes. Q17A: (UK3) ADHD medication complaints are directed to GP.
National complains: https://yellowcard.mhra.gov.uk/the-yellow-card-scheme/

prescription in your country: (UK3) In the UK we have specially trained nurse
prescribers who can diagnose and prescribe for children and adults on the NHS
and privately. They often do the follow ups for titrating medication
Q18: (UK3) The NHS or by the patient if going privately unless there is a shared
care arrangement.
Q19: (UK3) The Local Clinical Commissioners for Mental Health in each trust
review costs.
Q20: (UK3) Not at the moment but this may change after December 2020.

(UK3) In the UK we have specially trained nurse prescribers who can diagnose
and prescribe for children and adults on the NHS and privately. They often do
the follow ups for titrating medication.

• Dexamphetamine
• Guanfacin
No medication prices / details

72
Europe AISBL.

ADHD EU Survey-2020-FINAL

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Diagnosis and

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Figure 1: National Guideline Pie Chart .................................................................................................. 4

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Unfortunately, there remain circumstances that are in dire need of improvement:

1) Continued long waiting lists for children to access diagnostic services in

It is evident that research, support and contact between members of ADHD-

Copyright ADHD-Europe AISBL 2021

ADHD-Europe (2008) was set up in Belgium by 13 founding member organisations.

ADHD-Europe has a vision for an inclusive European community, where people

Attention Deficit Hyperactive Disorder (ADHD)

ADHD is a neurodevelopmental disorder of the brain, categorised as a mental

“Attention deficit hyperactivity disorder is characterized by a persistent pattern (at

History of the “Diagnosis and Treatment of ADHD in Europe” Survey

Copyright ADHD-Europe AISBL 2021

In 2020, the survey was answered by 22 organisations from 19 member countries.

Methodology of the Survey:

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The twenty-two members representing nineteen countries that contributed to

Figure 1: National Guideline Pie Chart

Figure 2: Standard ADHD procedures in health services

National Health Services

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Figure 4: Private Health Services

Diagnosis and Treatment

The NICE ‘gold’ standard recommendation is for assessment, diagnosis, and

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Figure 5: Child diagnosis of ADHD

Figure 6: Adult diagnosis of ADHD

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Figure 8: Diagnostic tests for ADHD in adults

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In summary, most members described the diagnostic process through the

The adult diagnostic assessment consists of self-rating disorder-specific

The ADHD diagnostic process by private health services

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The NICE ‘gold’ standard recommendation of “early intervention” is affected by

Advantages of private health services

Access to (highly) specialised professionals regarding ADHD was another

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Some members mention ADHD disability allowance (France), a monthly amount

The administrative process of getting ADHD medication (for a child or for an

In Finland, Denmark, Sweden and The Netherlands, this process is completely

Most medication is prescribed for 1 month, 28 days (France), or 3 months

Copyright ADHD-Europe AISBL 2021

Greece, France, Luxembourg, Italy and Hungary mention reluctance in

Figure 9: Medication prescription

Many countries do have access to different brands and generic medications as

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Figure 10: Medication complaint procedure

Any additional comments regarding ADHD diagnosis and medication

Some members commented on the lack of access to trained and prescribing

Religious and societal ‘stigma’ related to ADHD and medication (Hungary,

For additional comments, see the country form in the appendix.

Copyright ADHD-Europe AISBL 2021

Are there any significant differences between national citizens and EU

Any additional comments regarding ADHD medication and cost

Recurrent ‘out of stock’ of ADHD medication is an important problem mentioned

Secondly, the change from “brand” to “generic” ADHD medication labels is

Thirdly, the lack of access to a variety of medication options was mentioned by