Diagnosis and management of ADHD: A pediatric perspective on practice and challenges in Switzerland

doi:10.21203/rs.3.rs-1620034/v1

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Diagnosis and management of ADHD: A pediatric perspective on practice and challenges in Switzerland

https://doi.org/10.21203/rs.3.rs-1620034/v1

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published 04 Mar, 2023

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Background: Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders in childhood. In Switzerland, the complex diagnosis and treatment are being carried out by adolescent-/child psychiatrists, and pediatricians. Guidelines recommend a multimodal therapy for patients with ADHD. However, it has been questioned whether health professionals follow this approach or favor drug therapy. This study aims to provide insights into the practice of pediatricians in Switzerland regarding diagnosis and treatment of ADHD and their perceptions of these processes.

Method: An online survey (self-report) about current practices of diagnosis and management as well as challenges regarding ADHD was distributed to office-based pediatricians in Switzerland. 151 pediatricians participated. Results show that therapy options were almost always discussed with parents and older children. Exchange with parents (81%) and level of child’s suffering (97%) were central when selecting therapy options.

Results: Therapies about which pediatricians informed most often were: pharmacological therapy, psychotherapy, and multimodal therapy. Challenges voiced were the subjectivity of diagnostic criteria and dependence on third parties, low availability of psychotherapy, and a rather negative public attitude towards ADHD. Needs that were expressed were further education for all professionals, support for coordination with specialists and schools as well as improvement of information on ADHD.

Conclusions: Pediatricians do consider a multimodal approach when treating ADHD and take the families` and children`s opinions into account. Improvements of the availability of child and youth psychotherapy, the strengthening of the interprofessional cooperation with therapists and schools, and efforts to increase public knowledge about ADHD are proposed.

ADHD

pediatricians

guidelines

ADHD diagnosis

ADHD treatment

ADHD management

Attention deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood and youth with a worldwide prevalence between 5% and 8% (1,2). ADHD leads to numerous negative outcomes for the affected children with regards to their personal life, their family environment, school career, and professional achievements (3). Psychiatric comorbidities are common and overall quality of life of patients with ADHD is often impaired (4–6). ADHD also causes significant health costs (7,8) and represents a major public health problem. Therefore, an effective management of ADHD is needed. In Switzerland, diagnosis and treatment of ADHD are predominantly being provided by adolescent-/child psychiatrists, and pediatricians (9).

In practice, the diagnosis and management of ADHD is complex and involves various difficulties. First, there is no single, specific etiology that is able to explain the emergence of ADHD, and second, no biomarkers exist that can help to clearly establish the diagnosis (10,11). Hence, the diagnosis of ADHD is complex and challenging for less experienced physicians. In order to address concerns about the quality of ADHD management and to assist physicians in the diagnosis and treatment process, several guidelines have been developed (e.g. APP (American Academy of Pediatrics), CADDRA (Canadian ADHD Resource Alliance), NICE (National Institute for Health and Care Excellence), and the interdisciplinary evidence- and consensus-based (S3) guideline on ADHD in childhood, adolescence and adults (12–15)). However, it is still often criticized that the diagnostic criteria are unclear and the guidelines too vague and not compatible with practice (16–18).

Diagnostic procedures of ADHD

According to international guidelines, the diagnosis should be based on a comprehensive and structured exploration of the patient and his/her caregivers, including possibly other reference persons (e.g. teachers) in order to assess the frequency and extent of the symptoms and associated impairments in different situations and areas of life as well as comorbid conditions. Questionnaires and psychological tests can assist in establishing a diagnosis in the context of a professional evaluation, which should furthermore be based on a thorough medical history of the child and at least one reference person (e. g. parent, teacher), as well as an assessment of the child including observations and psychological tests (15).

Previous studies examined the diagnostic process of ADHD in children and reported that clinicians perceive the diagnostic assessment of ADHD as challenging (11,16,17,19). One study, which examines whether child psychologists and psychiatrists in Germany follow the guideline for diagnosing ADHD, has found that therapists did not strictly follow diagnostic manuals, which resulted in an overdiagnosis of ADHD in the presented case vignettes (19). The authors concluded that overdiagnosis also occurs in clinical practice (19). Similar, Leitner et al. found that clinicians (i.e. child/adolescent neurologists, - psychiatrists or pediatricians) often adhere to their specific skills when diagnosing ADHD, resulting in differences in the variety and specificity of applied tests and the frequency of performing neurological or physical examinations, which has a significant impact on the perception of the clinical issue (20). In recent years, concerns about the accuracy and thoroughness of ADHD diagnoses have been raised repeatedly due to the increasing number of children treated with methylphenidate (MPH) (21–23). Regarding primary care, concerns about the quality of ADHD diagnoses have been raised due to various barriers, such as constraints with diagnosis and treatment, the time-consuming interprofessional work with other specialists, teachers, school social workers and parents, the lack of reimbursement, misconceptions of ADHD among physicians, limited use of diagnostic instruments and consideration of comorbid conditions (16). However, the high prevalence of ADHD clearly calls for an engagement of primary care providers with regard to diagnosis and treatment of the condition - especially in the light of the limited capacity and the geographically skewed distribution of child/adolescent psychiatrists (14,24).

Treatment of ADHD

For the treatment of patients diagnosed with ADHD, as a first step, a comprehensive psychoeducation, in which the patient and her/his caregivers are informed about ADHD and different treatment options in order to enable a participative decision about the treatment, is recommended by the guidelines (15). In young children and mild forms of ADHD, primary psychosocial interventions are recommended, although dependent on the individual case supplemental pharmacotherapy may be supportive. In moderate to severe forms of ADHD, a multimodal therapy, combining non-pharmacological therapy options (e.g. psychosocial therapy) and pharmacological therapy is indicated. Personal factors and individual predisposition (e.g. level of suffering), the severity of the disorder, environmental factors and any comorbid disorder should be taken into account in the decision whether to delay or start treatment and which therapeutic approach to select (15).

Despite the fact that a multimodal therapy approach for ADHD is considered the “gold standard”, it is unclear to what extent this approach is followed in daily routine. Raising numbers of prescribed pharmacological treatments for ADHD (21–23) have led to concerns that this increase could correspond to a reduced use of other treatments options – particularly since resources for non-pharmacological treatment options are limited in many places. For instance, in Switzerland, in the period 2006 to 2012, the proportion of school aged children (7–15 years) in the canton of Zurich (overall population 2012: 1.4 million) who received an MPH treatment within one year increased from around 1.5–2.4% from 2006 to 2010, but then stagnated (25). Analyses of health insurance data for the whole of Switzerland (Helsana, Groupe Mutuel, KPT, Visana) yielded increases of MPH prescriptions of 40% (from 0.61–0.85% in children and adolescents (22)) from 2005 to 2008, and 42% (from 0.26–0.37% in all age groups (21)) from 2006 to 2009, respectively. A study on the prevalence of ADHD across European countries (United Kingdom, France, Germany, Italy, the Netherlands, Spain) showed that the predominant treatment choice was pharmacotherapy with methylphenidate; about 56% of the studied patients (6–17 years) received MPH, out of which 48.0% were treated with pharmacotherapy only, 34.5% received a combined treatment with pharmacotherapy and behavioral therapy, and 11.6% were treated with behavioral therapy only (26). Although various studies have described an increase in drug therapies for ADHD compared to other therapeutic measures, reasons for the increase are not entirely clear. Research in social science has indicated that the prevalence of ADHD diagnosis and medical treatment has been influenced by various social factors, such as performance pressure in the school environment (27), gender aspects such as a cultural constructions of masculinity (28–30), or unstable family settings (31). Even pressure from parents and teachers to prescribe medication has been reported (16). The question remains whether the guidelines are followed, the diagnosis is carefully clarified, and if multimodal therapy is considered accordingly. This is especially relevant with regard to primary care, which is estimated to account for a substantial proportion of all MPH prescriptions (32).

Building on these recommendations and studies on the practice of ADHD diagnosis and treatment, our study aims to examine Swiss pediatricians’ current practice as well as their perspectives on perceived barriers and facilitators to follow guidelines. Due to the limited number of child and adolescent psychiatrists, pediatricians play a central role in managing ADHD in Switzerland. This first national study of ADHD practices presents comprehensive data regarding the management of children and adolescents with ADHD in pediatric settings in Switzerland.

Data collection

An invitation to participate in the online survey was sent out by the Swiss Pediatric Society via e-mail to all regular and actively practicing members (n = 1620, hospital and office-based pediatricians, representing about 80% of pediatricians of Switzerland). Additionally, 65 pediatricians who took part in an advanced multi-day teaching and training courses on ADHD (a subgroup of the above mentioned) were explicitly invited to the online survey. The following closed and open questions, presented in Table 1, were asked.

Table 1

Questions asked in the survey, arranged according to the three topics.
Diagnostic procedure of ADHD (closed questions)
• “For what reasons do the children come to you? Who initiated the assessment?”
• “How often do you act as follows if you suspect ADHD during an initial consultation”
• “How many appointments do you usually schedule for the diagnosis?”
• “How many take place with the child?”
• “Do you use screening questionnaires?” [during the diagnostic process for ADHD]
Treatment of ADHD (closed questions)
• “What information about ADHD do you usually give parents/children when ADHD is diagnosed?”
• “In case of a diagnosis of ADHD, how often do you inform about the following forms of therapy?”
• “How often do you discuss different treatment options with the following people?”
• “How does the child's level of suffering have an impact on your choice of therapy?”
• “To what extent do you take the opinions of the following people into account when deciding on treatment?”
Challenges in diagnosis and treatment of ADHD in pediatric practice (open questions)
• “Current guidelines provide for multimodal therapy. In your view, what are the three biggest challenges in implementing the multimodal therapy concept?”
• “In your opinion, what are the three biggest challenges in the diagnosis and treatment of ADHD?”
• “In which areas would you like more support/further training?”

In order to achieve coverage throughout Switzerland, parallel language versions of the questionnaire were created in German, French and Italian. The online survey was conducted from January to March 2018 as part of the research project “How to support children with ADHD? Interdisciplinary study on children with ADHD”.

Participants and sample

Of the 1620 pediatricians who were invited, the starting page of the online questionnaire was visited by 200 participants, out of whom 49 (24.50%) aborted the questionnaire after the first seven questions (16% of the questionnaire) and were excluded from the analyses. Thus, the analysis is based on 151 questionnaires (107 completed, 44 largely completed), which corresponds to a response rate of 9.3%. Of the 151 questionnaires, 112 participants (74%) completed the German version, 35 participants (23%) the French version and four participants the Italian version (3%). The total of 151 participants consisted of 88 women (58%) and 59 men (39%) as well as four participants with unknown gender (3%). On average, participants had 17 years of work experience (range 4 to 35 years). Most of the participants were pediatricians (n = 122). Other specializations were (child and adolescent) psychiatry and psychotherapy (n = 22) and others or unknown specialization (n = 7). For the purposes of this study, only the results of the pediatricians are presented in the following. Analyses consist of frequency distributions.

Diagnostic procedure

To the question, who initiated the assessment in the first place, parents (M = 1.77, SD = 0.87, range = 5 − 1) and teachers/school (M = 1.64, SD = 0.72) were rated the most often, while school psychological service (M = 2.88, SD = 0.78) and the child itself (M = 4.41, SD = 0.80) were rated less often. When asked, “How often do you act as follows if you suspect ADHD during an initial consultation”, the majority of the participants stated that they almost always (i.e. in 81–100% of all cases) talk to parents about home, school and the well-being of the child (see Fig. 1). Furthermore, doctors mostly or almost always (i.e. in 61–80%) talk to the children themselves and try to obtain information from additional sources (e.g. school), 55% of pediatricians still mostly or almost always arrange for a second appointment to carry out a systematic diagnostic workup themselves and 42% never (i.e. in 0% of cases) or almost never (i.e. in 1–20% of cases) refer to specialized experts for a diagnostic workup.

[insert Fig. 1]

Pediatricians reported to plan about an average of three (M = 3.1, SD = 1.06) consultations to establish or rule out the diagnosis with parents and teachers; thereof on average of two (M = 2.4, SD = 0.97) with the child, when they generally perform the diagnostic workup themselves. The question about the use of ADHD screening instruments for diagnosis showed that half of the pediatricians use questionnaires for (psychiatric) differential diagnoses, 76% use screening questionnaires (e.g. SDQ - Strengths and Difficulties Questionnaire), and 85% specific ADHD questionnaires (e.g. Conners questionnaire, DISYPS - Diagnostic system for mental disorders according to ICD-10 and DSM-5 for children and adolescents).

Treatment

With regard to the question, what kind of information pediatricians provide to the families when ADHD has been diagnosed in their child, both general information on ADHD and specific information (e.g. brochures) about coaching possibilities, patient organizations, drug treatment and occupational therapy options were reported to be provided by more than 50% of the pediatricians (Fig. 2). The option ‘no further information’ was never chosen as the only one, thus, meaning that all pediatricians give at least some kind of information to their patients. Pediatricians who reported to inform about drug treatment also inform about other treatment options. However, frequency distribution of given information did not differ substantially between pediatricians who did or did not inform about drug treatment.

[insert Fig. 2]

When asked how often they inform about different therapy options, the majority (70–90%) reported to always or often inform about pharmacological therapy, psychotherapy, and multimodal therapy (Fig. 3). Over 50% reported to inform always or often about education counselling and occupational therapy. The frequency of information provided about family therapy and psychomotor therapy varied without a clear trend; 21% of the pediatricians inform never or rarely about family therapy while 42% often or always inform about this treatment option.

[insert Fig. 3]

When asked how much the child's level of suffering plays a role in the choice of therapy, from weak to very strong, 97% of pediatricians consider this to play a strong or very strong role in the choice of therapy.

The analysis to the question how often pediatricians discuss treatment options with parents and children of different ages showed that 81% always discuss with parents, and over 90% claimed to discuss them always or often with parents (Fig. 4). With respect to involving the children in such discussions, nearly half of the pediatricians stated to never or rarely discuss treatment options with young children of four to five years of age. From the age of 6 years upwards, however over 50% of the pediatricians often or always involve the child in these discussions. With increasing age of the children, they are more frequently included in the treatment decision. Among adolescents and young adults (15–18 years old), 84% of pediatricians frequently or always discuss treatment options. The frequency with which teachers are included in the discussion varies widely among pediatricians; 28% often include them, while 15% never or always include them.

The opinion of parents is very often (94%) considered in medical decision making, teachers opinions are only occasionally (42%) taken into account (Fig. 4).

[insert Fig. 4]

Challenges in diagnosis and treatment of ADHD in pediatric practice

In the following, summaries of the answers to questions with an open-ended response format are presented.

When asked about the main challenges in the diagnosis and treatment of ADHD, pediatricians pointed out difficulties in establishing a diagnosis, in particular the subjective nature of the symptoms, the lack of clarity and completeness of the criteria and the difficulty of obtaining usable information. The danger of overlooking co-morbidities and difficulties in multidisciplinary care were mentioned as well. Especially in regard to parents, teachers and the public, further challenges were the partly negative attitudes towards ADHD and explicit negative reactions, for example about the use of ADHD-specific drugs.

In an open question, various reasons were put forward as challenges in the implementation of a multimodal therapy concept: First, pediatricians pointed out low availability of coaching or psychotherapy in their local communities and a lack of reimbursement options, for example for counselling teachers, or a lack of cooperation and coordination between the actors involved. Furthermore, the requirement to improve the availability of child and adolescent psychiatry and psychotherapy was repeatedly addressed. In the context of children and families, their therapeutic adherence and compliance was frequently reported as a therapeutic challenge. In particular, the – at times – insufficient perseverance of the families concerned in following the therapy was perceived as challenging. Pediatricians assumed lack of motivation, capacity problems on the families` side, low time-management skills or communication problems as possible explanations for this phenomenon of low adherence.

Pediatricians expressed a need for further training and better support in terms of coordination and cooperation with other specialists, in particular with teachers and school social workers. More coaching and further training for school professionals was also proposed, but also the creation of an exchange platform in the sense of a peer consulting (e.g. in groups). Finally, stronger efforts were proposed to improve information on ADHD and its treatment in treatment settings (e.g. better parent brochures, information material independent of the pharmaceutical industry) as well as in public (e.g. correction of a false, often negative image).

This study provides insight into the pediatric practice and perceived challenges of ADHD management in Switzerland. In accordance with existing guidelines, the majority of participating pediatricians reported to perform a thorough and broad diagnostic procedure with valid diagnostic instruments and involvement of the parents and the child on a regular basis. Pharmacological therapy, psychotherapy, and multimodal therapy were the therapies about which pediatricians informed most often. Main reported challenges in the ADHD management were the subjectivity of diagnostic criteria, low availability of psychotherapy options due to a shortage of specialists, and a rather negative attitudes towards ADHD of parents, teachers and the public. Need for further education for all professionals involved, support for coordination with specialists, and schools and improvement of information on ADHD was expressed. In conclusion, we could not find any evidence for the assumption that participating office-based pediatricians prescribe MPH without embedding pharmacotherapy in a multimodal approach.

Diagnostic procedures

Acknowledged ADHD guidelines recommend that for the assessment of ADHD more than one visit is scheduled, which is technically difficult within primary care where time is often constrained (13,18). On average, pediatricians in this study arrange three meetings with parents for the diagnosis, of which two take place with the child concerned. To our knowledge, there is no published data from other countries for a comparison of how many meetings are in fact held. Parents and schools play the most important part with respect to initiating a diagnostic consultation, while the school psychological service or the children themselves play a less important role. Even though pediatricians report that they assign patients a central role in the diagnostic workup, the child apparently hardly ever initiates the consultation. The inclusion of parents, family members, and teachers in the assessment of ADHD, which has also been found in other studies, is in line with current guidelines (17,33).

Since the establishment of ADHD guidelines an increased use of screening instruments for the diagnosis has been described in the literature (33). In line with this, the majority of our participants reported that they use ADHD-specific screening tools. For differential diagnosis, half of our respondents used screening tools.

Pediatricians reported that they perceive the subjectivity of the ADHD diagnosis as challenging, which was also repeatedly reported in other studies (16,17,34). However, only few participants reported to refer children with suspected ADHD to a specialist for a further diagnostic workup. Similar, Gamma et al. observed that pediatricians more often diagnose patients with ADHD themselves compared to general practitioners (35). In our study, this finding might be accentuated by the fact that pediatricians, who consider themselves competent in this field and see patients with ADHD regularly predominantly participated in the survey. Nevertheless, some participants expressed the need for further training. Another reason for few referrals to specialists could be the shortage of child & adolescent psychiatrists, which was also expressed by our participants and is in line with research from other countries (24,34,36).

Treatment

Once the diagnosis is established, the exchange with parents and children as well as the level of suffering of the child are reported to be central reasons in favoring or deciding against initiating a therapy. Next to drug therapy, pediatricians reported to inform about occupational therapy, educational counselling and patient organizations most frequently. Most probably, occupational therapy is favored when fine motor impairments are present, which have been described in up to 50% of ADHD patients (37–39).

In our study, involvement of the affected children or adolescents and parents in treatment decisions seems to be standard for many pediatricians and has been reported to be very important for the adherence to therapy (34). However, pediatricians described the families` therapeutic adherence and cooperation as a difficulty, they commonly face. This resonates with previous research where despite substantial evidence supporting the efficacy of stimulant medication for children with ADHD, adherence to stimulant treatment was often not optimal (40). The cause for low adherence was not assessed in the current study. However, proper involvement of the child and family in the therapy process is considered crucial for long-term compliance with therapy (34). With respect to involvement of the child there seems to be room for improvement.

According to the multimodal approach, the majority (80–90%) of pediatricians reported to always or often inform about multimodal therapy, pharmacological therapy and psychotherapy, and the majority (approx. 60%) stated that they always or often inform about education counselling and occupational therapy. This is comparable with the literature, although patients in the study by Venter et al. were more frequently (89%) referred to occupational therapy (35,37).

Even though pediatricians obviously inform about and apply multiple treatment options, the most frequent therapy still is pharmacological treatment, which corresponds with other findings (35,37). Although medication may be prescribed in combination with other therapies, the high use of medication may partly be explained by the reported poor availability of other treatment options such as psychotherapy and occupational therapy. Furthermore, monetary issues for other therapies seem to be a hurdle: for example, occupational therapy was described as problematic with respect to coverage by health insurance companies. An interesting aspect was reported by French et al. which found that physicians felt pressured by parents and teachers to prescribe medication (16).

Challenges in diagnosis and treatment of ADHD in pediatric practice

Pediatricians reported several challenges in the pediatric ADHD management which mostly correspond with other findings from Switzerland and international studies on ADHD management (16–18,34,35). In a systematic review, French et al. (16) identified four main issues in the management of ADHD in primary care: need for education on ADHD for primary care physicians, misconception and stigma towards ADHD among primary care physicians, constraints with recognition, management, and treatment such as limited time for gathering information from third parties, and issues with the multiprofessional approach, i.e. issues with communication between specialists, schools and parents. In our study, the same issues were found, however the need for specific education on ADHD and stigmata were only reported by a minority of participants. This might reflect the selection of participants, who predominantly see themselves as being competent. Interestingly, while French et al. found stigma and misconceptions among physicians (16), in the current study, participants were referring to stigma in the context of stigmatization of ADHD patients by their environment. However, more education and better information on ADHD for professionals and the public is a finding, which has already been identified in the literature, especially considering the perceived subjectivity of diagnostic criteria and vagueness of guidelines (16,17). In our study, pediatricians also suggested further education for school professionals (i.e. teachers and school social workers) and other specialists involved.

Another frequently mentioned issue in our study concerns the multi-professionality of ADHD management, coordination with specialists, schools/teachers and parents, which was described as time-consuming, complicated, and poorly reimbursed. Need for support for interprofessional exchange and case-specific discussions (“patient-centered round tables”) and improvements of reimbursement consequently was frequently stated by our sample and in the literature(16,17,33,37). Moreover, low availability of psychotherapy places is also a problem that is present not only in Switzerland, but internationally (24,34,36).

This first national study on ADHD management presents comprehensive data regarding the management of children and adolescents with ADHD in pediatric outpatient settings in Switzerland. Due to the low response rate, the results should be interpreted with caution, as selection effects may have influenced the results. We most probably reached highly motivated professionals, and pediatricians who treat ADHD in their practice, which already is a selected group. Additionally, all results are based on self-reported data. A non-participation analysis for assessing the reasons of renouncing participation in the survey could not be performed. However, as pediatricians are known to have limited time and resources available, a low response rate was expected.

Most pediatricians not only invest adequate time in a careful diagnosis of ADHD, but they also follow current diagnostic guidelines by considering a multi-modal approach when treating ADHD and show a high involvement of the family and the child in the choice of therapy options. However, they highlight further potential in the treatment of ADHD by improving the availability of psychotherapy, the cooperation with other specialists, such as teachers and school social workers, and public information on ADHD in Switzerland. Furthermore, better reimbursement of therapies and efforts in the context of interprofessional cooperation with therapists and schools were proposed. Various efforts directed at physicians involved in the care for ADHD patients, therapists, politicians, schools, and families emerged to be relevant 1.) to inseminate sufficient know-how about diagnostics and treatment to primary care providers, 2.) to install adequate reimbursement tools for covering interprofessional work for patients with ADHD, 3.) to improve the availability of non-pharmaceutical therapies and support for ADHD in order to support a sustainable adherence with the recommended guidelines.

ADHD

Attention deficit/hyperactivity disorder

APP

American Academy of Pediatrics

CADDRA

Canadian ADHD Resource Alliance

NICE

National Institute for Health and Care Excellence

MPH

methylphenidate

Ethics approval and consent to participate: The study is in accordance with the Declaration of Helsinki and was approved by all three involved local cantonal ethics committees: La Commission cantonale d'éthique de la recherche sur l'être humain Vaud (CER-VD), Comitato etico cantonale ticino and Ethikkommission Zürich (BASEC-Nr. VD-393/25, TI-2973, ZH-2015-0556). All participants provided written consent to take part in the survey.

Consent for publication: All authors agreed to publish the current version of the manuscript.

Availability of data and material: The data presented in this study are available on request from the corresponding author. The data are not yet publicly available due to legal and privacy issues.

Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding: The study is funded by Stiftung Mercator, as part of the project "How to support children with ADHD? Interdisciplinary study on children with ADHD".

Authors’ contribution: FW, MvR and SH developed the research question and designed the questionnaire. FW, MvR and AZ analyzed the data. AZ wrote first version of the manuscript. All authors contributed to writing the manuscript and read and approved the final manuscript.

Acknowledgements: We would like to thank the Swiss Society for Pediatrics for supporting the survey as part of the invitation mailing. We would also like to thank Dr. Kurt von Siebenthal for his helpful feedback on the design of the questionnaire and the opportunity to send invitations to participants in the ADHD training event for pediatricians. Finally, we would like to thank Mr. Serafino Dennert for the translation of the questionnaire into Italian.

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Diagnosis and management of ADHD: A pediatric perspective on practice and challenges in Switzerland

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Abstract

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Background

Diagnostic procedures of ADHD

Treatment of ADHD

Methods

Data collection

Participants and sample

Results

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Treatment

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Challenges in diagnosis and treatment of ADHD in pediatric practice

Discussion

Diagnostic procedures

Treatment

Challenges in diagnosis and treatment of ADHD in pediatric practice

Strength And Limitations

Conclusions

Abbreviations

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References

Status:

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