For Doctors in a Hurry
- Clinicians lack updated data on long-term trends in attention deficit hyperactivity disorder medication use among children and adolescents in Denmark.
- The researchers analyzed prescription data for youths aged 5 to 17 years across the entire Danish population from 2010 to 2023.
- By 2023, prevalence reached 3.4% for boys and 1.8% for girls, with the female prevalence tripling over the study period.
- The authors conclude that rising medication use likely reflects increased diagnostic awareness, particularly among the female population in Denmark.
- The two-year delay in treatment initiation for girls compared to boys suggests a need for earlier clinical screening and intervention.
Evolving Trends in Pediatric ADHD Pharmacotherapy
Pharmacological intervention remains a cornerstone of multimodal management for attention deficit hyperactivity disorder (ADHD), with stimulants and non-stimulants significantly reducing core symptoms and improving quality of life in pediatric populations [1, 2, 3]. Despite the established efficacy of these agents, clinicians face persistent challenges regarding long-term treatment adherence, as data indicate that only 22.9% of youth maintain good adherence at a 12 month follow-up [4]. Cardiovascular safety also remains a primary monitoring concern, although meta-analytic data of nearly four million participants suggest no statistically significant association between ADHD medications and serious cardiovascular events across age groups [5]. Furthermore, rising diagnosis rates among female patients have introduced new complexities in managing ADHD across the lifespan, including considerations for reproductive health and the prevalence of medication exposure during pregnancy [6]. While current treatments effectively mitigate functional impairments, they rarely normalize long-term outcomes to the level of neurotypical peers, necessitating a deeper understanding of how prescribing patterns are shifting in real-world clinical practice [7]. A comprehensive analysis of Danish national registry data from 2010 to 2023 now provides a detailed look at how these treatment dynamics have transformed over the last decade.
Divergent Incidence and Prevalence Patterns by Sex
The researchers identified distinct longitudinal trends in incidence rates (the frequency of new patients starting medication within a specific timeframe) for ADHD pharmacotherapy between 2010 and 2023. For boys, the data revealed a u-shaped pattern where incidence rates initially declined from 0.59 per 100 person-years in 2010 to 0.34 per 100 person-years in 2014. This trend subsequently reversed, with the incidence rate for boys rising to 1.0 per 100 person-years by 2023. In contrast, the incidence rates among girls exhibited a continuous and steady increase throughout the study period, rising from 0.20 per 100 person-years in 2010 to 0.67 per 100 person-years in 2023. These divergent patterns suggest that while the initiation of treatment for boys fluctuated over the last decade, the clinical identification and treatment of girls has seen a persistent upward trajectory. This may reflect a stabilization of diagnostic practices for the classic externalizing presentations often seen in males, contrasted with an ongoing catch-up effect in the identification of female patients.
When analyzing prevalence proportions (the total percentage of the pediatric population with an active prescription at any given time), the study found that rates remained stable until 2018. After this point, a notable increase in prevalence was observed for both sexes. By 2023, the prevalence proportion reached 3.4% for boys and 1.8% for girls. Although the absolute prevalence remains higher in males, the rate of increase was significantly more pronounced in the female population. Specifically, the ADHD medication prevalence tripled among girls from 2010 to 2023, compared to a 1.5-fold increase among boys during the same period. For the practicing clinician, these data highlight a narrowing sex gap in ADHD treatment, likely driven by increased diagnostic sensitivity to the often less disruptive or more internalized presentations of ADHD in female patients, such as inattentiveness without overt hyperactivity.
The Narrowing Sex Gap and Initiation Delays
The longitudinal data from the Danish registries indicate a significant shift in the demographic distribution of ADHD pharmacotherapy over the last decade. Throughout the study period, the researchers observed that the male to female incidence and prevalence ratios decreased consistently from 2010 to 2023, signaling a narrowing gap between the sexes in clinical practice. While ADHD has historically been diagnosed and treated more frequently in males, these findings suggest that clinicians are increasingly identifying the condition in female patients. This trend likely reflects an evolving clinical awareness of the diverse presentations of ADHD, particularly in girls who may present with less disruptive or more internalized symptoms than their male counterparts, which can often be mistaken for anxiety or mood disorders in primary care settings.
Despite the rising prevalence among females, the timing of treatment initiation remains a point of clinical concern. The study found that ADHD medication was initiated at a median age of 13 years for girls, whereas ADHD medication was initiated at a median age of 11 years for boys. This disparity results in a two year treatment delay for girls compared to boys, a finding that warrants specific attention from pediatricians and psychiatrists. For the practicing physician, this delay suggests that many girls may navigate the early years of primary education without pharmacological support, potentially impacting their long-term academic and social trajectories. Identifying these patients earlier in their development could be critical for mitigating the cumulative effects of untreated symptoms during key developmental windows, such as the transition to middle school where executive function demands increase sharply.
Prescribing Sources and Long-term Treatment Persistence
The study analyzed filled prescriptions for ADHD medication in youths aged 5 to 17 years in Denmark from 2010 to 2023, providing a comprehensive view of how clinical management has shifted over time. Researchers calculated incidence rates, prevalence proportions, male to female ratios, treatment persistence, age at initiation, and prescriber setting, with all analyses stratified by sex and age to capture demographic nuances. A significant finding regarding the clinical pathway is that the share of index prescriptions (the very first prescription a patient receives to begin therapy) from child and adolescent psychiatry increased to 87% in 2023. This concentration of initial prescribing within specialized psychiatric settings suggests a move away from primary care initiation, potentially reflecting more standardized diagnostic protocols or a higher complexity of cases requiring specialist oversight before medication is commenced.
Long-term treatment continuity, or persistence, showed a distinct age-dependent decline that has implications for the management of transition-age youth. The researchers found that five years after treatment initiation, 65% of 5 to 9 year olds were covered by an ADHD medication prescription, indicating high levels of treatment retention in the youngest cohort. This rate dropped as the age of initiation increased; five years after treatment initiation, 45% of 10 to 13 year olds were covered by an ADHD medication prescription, and only 29% of 14 to 17 year olds remained on medication after the same five year interval. For the practicing clinician, these data highlight a critical period of treatment attrition during the late teenage years and the transition to adulthood. This phase, often characterized by a shift in healthcare responsibility from parent to child, is where the loss of pharmacological support may intersect with increasing academic and social demands, suggesting a need for more robust transition planning in clinical practice.
References
1. Catalá-López F, Hutton B, Núñez-Beltrán A, et al. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: A systematic review with network meta-analyses of randomised trials. PLoS ONE. 2017. doi:10.1371/journal.pone.0180355
2. Cerrillo-Urbina AJ, García-Hermoso A, Pardo-Guijarro MJ, Sánchez-López M, Santos-Gómez JL, Martínez-Vizcaíno V. The Effects of Long-Acting Stimulant and Nonstimulant Medications in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials. Journal of child and adolescent psychopharmacology. 2018. doi:10.1089/cap.2017.0151
3. Tsujii N, Okada T, Usami M, et al. Effect of Continuing and Discontinuing Medications on Quality of Life After Symptomatic Remission in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis.. The Journal of clinical psychiatry. 2020. doi:10.4088/JCP.19r13015
4. Ferrin M, Häge A, Swanson J, et al. Medication adherence and persistence in children and adolescents with attention deficit hyperactivity disorder (ADHD): a systematic review and qualitative update.. European child & adolescent psychiatry. 2025. doi:10.1007/s00787-024-02538-z
5. Zhang L, Yao H, Li L, et al. Risk of Cardiovascular Diseases Associated With Medications Used in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis.. JAMA network open. 2022. doi:10.1001/jamanetworkopen.2022.43597
6. Russell DJ, Quintrell E, Wyrwoll CS, Kelty E. Prevalence of the Prescribing of Attention-Deficit Hyperactivity Disorder Medication During Pregnancy: A Systematic Review.. Journal of psychoactive drugs. 2025. doi:10.1080/02791072.2025.2478085
7. Shaw M, Hodgkins P, Caci H, et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Medicine. 2012. doi:10.1186/1741-7015-10-99
