Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

Journal of Health Monitoring · 2018 3(3)

DOI 10.17886/RKI-GBE-2018-085
ADHD in children and adolescents in Germany.
Robert Koch Institute, Berlin
Results of the cross-sectional KiGGS Wave 2 study and trends
Kristin Göbel, Franz Baumgarten,
Benjamin Kuntz, Heike Hölling, Robert Schlack Abstract
Attention deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders in childhood and adolescence
Robert Koch Institute, Berlin
and is associated with functional, psychosocial and cognitive impairment. As part of the second wave of the German
Department of Epidemiology and
Health Monitoring
Health Interview and Examination Survey for Children and Adolescents (2014-2017), parents of children and adolescents
aged between 3 and 17 years reported whether their child was diagnosed with ADHD by a physician or psychologist.
Overall, 4.4% of children and adolescents have been diagnosed with ADHD in Germany. In comparison, the KiGGS
baseline study (2003-2006) showed a reduction of lifetime ADHD diagnoses of almost one percentage point over a
period of ten years. The reduction of parent-reported ADHD diagnoses primarily occurred among 3- to 8-year old children
and boys. The results are discussed in terms of health promotion and the introduction of health care measures.

MENTAL HEALTH · ADHD · PREVALENCE AND TIME TREND · HEALTH MONITORING · KIGGS

Introduction symptoms persist beyond developmentally inappropriate

Attention deficit/hyperactivity disorder (ADHD), with its levels for at least six months, are pervasive across settings
three core symptoms of inattentiveness, hyperactivity (e.g. school and home) and associated with substantial
(motor unrest) and impulsivity, is one of the most common functional psychosocial impairment [7, 8]. Boys are diag-
mental disorders in childhood and adolescence [1-3]. ADHD nosed more frequently with ADHD than girls [9]. Approxi­
is estimated to have a worldwide prevalence of approxi- mately, 60% to 70% of patients with ADHD in childhood
mately 5%; this has remained relatively stable over the last show a persistence of symptoms into adulthood [1, 10].
few decades [1, 4, 5]. ADHD is commonly diagnosed among children of prima-
According to the diagnostic criteria used by the classifica­ ry-school age [3] as symptoms become progressively more
tion systems (International Statistical Classification of Dis- evident and cause greater impairment due to the increas-
eases and Related Health Problems, 10th revision, ICD-10; ing external demands placed upon children in school
Diagnostic and Statisti­cal Manual of Mental Disorders, 5th (e.g. maintaining attention, remaining seated) [1].
Edition, DSM-5) and diagnostic guidelines (e.g. the ADHD Comorbidities are highly prevalent among children and
working group of physicians in child and adolescent adolescents with ADHD and vary between 60% and 80%
medicine [6]), a diagnosis of ADHD requires that core depending on the study [11, 12]. The most common

Journal of Health Monitoring 2018 3(3) 42

 Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

comorbid mental disorders are oppositional defiant disor- as well as KiGGS Wave 2 cross-sectional study – participant
KiGGS Wave 2 der (ODD), conduct disorder (CD), depression, anxiety, acquisition, response rates and representativeness in issue
Second follow-up to the German Health and learning disabilities [7, 12]. Furthermore, the symptoms 1/2018 of the Journal of Health Monitoring [21, 22].
Interview and Examination Survey for Children of ADHD among children and adolescents are associated The lifetime prevalence of ADHD was assessed for chil-
and Adolescents
with a reduced subjective health-related quality of life [13, dren and adolescents aged 3 to 17 years using parent-re-
Data owner: Robert Koch Institute 14], increased accident-proneness [15], decreased educa- ported ADHD diagnoses given by a physician or a psycholo-
Aim: Providing reliable information on health tional attainment [16], increased disruption of family func- gist (see [23]). The results for the current lifetime prevalence
status, health-related behaviour, living condi-
tions, protective and risk factors, and health
tioning [17], conflict-ridden relationships with peers [16], are based on data from 13,270 children and adolescents
care among children, adolescents and young and social stigmatisation [18]. Moreover, alongside the sig- (6,671 girls, 6,599 boys) between 3 and 17 years of age from
adults living in Germany, with the possibility nificant functional impairment and the broad impact of KiGGS Wave 2. Data from 13,487 children and adolescents
of trend and longitudinal analyses
ADHD on individuals and families, it is likely to incur a (6,736 girls, 6,751 boys) from the KiGGS baseline study
Study design: Combined cross-sectional and
high level of health-care related costs [19, 20]. Consequently, were used for comparison to analyse time trends. Preva-
cohort study
it also has implications for health policy. lences of ADHD diagnoses are presented stratified by gen-
Cross-sectional study in KiGGS Wave 2
Age range: 0 -17 years This study presents lifetime prevalences of parent-re- der, age and socioeconomic status (SES, [24]).
Population: Children and adolescents with ported ADHD diagnoses from the second wave of the Ger- The analyses were carried out using a weighting factor
permanent residence in Germany man Health Interview and Examination Survey for Children that corrected for deviations within the sample from the
Sampling: Samples from official residency
registries - randomly selected children and and Adolescents (KiGGS Wave 2, 2014-2017). Furthermore, population structure with regard to age in years, gender,
adolescents from the 167 cities and municipal- it also describes time trends for a period of ten years by com- federal state, German citizenship and the parents’ level of
ities covered by the KiGGS baseline study
paring data with the KiGGS baseline study (2003-2006). education [25]. Results report lifetime prevalences strati-
Sample size: 15,023 participants
fied by gender, age, and SES with 95% confidence intervals
KiGGS cohort study in KiGGS Wave 2
Age range: 10 -31 years Indicator (95% CI). The p-values calculated for the analysis of time
Sampling: Re-invitation of everyone who took The German Health Interview and Examination Survey for trends are based on age-standardised prevalences (popu-
part in the KiGGS baseline study and who Children and Adolescents (KiGGS) is part of the health lation on 31 December 2015). Differences were examined
was willing to participate in a follow-up
Sample size: 10,853 participants monitoring system established at the Robert Koch Institute. using univariate logistic regression. A statistically signifi-
KiGGS survey waves
KiGGS includes repeated cross-sectional surveys of chil- cant difference between groups is assumed to have been
▶ KiGGS baseline study (2003-2006), dren and adolescents aged between 0 and 17 years (KiGGS demonstrated where p-values are less than 0.05.
examination and interview survey cross-sectional study). Both the KiGGS baseline study
▶ KiGGS Wave 1 (2009-2012),
interview survey (2003-2006) and KiGGS Wave 2 (2014-2017) were conduct- Results and discussion
▶ KiGGS Wave 2 (2014-2017), ed as a combined examination and interview survey. A Overall, 4.4% of children and adolescents between 3 and 17
examination and interview survey detailed description of the methodology used in KiGGS years of age showed a parent-reported lifetime diagnosis of
More information is available at
Wave 2 can be found in New data for action. Data collec- ADHD given by a physician or psychologist for KiGGS
www.kiggs-studie.de/english tion for KiGGS Wave 2 has been completed in issue S3/2017 Wave 2 (2014-2017) (Table 1). For the KiGGS baseline study,

Journal of Health Monitoring 2018 3(3) 43

 Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

Table 1 KiGGS baseline study KiGGS Wave 2

Prevalences for parent-reported ADHD* % (95 % CI) % (95 % CI)
diagnoses according to gender and age from
Girls 1.9 (1.5-2.4) 2.3 (1.9-2.8)
the KiGGS baseline study
Boys 8.5 (7.7-9.5) 6.5 (5.7-7.3)
(n=6,736 girls, n=6,751 boys) and
Age group
KiGGS Wave 2 (n=6,671 girls, n=6,599 boys)
3-5 Years 1.5 (1.0-2.3) 0.2 (0.1-0.7)
Source: KiGGS baseline study (2003-2006),
6-8 Years 3.8 (3.1-4.7) 2.1 (1.5-2.9)
KiGGS Wave 2 (2014-2017)
9-11 Years 7.6 (6.4-8.9) 6.1 (4.9-7.5)
* ADHD = Attention deficit/hyperactivity disorder 12-14 Years 6.7 (5.6-7.9) 6.4 (5.3-7.6)
15-17 Years 6.4 (5.4-7.7) 6.9 (5.8-8.2)
Total (girls and boys) 5.3 (4.8-5.8) 4.4 (3.9-4.9)
CI=confidence interval

4.4% of children and

the prevalence of age-adjusted lifetime ADHD diagnoses number of ADHD diagnoses among boys. No significant
adolescents between
was 5.3%. In contrast, a significant reduction in the preva- difference was observed for girls between both waves.
3 and 17 years of age had lence of ADHD diagnoses of 0.9 percentage points (corre- In comparison to the KiGGS baseline study, the results
received a parent-reported sponding to about 17 % compared to the baseline value) suggest that the diagnostic gap between girls and boys may
lifetime diagnosis of ADHD was identified from the data collected for KiGGS Wave 2. be closing, however, the data show that boys are still diag-
from a physician or A gender comparison showed a significant reduction in the nosed with ADHD twice as often as girls. Moreover, the
time trend demonstrates that lifetime ADHD diagnoses
psychologist at KiGGS Wave 2
Percent significantly dropped among 3- to 5-year-olds and 6- to
(2014-2017). 8
8-year-olds. No valid findings about gender specific differ-
7
ences within age groups can be made due to the small
6 sample size within each group.
5
Children and adolescents living in socioeconomically
disadvantaged families are more frequently diagnosed with
4
Figure 1 ADHD compared to their peers from high SES families
Prevalences for parent-reported 3 (Figure 1). Previous results of the KiGGS baseline study and
ADHD diagnoses* for 3- to 17-year-olds 2 KiGGS Wave 1 confirm distinctive differences between the
according to socioeconomic status prevalence of ADHD diagnoses which are to the disadvan-
(n=6,671 girls, n=6,599 boys) 1
tage of lower SES households [3].
Source: KiGGS Wave 2 (2014-2017)
Over the last decade, a continuous increase in media
* ADHD = Attention deficit/hyperactivity disorder Socioeconomic status: Low Medium High reports and research, as well as the reported rise in the

Journal of Health Monitoring 2018 3(3) 44

 Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

diagnostic prevalence of ADHD, have driven a broad debate for ADHD more often and earlier as their behaviour tends
involving society, health policy, medical and psychological to be more disruptive (i.e. more hyperactive or impulsive)
health care professionals, and service providers in the than girls [29]. A previous study found that ADHD is almost
health system (see e.g. [26]). equally distributed between girls and boys when a higher
This debate has resulted in the initiation of several meas- level of diagnostic recognition is placed on the inattentive
ures related to health care policy and provision. One exam- subtype and the less overt symptoms of ADHD which are
In contrast to the KiGGS ple is the directive issued by the Federal Joint Committee more commonly found among girls [30].
(G-BA) for the modification of drug policies aimed at a Conclusions about the accuracy of ADHD diagnoses,
baseline study (2003-2006),
more restrictive prescription of psychostimulants (i.e. whether these follow the guidelines, or the severity of the
KiGGS Wave 2 showed a methylphenidate) in the case of children and adolescents disorder cannot be drawn from the parent-reported ADHD
significant reduction in the with ADHD [27]. The directive reflects the concern about diagnoses collected for the KiGGS study. Additionally, the
prevalence of ADHD the rate of prescriptions provided for stimulants as this question as to whether the parents’ response behaviour
diagnoses of about one increased over several years. Subsequently, medical guide- towards ADHD diagnoses might have been influenced by
lines for the diagnostics and therapy of ADHD have also the changing public and professional perception over the
percentage point.
been adapted (see [6]) and the Scientific Medical Societies last ten years remains open.
in Germany (AWMF) has recently (June 2018) published a Overall, the study found a significant reduction in the
new version of its guidelines [28]. diagnostic prevalence of about one percentage point over
It cannot be ruled out that these changes may have led a period of ten years. Hence, it cannot be ruled out that
to the introduction of a more restrictive diagnostic practice this reduction might be a consequence of a more restric-
A reduction of parent- in the case of ADHD. This assumption is supported by the tive diagnostic practice for ADHD. This explanation is cur-
recent reduction in the lifetime prevalence of ADHD among rently supported by routine data gained from statutory
reported ADHD diagnoses
the youngest age groups, particularly as these were at the health insurers that report a small reduction in ADHD diag-
was identified among boys focus of the debate and have continued to be so. Other noses [31].
and 3- to 8-year old children. initiatives to promote children’s health at the federal level
have also been introduced. These include the German gov- Corresponding author
Kristin Göbel
ernment’s strategy for the promotion of children’s health, Robert Koch Institute
the promotion of the national centre for early support, Department of Epidemiology and Health Monitoring
which began in 2007, and the medical check-up (U10) put General-Pape-Str. 62–66
in place in 2006. However, the impact that they might have D-12101 Berlin, Germany
E-mail: GoebelK@rki.de
had on the prevalence of ADHD diagnoses remains open.
The results show that boys are still diagnosed twice as
often with ADHD as girls. Boys are referred for treatment

Journal of Health Monitoring 2018 3(3) 45

 Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

Please cite this publication as Acknowledgement

Göbel K, Baumgarten F, Kuntz B, Hölling H, Schlack R (2018) Foremost we would like to express our gratitude to both
ADHD in children and adolescents in Germany.
Results of the cross-sectional KiGGS Wave 2 study and trends.
the participants and their parents. We would also like to
Journal of Health Monitoring 3(3): 42-49. thank everyone at the 167 study sites who provided us with
DOI 10.17886/RKI-GBE-2018-085 space and active support on site.
KiGGS Wave 2 could not have been conducted without
Data protection and ethics the dedication of numerous colleagues at the Robert Koch
All of the Robert Koch Institute’s studies are subject to Institute. We would especially like to thank the study teams
strict compliance with the data protection provisions set for their excellent work and their exceptional commitment
out in the EU General Data Protection Regulation (GDPR) during the three-year data collection phase.
and the Federal Data Protection Act (BDSG). Charité – Uni-
versitätsmedizin Berlin’s ethics committee assessed the References
1. Banaschewski T, Becker K, Döpfner M et al. (2017) Attention-
ethics of the KiGGS baseline study (No. 101/2000) and Deficit/Hyperactivity Disorder. Dtsch Arztebl Int 114(9):149-159
KiGGS Wave 1 (No. EA2/058/09), and Hannover Medical
2. Polanczyk G, De Lima MS, Horta BL et al. (2007) The worldwide
School’s ethics committee assessed KiGGS Wave 2 prevalence of ADHD: a systematic review and metaregression
(No. 2275-2014); both committees provided their approval analysis. Am J Psychiatry 164(6):942-948

for the respective studies. Participation in the studies was 3. Schlack R, Mauz E, Hebebrand J et al. (2014) Hat die Häufigkeit
elternberichteter Diagnosen einer Aufmerksamkeitsdefizit-/
voluntary. The participants and/or their parents/legal Hyperaktivitätsstörung (ADHS) in Deutschland zwischen
guardians were also informed about the aims and contents 2003–2006 und 2009–2012 zugenommen? Bundesgesundheits-
bl 57(7):820-829
of the study, and about data protection. Informed consent
4. Polanczyk GV, Willcutt EG, Salum GA et al. (2014) ADHD
was obtained in writing. prevalence estimates across three decades: an updated system-
atic review and meta-regression analysis. Int J Epidemiol
43(2):434-442
Funding
5. Safer DJ (2018) Is ADHD really increasing in youth?
KiGGS is funded by the Federal Ministry of Health and the Journal of attention disorders 22(2):107-115
Robert Koch Institute. 6. AG ADHS e.V. (2014) Leitlinie der Arbeitsgemeinschaft ADHS der
Kinder- und Jugendärzte e.V. Aktualisierte Fassung Januar 2007.
Mit Update des Kapitels „Medikamentöse Therapie“ März 2014.
Conflicts of interest https://www.ag-adhs.de/files/Leitlinie2014mr.pdf
The authors declared no conflicts of interest. (As at 10.07.2018)
7. Döpfner M, Frölich J, Lehmkuhl G (2013) Aufmerksamkeitsdefizit-/
Hyperaktivitätsstörung (ADHS). Hogrefe Verlag, Göttingen
8. Tarver J, Daley D, Sayal K (2014) Attention deficit hyperactivity
disorder (ADHD): an updated review of the essential facts. Child
Care Health Dev 40(6):762-774

Journal of Health Monitoring 2018 3(3) 46

 Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

9. Huss M, Hölling H, Kurth BM et al. (2008) How often are 21. Hoffmann R, Lange M, Butschalowsky H (2018) KiGGS Wave 2
German children and adolescents diagnosed with ADHD? cross-sectional study – participant acquisition, response rates
Prevalence based on the judgment of health care professionals: and representativeness. Journal of Health Monitoring 3(1):78-91.
results of the German health and examination survey (KiGGS). https://edoc.rki.de/handle/176904/5637 (As at 10.07.2018)
Eur Child Adolesc Psychiatry 17 Suppl 1:52-58 22. Mauz E, Gößwald A, Kamtsiuris P et al. (2017) New data for
10. Groß S, Figge C, Matthies S et al. (2015) ADHS im Erwachsenen- action. Data collection for KiGGS Wave 2 has been completed.
alter. Der Nervenarzt 86(9):1171-1180 Journal of Health Monitoring 2(S3):2-27.
https://edoc.rki.de/handle/176904/2812 (As at 10.07.2018)
11. Kadesjö B, Gillberg C (2001) The comorbidity of ADHD in the
23. Schlack R, Hölling H, Kurth BM et al. (2007) Die Prävalenz der
general population of Swedish school-age children. J Child
Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) bei
Psychol Psychiatry 42(4):487-492 Kindern und Jugendlichen in Deutschland. Bundesgesundheitsbl
12. Larson K, Russ SA, Kahn RS et al. (2011) Patterns of comorbidity, 50(5-6):827-835.
functioning, and service use for US children with ADHD, 2007. https://edoc.rki.de/handle/176904/431 (As at 10.07.2018)
Pediatrics 127(3):462-470 24. Lampert T, Hoebel J, Kuntz B et al. (2018) Socioeconomic status
13. Hölling H, Schlack R, Dippelhofer A et al. (2008) Personale, and subjective social status measurement in KiGGS Wave 2.
familiäre und soziale Schutzfaktoren und gesundheitsbezogene Journal of Health Monitoring 3(1):108-125.
https://edoc.rki.de/handle/176904/5639 (As at 15.03.2018)
Lebensqualität chronisch kranker Kinder und Jugendlicher.
Bundesgesundheitsbl 51(6):606 25. Forschungsdatenzentren der Statistischen Ämter des Bundes
und der Länder (2017) Mikrozensus, 2013, eigene Berechnungen.
14. Klassen AF, Miller A, Fine S (2004) Health-related quality of life www.forschungsdatenzentrum.de/bestand/mikrozensus
in children and adolescents who have a diagnosis of atten- (As at 20.11.2017)
tion-deficit/hyperactivity disorder. Pediatrics 114(5):e541-547
26. AG ADHS e.V. (2009) Gutachten des Sachverständigenrates und
15. Ruiz-Goikoetxea M, Cortese S, Aznárez-Sanado M et al. (2018) Stellungnahme des zentralen adhs-netzes zur Begutachtung der
Risk of unintentional injuries in children and adolescents with Entwicklung im Gesundheitswesen.
ADHD and the impact of ADHD medications: a systematic http://www.adhs-deutschland.de/Home/Unser-Angebot/
review and meta-analysis. Neurosci Biobehav Rev 84:63-71 Leseecke/Leseecke-Politik/Gutachten-des-Sachverstaendigenra-
tes-zur-Begutachung-der-Entwicklung-im-Gesundheitswesen.
16. Schulte-Körne G (2016) Psychische Störungen bei Kindern und aspx (As at 10.08.2018)
Jugendlichen im schulischen Umfeld. Dtsch Arztebl Int
113(11):183-190 27. Gemeinsamer Bundesausschuss (G-BA) (2010) Zum Schutz von
Kindern und Jugendlichen – Verordnung von Stimulantien nur in
17. Wymbs BT, Pelham WE Jr, Molina BS et al. (2008) Rate and bestimmten Ausnahmefällen - Beschluss: Arzneimittel-Richtlinie/
predictors of divorce among parents of youths with ADHD. Anlage III Nummer 44 (Stimulantien)
J Consult Clin Psychol 76(5):735 https://www.g-ba.de/informationen/beschluesse/1185/
(As at 10.07.2018)
18. Lebowitz MS (2016) Stigmatization of ADHD: A Developmental
Review. J Atten Disord 20(3):199-205 28. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen
Fachgesellschaften (AWMF) (2018) S3-Leitlinie zur Diagnostik
19. Erskine H, Moffitt TE, Copeland W et al. (2015) A heavy burden und Behandlung von Kindern, Jugendlichen und Erwachsenen
on young minds: the global burden of mental and substance use mit ADHS.
disorders in children and youth. Psychol Med 45(7):1551-1563 https://www.awmf.org/leitlinien/detail/ll/028-045.html
20. Schöffski O, Sohn S, Happich M (2008) Die gesamtgesellschaft- (As at 11.07.2018)
liche Belastung durch die hyperkinetische Störung (HKS) bzw. 29. Skogli EW, Teicher MH, Andersen PN et al. (2013) ADHD in girls
Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS). and boys–gender differences in co-existing symptoms and
Gesundheitswesen 70(07):398-403 executive function measures. BMC psychiatry 13(1):298

Journal of Health Monitoring 2018 3(3) 47

 Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

30. Biederman J, Kwon A, Aleardi M et al. (2005) Absence of gender

effects on attention deficit hyperactivity disorder: findings in
nonreferred subjects. Am J Psychiatry 162(6):1083-1089
31. Grobe TG (2017) Regionale Unterschiede von ADHS-Diagnose­
raten in Krankenkassendaten 2005 bis 2015. Bundesgesundheits-
bl 60(12):1336-1345

Journal of Health Monitoring 2018 3(3) 48

 Journal of Health Monitoring ADHD in children and adolescents in Germany FACT SHEET

Imprint
Journal of Health Monitoring

Publisher
Robert Koch Institute
Nordufer 20
D-13353 Berlin, Germany

Editors
Susanne Bartig, Johanna Gutsche, Dr Birte Hintzpeter,
Dr Franziska Prütz, Martina Rabenberg, Alexander Rommel,
Dr Livia Ryl, Dr Anke-Christine Saß, Stefanie Seeling,
Martin Thißen, Dr Thomas Ziese
Robert Koch Institute
Department of Epidemiology and Health Monitoring
Unit: Health Reporting
General-Pape-Str. 62–66
D-12101 Berlin
Phone: +49 (0)30-18 754-3400
E-mail: healthmonitoring@rki.de
www.rki.de/journalhealthmonitoring-en

Typesetting
Gisela Dugnus, Alexander Krönke, Kerstin Möllerke

Translation
Simon Phillips/Tim Jack

ISSN 2511-2708

Note
External contributions do not necessarily reflect the opinions of the
Robert Koch Institute.

This work is licensed under a

Creative Commons Attribution 4.0 The Robert Koch Institute is a Federal Institute within
International License. the portfolio of the German Federal Ministry of Health

Journal of Health Monitoring 2018 3(3) 49