Abstract
<title>Abstract</title> <p> <bold>Background</bold> : Translating treatment guidelines for Attention-Deficit/Hyperactivity Disorder (ADHD) into uniform real-world practice remains a key public health challenge across Europe. Adding to previous data from other European countries, this study is the first to evaluate nationwide ADHD pharmacotherapy practices in Hungary. <bold>Methods</bold> : Utilizing data from the health insurance system over a ten-year period (2013–2022) for 36,091 children newly diagnosed with ADHD, we tracked medication initiation, first-line treatment choices, 180-day persistence, and antipsychotic use. <bold>Results:</bold> 21.7% [21.3; 22.2] of diagnosed children were started on ADHD-specific pharmacotherapy. Marked inter-regional variability in treatment initiation rates was observed across the country, ranging from 11.8% to 29.8% across regions. First-line treatment selection showed a nationwide preference for atomoxetine over methylphenidate, with nearly two-thirds of all treated children (65.0% [64.0; 66.1]) being prescribed atomoxetine initially. Six-month treatment persistence was significantly higher for atomoxetine than methylphenidate (63.4% versus 50.9%; absolute difference: 12.5 percentage points [10.3; 14.7]). The use of non-ADHD-specific medication was relatively frequent, with 9.4% of the entire diagnosed cohort receiving antipsychotics. <bold>Conclusions:</bold> These findings reveal critical implementation gaps, widespread guideline divergence, and region- and gender-specific treatment disparities. Even within a small and centralized European healthcare infrastructure, achieving guideline-compliant care requires targeted interventions to optimize treatment initiation and persistence for vulnerable populations. </p>