European Child & Adolescent Psychiatry https://doi.org/10.1007/s00787-023-02148-1 REVIEW Remote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID‑19 pandemic P. Santosh1,2,3 · S. Cortese4,5,6,7,8 · C. Hollis9 · S. Bölte10,11,12 · D. Daley13 · D. Coghill14,15,16 · M. Holtmann17 · E. J. S. Sonuga‑Barke1,18 · J. Buitelaar19,20 · T. Banaschewski21 · A. Stringaris22,23 · M. Döpfner24,25 · S. Van der Oord26 · S. Carucci27,28 · D. Brandeis21,29,30,31 · P. Nagy32 · M. Ferrin33 · D. Baeyens26 · B. J. van den Hoofdakker34,35,36 · D. Purper‑Ouakil37,38 · A. Ramos‑Quiroga39 · M. Romanos40 · C. A. Soutullo41 · A. Thapar42 · I. C. K. Wong43,44 · A. Zuddas27,28 · C. Galera45,46,47 · E. Simonoff1 Received: 14 June 2022 / Accepted: 19 January 2023 © The Author(s) 2023 Abstract The COVID-19 pandemic led ADHD services to modify the clinical practice to reduce in-person contact as much as possible to minimise viral spread. This had far-reaching effects on day-to-day clinical practice as remote assessments were widely adopted. Despite the attenuation of the acute threat from COVID, many clinical services are retaining some remote practices. The lack of clear evidence-based guidance about the most appropriate way to conduct remote assessments meant that these changes were typically implemented in a localised, ad hoc, and un-coordinated way. Here, the European ADHD Guidelines Group (EAGG) discusses the strengths and weaknesses of remote assessment methods of children and adolescents with ADHD in a narrative review based on available data and expert opinions to highlight key recommendations for future studies and clinical practice. We conclude that going forward, despite remote working in clinical services functioning adequately during the pandemic, all required components of ADHD assessment should still be completed following national/interna- tional guidelines; however, the process may need adaptation. Social restrictions, including changes in education provision, can either mask or exacerbate features associated with ADHD and therefore assessment should carefully chart symptom profile and impairment prior to, as well as during an ongoing pandemic. While remote assessments are valuable in allowing clinical services to continue despite restrictions and may have benefits for routine care in the post-pandemic world, particular attention must be paid to those who may be at high risk but not be able to use/access remote technologies and prioritize these groups for conventional face-to-face assessments. Keywords ADHD · COVID-19 · Remote assessment · European ADHD Guidelines Group (EAGG) · Pandemic · Children · Adolescents Abbreviations DAWBA Development and Well-Being Assessment ADHD Attention-deficit/hyperactivity disorder DD Developmental disabilities ADHD-RS ADHD rating scale DISYPS Diagnostik-System für psychische Störungen ASD Autism Spectrum Disorders nach ICD-10 und DSM-5 für Kinder- und CAMHS Child and Adolescent Mental Health Jugendliche (DISYPS-III) Services EAGG​ European ADHD Guidelines Group CBCL Child Behavior Checklist NICE UK National Institute of Healthcare and Conners Conners rating scale for ADHD Clinical Excellence PCPs Primary care providers PONS Profile of Neuropsychiatric Symptoms In Memoriam of Professor Alessandro Zuddas (1957–2022). QbTest Quantified Behavioral Test * P. Santosh QoL Quality of Life paramala.1.santosh@kcl.ac.uk SDQ Strengths and Difficulties Questionnaire Extended author information available on the last page of the article 13 Vol.:(0123456789) European Child & Adolescent Psychiatry SEN/ND Special educational needs and/or neurodevel- the assessment and monitoring of emotional, behavioural, opmental differences and cognitive problems and functioning [11]. The urgent SNAP SNAP-IV rating scale need to adopt remote approaches and to modify conventional SWAN SWAN rating scale for ADHD assessments has had far-reaching effects on day-to-day clini- TRAM Transition Readiness and Appropriateness cal practice. However, there is a shortage of systematic evi- Measure dence about which approaches are most feasible, reliable, Vanderbilt Vanderbilt ADHD Diagnostic Rating Scale accurate, and acceptable to patients and their families, and which are cost effective and time efficient. Guidance about the best way to work remotely was therefore lacking and Introduction changes were typically implemented in a localised ad hoc and un-coordinated way. In this article, the European ADHD Attention-deficit/hyperactivity disorder (ADHD) is a com- Guidelines Group (EAGG) reflects on the practice of remote mon neurodevelopmental condition characterized by per- ADHD assessment during the COVID-19 pandemic and pro- vasive (present in more than one setting), impairing, and vides recommendations for best practice going forward. The developmentally inappropriate symptoms of inattention and/ EAGG was set up as a working group of the European Net- or hyperactivity-impulsivity. ADHD typically begins dur- work for Hyperkinetic Disorders (EUNETHYDIS) in 2010 ing childhood and often persists into adulthood, although with the aim of providing clinical guidance to practitioners the manifestations may change, and the severity of hyper- on the clinical management of ADHD based on a rigorous activity can diminish with age. The prevalence of ADHD is assessment of the evidence. The group currently includes estimated at 5–7% [43] in school-aged children and 2.5% in 28 members (mainly child and adolescent psychiatrists or adulthood [58]. A wide range of other neurodevelopmental, psychologists) with expertise in the pharmacological and/ psychiatric, and physical disorders often co-occur causing or non-pharmacological treatments for ADHD in children, additional impairment [19]. Individuals with ADHD fre- adolescents, and adults. To date, the EAGG has published quently experience difficulties with relationships, academic 13 papers in high profile journals. Additional information and vocational problems [1, 20]. Pharmacological treatments on the EAGG and its members is reported online at: https://​ for ADHD can be highly effective in reducing core symp- eunet​hydis.​eu/​eunet​hydis-​initi​atives/​europ​ean-​adhd-​guide​ toms, at least in the short term. In addition, different behav- line-​group/. ioural or cognitive behavioural interventions tailored to the We aim to highlight what we think are promising age of the person with ADHD are recommended by inter- approaches as well as identify areas where remote assess- national clinical guidelines to address aspects beyond the ments may currently be insufficient or unsatisfactory and core symptoms [12, 16]. Because ADHD is often a lifelong where conventional approaches to assessment remain prefer- disorder with serious mental and physical impacts across able. We also consider whether such approaches should con- the lifespan, and interventions can improve its course, early tinue to be used as part of routine care in a post-pandemic and accurate diagnosis is a public health priority [52, 60]. world. This is a rapidly developing area and so our goal is The COVID-19 pandemic led ADHD services to modify to present recommendations to assist remote ADHD assess- their practice and reduce in-person contact as much as pos- ment and research and provide examples of good practice sible. Clinicians had to rapidly adjust and adapt their usual and potential pitfalls. practice to reduce the viral spread and protect the health of their child and adolescent ADHD patients, their fami- lies, other healthcare professionals and the broader com- Impact of the pandemic on manifestations munity. This situation disrupted ongoing care for existing of ADHD and comorbid mental health patients, and reduced access to services for new ones, during problems a period where lock-down restrictions may have exacerbated the difficulties experienced by people with ADHD [54, 57]. The impact of the COVID-19 pandemic on the mental Furthermore, in many contexts and different countries, pre- health of children and adolescents, in general, appears to be existing delays in assessment and interventions in Child and multifaceted and substantial, with increases in anxiety and Adolescent Mental Health Services (CAMHS) or Paediatrics depression prevalence (rates of depression increased from were exacerbated by COVID-19 due to difficulties arising pre-pandemic 2–6% to 12.9%) in a meta-analysis by Racine from increased demand and reduced availability of in-person et al. [44], with higher rates in studies conducted later in assessments. To maintain services as best they could, clini- the pandemic and in girls [44]. Individuals with ADHD are cal teams, where possible, turned to telemedicine/telehealth, likely to be vulnerable to the confinements, changing rules with telephone and audio-visual appointments, to conduct and unpredictability caused by the COVID-19 pandemic assessments and consultations and used on-line tools for [32]. The early observed increases in adolescent mental 13 European Child & Adolescent Psychiatry health symptoms during the COVID-19 pandemic do not, levels of these behaviours significantly worsened during on average, appear to be sustained following the lifting of the lockdown, but those with moderate and severe levels stay-at-home orders [45], though studies evaluating impacts showed important improvement during the lockdown [32]. on mental health across longer periods of time are needed It is important to appreciate the likely consequences of [59]. Compared to the pre-pandemic period, children had repeated lockdowns or periods of self-isolation and uncer- less exercise, less outdoor time, and experienced less enjoy- tainty around future restrictions on the mental health of ment in activities, while television, social media, gaming, young people with ADHD alongside the impact of a less sad/depressed mood, and loneliness were increased. Child agile economy on the family unit [27]. A recent narrative stress about COVID-19 restrictions was associated with review found that during confinement, children and ado- poorer functioning across most domains [53]. lescents with ADHD reported increased behavioural and Systematic reviews [31, 39, 41] and longitudinal stud- ADHD-related symptoms and overall decreased psycho- ies [29, 42], have estimated the impact of the pandemic on logical well-being. Less physical activity, adverse parental children with neurodevelopmental disorders. These groups behaviour, difficulties in coping with preventive COVID- are reported to have higher rates of mental health difficulties 19 guidelines, and school closure and remote learning con- than those without pre-existing psychiatric disorders, due to sequences negatively impacted ADHD-related symptoms COVID-19-related changes to daily life [41]. This finding is and decreased psychological well-being [17]. also supported by a survey of patients attending CAMHS at Reduced cognitive and social demands, and more read- the South London and Maudsley NHS Trust, London, UK ily available resources in the home environment during the (Parlatini et al., personal communication). A longitudinal COVID-19 period resulted in increased home participation study, Co-SPACE, found a significant lock-down-related in ADHD children compared to the pre-COVID-19 period increase in symptoms of inattention and hyperactivity as [28], and parents reported positive family time with their well as behavioural problems in the general population children with ADHD [53]. However, youth with ADHD in primary school-aged children and those with identified were less responsive to protective environmental variables special educational needs or from low-income households, (e.g., parental monitoring, school engagement) during the which were less likely to improve when schools opened [45, pandemic and may need more specialized support with 56]. The study reported that in March 2021, as restrictions a return to in-person schooling and daily activities [47]. in the UK were eased, unlike the general child population, In terms of impact on parents, psychological distress parents of children with special educational needs or neu- and burden have been reported to have increased in car- rodevelopmental disorders and those in low-income families egivers of children with and without special educational continued to report high levels of symptoms [56]. needs and/or neurodevelopmental differences (SEN/ND) Despite these observations, trajectories of ADHD, six months into the COVID-19 pandemic, with greater emotional, and behavioural symptoms during the periods challenges for caregivers of children suffering from ADHD of quarantine are less clear, with mixed and heterogene- or autism spectrum disorders (ASD), although they seem ous findings across studies and within study samples. For to be somewhat more resilient compared to caregivers of instance, a survey of parents of children and adolescents children without developmental disabilities (DD) [27]. aged 3–20 years with ADHD early in the first lockdown ADHD is associated with poorer outcomes in COVID- in France showed an improvement in anxiety, less school- 19 infection, and untreated ADHD seems to constitute a related problems and flexible schedules that adapted to risk factor for COVID-19 infection while drug treatment the child together with improved self-esteem [6]. Another reduces this effect [33]. Emerging data have also sug- study of 238 adolescents aged 15–17 years (118 with gested that mental health complications can occur follow- ADHD), in which parents and adolescents provided rat- ing COVID-19 infection [62, 67]. In an analysis of 40,469 ings of mental health symptoms, found that early observed adult COVID-19 patients between January and June 2020, increases in adolescent mental health symptoms during the about 9,000 patients presented with additional psychiatric COVID-19 pandemic did not on average appear to be sus- symptoms, with the most frequent psychiatric manifes- tained following the removal of stay-at-home orders, but tations being anxiety and other related disorders (4.6%), emotion dysregulation and ADHD increased the risk for followed by mood disorders (3.8%) and suicidal idea- sustained negative mental health functioning [7]. Another tion in about 0.2% of subjects [36], indicating that these survey of 992 parents of children and adolescents aged symptoms are not specific to only individuals with ADHD. 5–18 years with ADHD in Italy investigated the degree of However, for some, long-COVID symptoms include cog- severity of emotional/mood states and disrupted behav- nitive impairment and memory loss, as well as disturbed iours before and during the lockdown. Important fluctua- sleep and increased anxiety, which can be mistaken for tions were found in all dimensions during the lockdown, ADHD symptoms and will in the future require accurate and children and adolescents with previous low severity diagnosis and treatment. 13 European Child & Adolescent Psychiatry Core components of ADHD assessment Remote ADHD Diagnostic Assessment in the COVID‑19 era The aim of this section is to remind the reader of the core elements of an ADHD assessment as described in clini- Published guidance cal guidelines such as those from the European ADHD Guidelines Group (EAGG) [63] and the UK National During the pandemic, remote diagnostic assessment and Institute of Healthcare and Clinical Excellence (NICE) management of ADHD during the pandemic have been guidelines (NICE 2018). A full clinical and psychosocial facilitated by rapid publication guidance, such as those from assessment should include a discussion about behaviour the European ADHD Guidelines Group (EAGG) [15, 16] and symptoms of concern in the different domains and and the Canadian ADHD Resource Alliance [10]. These settings of the person’s everyday life; a full developmental sources provide useful information on approaches that could and psychiatric history and screen for symptoms; observer be considered when making a remote assessment. It is rec- reports and assessment of the person’s mental state and ommended that clinicians conducting telehealth work follow global functioning (NICE 2008, 2018). The purpose of the the digital guidance from official bodies such as the Royal assessment is not only to determine whether the patient College of Psychiatrists (https://​www.​rcpsy​ch.​ac.​uk/​about-​ has ADHD but also to consider differential and co-occur- us/​respo​nding-​to-​covid-​19/​respo​nding-​to-​covid-​19-​guida​ ring disorders as well as formulating the case focusing on nce-​for-​clini​cians/​digit​al-​covid-​19-​guida​nce-​for-​clini​cians) medical, cognitive, psychosocial, and wider environmen- (see Table 1). Remote ADHD assessments should be adapted tal predisposing and maintaining factors and protective in line with national and international evidence-based guide- influences. It should also evaluate the risk of harm and lines and practice recommendations as described above. distress to and from the child or adolescent. To achieve Even though one is doing an ADHD assessment remotely, this, in all cases, diagnostic assessment must include: (i) we recommend that all required components of assessment a detailed history-taking from parents/caregivers of devel- as summarized above should be completed although may opment and current state as well as medical, psychiatric, be adapted. and family history; (ii) obtaining collateral information about symptoms in other contexts such as school; and (iii) Recommendations for remote assessment direct interview, including observation, with the child or adolescent. Assessment should consider the developmental Remote assessment should be multidisciplinary, with input level of the patient, (which may differ from chronological from parents/caregivers, children and young people, edu- age) for example, early childhood, middle childhood, and cation and, where appropriate, social care. To assist in adolescence, and ensure that the reported symptoms are remote assessment, multiple platforms could be lever- inappropriate for their developmental level. However, the aged to obtain information previously gathered by paper pandemic may have wider impacts on the attainment of and pencil measures. Systems such as the web-based sur- age-expected trajectories and milestones due to challenges vey tools Qualtrics (https://​www.​qualt​r ics.​com) and the arising from online schooling, adjusting to going back to Research Electronic Data Capture (REDCap) [23] and school, impact of missed curricula, and for those who other web-based platforms such as the HealthTracker™ had their whole school history during the in-pandemic [50, 51] or the Hogrefe Testsystem (https://​www.​hogre​fe.​ period. Typically, with ADHD, impairment will exist com/​us/​tests​ystem) can be used in several healthcare set- independently of the pandemic. Effects of lockdown can tings in different countries. It is, however, important to worsen pre-existing symptoms and impairment. Patients ascertain whether the system selected has the ease with who develop ADHD symptoms solely during lockdown which routine care providers can obtain and engage with should be re-assessed when lockdown restrictions have it and meets the appropriate privacy-compliance and level been lifted, with the standard criteria for the duration (per- of confidentiality requirements necessary in the country sistence) and pervasiveness still being applied. Cognitive of use. Providers should be aware of the impact that dif- and/or language assessments may be necessary for some ferent technology platforms can have on patient-clinician individuals with suspected specific learning or language rapport and communication. Remote assessments are typi- disability, or intellectual disability. History taking about cally supported by additional communication technologies medical conditions is mandatory and physical/neurological such as e-mailed consultation information, patient portals, examination is usually necessary before initiating treat- telephone, mobile devices, and electronic health records. ment, to identify neuro-genetic disorders, and (rare) physi- Providers should have clear policies pertaining to com- cal causes as well as identifying any possible contraindica- munications with patients, which describe the boundaries tions to medication such as cardiac problems. around ways in which patients can communicate with a 13 Table 1  The digital health guidance from the Royal College of Psychiatrists, UK Operational issues for those undertaking remote consultations Access to technology Problems with accessibility due to disability Availability of a carer to assist Avoid generalization and personalise at a case by case level Ensure the patient has access to the technol- Consider any problems with accessibility, in Plan the video consultation when there may Avoid generalisation about any specific group ogy they require, including internet access, terms of hearing loss or difficulties with be a carer who can help the patient if they in terms of whether video consultation may as well as the skills to use it—check this and dexterity due to coordination problems or have difficulties in doing this or may not be suitable. Consider on a case by provide a quick training session of how to arthritis case, using an understanding of the patient’s use the video chat if necessary needs and circumstances The 6 “C’s” useful in professionals’ own approach and development when considering video-consultations European Child & Adolescent Psychiatry Competence Communication Contingencies Take time to develop enough competence in the platform you Consider how to adapt your communication skills to improve Have a clear understanding of what to do when the consultation intend to use the experience. Where the patient is new to you—take even is not going well for technical or clinical reasons more time over the introduction and signpost what is going to happen next Familiarise yourself with the video consultation platform Try to allow for as much non-verbal communication to be cap- Have a backup plan for managing any technical difficulties (e.g., available to you, and ensure you understand what all the tured as possible. Including your head, neck, upper body and loss of connection) and provide this via email to the patient "buttons" or options do arms may be better than just your head. Encourage patient ahead of the session for example or in the first few minutes of do the same the call. Check you have the right mobile telephone number to call them as a backup. Agree who will contact whom in the event of a lost connection Test the use of the platform and its features with a colleague Lighting and background are important—plain, darker static/ Brief the patient that if you do not feel able to complete an who may be working from home uncluttered background with light directly on your face may adequate assessment you will discuss what steps to take next. help, particularly where the connection is of lower quality This will include reviewing the risks of a face-to-face contact in the context of the local recommended social distancing policy and delay in care that might result Make a note of the features you might want to use and have a Slow the rate of speech to allow for problems with slow con- Ideally have this process mapped out in front of you until you crib sheet available to you in case you need to refer to it nections and pause between sentences longer than you might are familiar with it quickly do face-to-face Use clear language—again this may be shorter than in face-to- Practise the “script” that you might want to use for managing face to ensure clarity of expression across the video call contingencies and ensure that the description of how to man- age the “what ifs” are clear To establish eye contact, you need to look at the camera, not at Make sure the technology (laptop, phone) is charged or plugged the eyes of the person you are interviewing in and advise, where possible, the patient does the same. If Use any features, such as a shared “white board” function, you possible, have a backup device available are familiar with to help with sharing of information Confidentiality Consent Confidence If the patient is new to you, verify they are the right person As with all appointments, it is important to consider the rel- In addressing the other “C’s” you can build the critical sense of where possible, and check they are expecting the appoint- evant aspects for meaningful consent confidence for you and the patient in using video consultations ment for their mental health and not another condition or problem 13 European Child & Adolescent Psychiatry provider, using appropriate content that can be shared over You need to be confident that you have been able to a do a good need to do next with patient—just like you would in a face-to- face consultation. Whilst under pressure to continue to deliver enough review or assessment. If you have not been able to, do not be afraid to say this, and develop a clear plan of what you remains the most important factor in safe care and discussing different technology platforms, anticipated response times, sense of what to do if something goes wrong and what the this with the patient is key to them having confidence too Be clear with the patient on the limitation of the assessment or Being confident about using the technology, having a clear services against significantly unusual circumstances, this limitations of the technology are will help you develop a and how and when to contact a provider [55]. Wherever possible, it is important to offer choice in terms of how an assessment is conducted. It is possible confident approach to using video consultations to mix and match components, with some aspects (for example, parental history-taking) being done remotely using videoconferencing (as opposed to telephone calls) and others (for example, meeting with the child or the young person) done in person, allowing direct observa- tion. While online communication is increasingly familiar to the public, some families will continue to need support in using videoconferencing tools. We recommend enquir- ing about this in advance of the assessment. Disruptions in video conferencing technology would need to be con- Confidence sidered when carrying out remote assessments as not all young people, their families or carers will have access to high-speed internet and cameras or the privacy needed for assessment. Both parents/caregivers and children require you are using and that it is fit for purpose to be used for such agree what might be useful for them to be able to take away they require. Your local IT training/support team will help Ensure that you discuss with the patient about recording the private space to be able to discuss things openly. Access an encounter and be able to discuss this with the patient if Ensure that you are clear about the security of the platform session—ask about the use of this recording and ideally to care and privacy and confidentiality may be more dif- ficult in the overcrowded homes of disadvantaged families [13]. Moreover, such a virtual environment may not be as review, and whether they have any concerns rewarding as the one that families and carers would oth- erwise get during face-to-face clinical visits [2], although and that it will only be for private use the experience of assessment done face-to-face because masks may not be well accepted by children, young peo- ple and their families. Some individuals, especially those with communication problems may find it overwhelming to video-call, but these can often be identified with the pre-assessment courtesy call and modifications put in place. Some individuals may prefer remote assessments, you with this while others may find it more distracting than face-to-face meetings because of other factors (phones, things in their Consent room) and may find it uncomfortable to share emotional content (e.g., depressive, suicidal thoughts) remotely, details in the background. Lock the door to the room you are and importantly, providing appropriate and timely sup- Some platforms have a function that will blur the background introduced to you, and if possible/practical that they remain with them whether it is appropriate to continue at that time. Check who is in the room with the patient, ask for them to be as a relative/carer/advocate)? If so, allow them to introduce Does the patient have anyone else present in the room (such Have a dedicated clinical account, if you use the video plat- If the patient is in a public place (e.g., on the bus), consider If the need to be in a public place to make use of a public connectivity, explore whether they can move to a private port may be difficult remotely if this is happening. For themselves and clarify the purpose of the interview with Manage your own environment. avoid sensitive, personal other patients and families, the advantages of telehealth in avoiding travel time, costs for travel or loss of parental behind you—be familiar with how to enable this earnings due to taking time off for the in-person assess- room or consider alternative arrangements ment and challenges around travelling with hyperactive form socially as well as professionally and impulsive children are considerable. A recent study investigated whether telemedicine/tel- in, if possible, to avoid disruption ehealth were preferable to face-to-face consultations for 117 adults referred to an NHS Autism and ADHD Service during the COVID-19 pandemic from April to September 2020 [69]. Patients reported that they found telemedicine/ Table 1  (continued) telehealth to be useful, effective, reliable, and satisfactory. Confidentiality There was no difference in the choice of contact between the ADHD and Autism pathways. Despite this, almost half of in view them the service users stated a general preference for face-to-face consultations [69]. 13 European Child & Adolescent Psychiatry Information gathering from teachers participant. In clinic settings, such assessments provide an additional opportunity for direct observation, which is not Information from teachers should include contextual possible during remote delivery of care. Parent ‘coaching’, information such as percentage rate of school attendance, often aimed at increased compliance, or environmental periods of remote or virtual teaching, periods of lock- distractions can limit confidence in interpretation. down, and degree of engagement in education, as it may be difficult to judge a pupil’s attention, activity level and Conducting physical assessments impulsivity under these circumstances. School information can be gathered using a telephone interview such as the Basic physical measurements such as height and weight, CHATTI [25]. The validity of information from schools pulse and blood pressure measurements are important as (including teacher-reported ADHD questionnaires) in peri- part of the assessment to rule out non-psychiatric medical ods of remote or virtual schooling is uncertain and has factors, and as a baseline when considering medication. not been formally assessed. It might be difficult to differ- Families are usually able to report on height and weight, entiate who is presenting with ADHD symptoms because but pulse and blood pressure measurements may also need to individuals may have “adapted” to a complex situation, be obtained by training families in the use of a digital blood from those who have neurodevelopmental symptoms and pressure monitor. It is especially important to recognize that would have presented with similar difficulties anyway. many families may not have a paediatric blood pressure cuff With home schooling, the duration of teacher observa- available at home. The general advice is to use age-adapted tions was reduced [64] and occured in a different context cuff size, take the BP at least 2 h after taking a dose, sit to the classroom. As a result, standard teacher reports may down for 10–15 min before taking the reading, taking the be either partial or missing. When necessary, one can use reading on the left arm, and take the lowest of three read- parental/caregiver reports about the quality of engagement ings, approximately the same time on three separate days in remote or virtual learning during periods when teach- and send the readings, alongside the pulse values, to the ing is totally virtual but getting an additional independent prescribers [14]. report from teachers as soon as possible would be appro- priate. However, there is a need to systematically exam- ine whether remote assessments lead to increased rates of Impact of telemedicine/telehealth mis-, under- or overdiagnosis. The psychological aspects of using a virtual environment A pilot project evaluated a school-based ADHD Tel- and the lack of in-person contact in a physical therapeu- emedicine Clinic’s adherence to AAP guidelines using tic setting, alongside the potential loss of engagement, also chart data before the COVID-19 pandemic [40]. The study need consideration. This lack of engagement could also pose included 22 patients (Mean age = 9.3 years, SD = 2.3 years) problems for the quality of the diagnostic assessment. In participating in 69 telemedicine visits across 13 differ- addition, remote assessments can make it more difficult to ent school-related sites. The ADHD Telemedicine Clinic identify child abuse and related ADHD-like symptomatol- achieved extremely high adherence rates across the AAP ogy, self-harm, and tics, and hence one needs to have a low evaluation guidelines for ADHD, ranging from 95 to 100% threshold for bringing patients in for a face-to-face assess- across the six guidelines. No factor inherent to the tel- ment if one suspects child abuse or maltreatment. On the emedicine service delivery mechanism impeded adherence other hand, the lower cost (no need for transportation, park- to national guidelines for ADHD evaluation. The school- ing, less time off work and off school) and higher flexibility based telemedicine clinic allowed increased communica- (allowing adaptation to parents work schedules, ability to tion across the school and specialty mental health systems access care from far away distance) of Telemedicine/Tel- and facilitated greater input across child, parent, school ehealth may be an advantage, as the alternative may be no personnel, and mental health professionals [40]. care, especially for underserved areas far from large metro- politan areas [35]. Conducting complex assessments Where cognitive or language evaluation is deemed impor- Novel/supplementary digital assessment tant in the diagnostic process, assessments such as Q tools/approaches Global, Q Interactive or the Hogrefe Testsystem are feasi- ble, but patients may require considerable support to use The various digital health strategies that have been proposed them. One often requires two monitors and a cooperative to help ADHD assessment and management are described below: 13 European Child & Adolescent Psychiatry a. Remote triaging: Despite limited validation of digital sensitivity and specificity have not been established for completions of generic symptom questionnaires (e.g., QbTest and it may be used to augment standard clinical SDQ, CBCL, PONS) and ADHD-specific measures assessment and not as a stand-alone diagnostic tool for (e.g., SNAP, SWAN, Vanderbilt, ADHD-RS, Conners’, ADHD. ADHD ratings from the DISYPS system), cut-off scores c. Nodal ADHD re-assessment: A nodal ADHD re- may assist in identifying patients that require a detailed assessment is undertaken when a patient is coming up ADHD assessment [34]. to the age of the cut-off boundary for adult services. b. Diagnostic assessment: Digitally completed referral The purpose is to establish the need for continuing care forms for specialist ADHD assessment can assist uni- and treatment into adulthood. Assessment at this point formity and could help reduce time to specialist assess- should consider personal, educational, occupational, ments. A diagnosis of ADHD should not be made solely and social functioning, and include an assessment for based on rating scales or observational data. However, coexisting conditions, especially drug misuse, person- ADHD-specific rating scales such as those listed above ality disorders, emotional problems and learning diffi- can be valuable adjuncts in establishing a baseline in culties. The Transition Readiness Assessment Measure terms of the severity of the symptoms, which can be (TRAM), a web-based measure for transition readi- tracked longitudinally, though one must understand the ness in young people in CAMHS, has been designed sensitivity and specificity of the measures. Sections of to guide transition planning and was developed as part the Diagnostic Interview for Children and Adolescents– of the Managing the Link and Strengthening Transition Revised (DICA–R), the Diagnostic Interview Schedule from Child to Adult Mental Health Care (MILESTONE) for Children (DISC), the Kiddie Schedule for Affective Project, which focussed on the transition of patients Disorders and Schizophrenia (K–SADS), and the Child (including those with ADHD) from CAMHS to Adult and Adolescent Psychiatric Assessment (CAPA) can Mental Health Services [51]. It may be useful to review assist in getting detailed systematic information about the diagnosis again at the first face-to-face meeting when ADHD. Remote observations at home and while access- the initial diagnosis was conducted remotely, especially ing remote education may be useful when there is doubt in those patients where the clinicians have had some about ADHD symptoms. To supplement clinical diag- doubt or need extra cognitive assessments to rule out nosis, different online platforms and ADHD assessment learning disabilities or intellectual disability. tools are available—these are not necessarily available d. Follow-up symptoms and post-treatment monitoring: in all languages but have been provided as examples. Information can be obtained using standardized ques- Completion of the ADHD and related modules of the tionnaires, through ecological momentary assessments Development and Well-Being Assessment (DAWBA) by smartphones and/or digital platforms that can capture which can be completed by multiple informants (parents, symptom change, side effects, QoL, impairment, and teachers, and young people [if age appropriate]), includ- participation measures. The Children’s ADHD Telemen- ing free text enquiries, and following clinician review, tal Health Treatment Study (CATTS) was a randomized can often provide an accurate diagnostic assessment of controlled trial done in seven communities in Washing- ADHD [21] and co-morbid conditions. However, this is ton and Oregon, that demonstrated the superiority of a not an interview-based assessment, and does not allow telehealth service delivery model for the treatment of for clarification by the clinician with the patient/parent, ADHD with combined pharmacotherapy and behaviour that is often needed, particularly where co-occurring training (n = 111) in reducing distress in caregivers of conditions and/or alternative neurodevelopmental dis- children with ADHD, compared with management in orders are being considered. The HealthTracker platform primary care augmented with a telepsychiatry consul- ADHD modules can be completed remotely by multiple tation (n = 112). A diagnosis of ADHD was established raters (patient, parent/carer/partner, teachers, employ- with the Computerized Diagnostic Interview Schedule ers etc.). It includes ratings of impairment, automati- for Children (CDISC), and comorbidity for oppositional cally scored; its results are intuitively presented (https://​ defiant disorder (ODD) and anxiety disorders (AD) was www.​healt​htrac​ker.​co.​uk) and be used as would have established using the CDISC and the Child Behaviour been done previously with paper-based questionnaires. Checklist. Telepsychiatrists used the Texas Children’s To supplement clinical diagnosis, the utility of the com- Medication Algorithm Project (TCMAP) for ADHD puterised QbTest for attention and activity (which must to guide pharmacotherapy. Psychoeducation, and car- be done face to face, with clinician observation) has egiver behavioural training were also provided. The been explored [22, 26]. One trial of QbTest to augment study showed that ADHD could be managed remotely standard clinical assessment, reduced the time taken to in communities with poor access to specialised mental diagnostic decision regarding ADHD [24]. However, the health services [35] and that effective pharmacotherapy 13 European Child & Adolescent Psychiatry for ADHD can be provided [46], with improved out- 7. In the US and many other countries, clinicians and pro- comes [66]. Existing literature supports remote behav- viders should be aware of geographic limitations of their ioural health interventions including behavioural parent practice based on local licensure laws if seeing patients training and combination approaches for externalizing via Telemedicine. disorders as well as cognitive-behavioural based inter- ventions for internalizing disorders [48]. Future directions Current limitations of remote assessment | ADHD assessments can be implemented remotely, most poor practice often maintaining high standards. There is a scarcity of research on assessment via telehealth and establishing evi- It is important to acknowledge that remote assessments may dence-based assessment via telehealth will be of increased also have limitations, as it may be more difficult to view importance [48]. Differential impact of remote assessment the whole family on the screen, observe the parent–child in children versus adolescents will need to be examined. interactions, and to keep the child in view as hyperactivity Rating scales that are available for remote administration can lead to the child moving away from the camera, and using protected Apps/Devices are appropriate for use during some individuals may struggle to focus for the whole period. telehealth evaluation, but future work is needed examining Privacy can be compromised as one cannot be certain about their psychometric properties when administered remotely. who is in the room, and if children (or one or the other par- Moreover, there are challenges to overcome and improve- ent) can speak openly and freely [55]. Basavarajappa et al. ments that need to be made. For example, physical assess- [3] reported on a survey of 340 psychiatrists regarding the ment, including cardiovascular assessment remains a chal- advantages and disadvantages of telemedicine during the lenge when in-person visits are disrupted due to lockdowns. pandemic. The responders felt that telepsychiatry would pro- Before initiating pharmacotherapy for ADHD, vital signs vide easy accessibility to mental health services (83.24%), such as blood pressure and heart rate, alongside height and would lead to less exposure to infections (65.29%) and weight, are routinely measured. We have provided some increased doctor shopping resulting in poor care (52.06%). recommendations for starting medications during the pan- However, they also pointed out that there would be problems demic [15]. As indicated by others [30], it might be prudent dealing with suicidal or homicidal patients (72.06%), and to encourage the use of blood pressure monitors or contact were worried that the patient may record the consultation, photoplethysmography using mobile devices. These tech- leading to legal issues (36.56%) [3]. nologies could assist in the clinical decision-making process Table 1 gives details about guidelines in relation to when a diagnosis has been made and before tele-prescribing remote assessments. has been initiated. Here are a few examples of practice to be avoided Future studies should collect data on patient/family preferences and feedback regarding remote assessment for 1. Issues such as lack of secure space for confidential ADHD and other disorders. Identifying characteristics of remote assessment, bad lighting, bad microphone, bad patients, families, and clinicians who prefer remote assess- visualization, and audio, in general, can affect optimal ments versus face-to-face assessments could help match the remote interactions. type of assessment to appropriate patient and clinician. Also, 2. Screen distractions, such as having emails flash or arrive there is a need to collect health economic data to identify at the same time can compromise confidentiality. whether remote assessments lead to more cost-effective and/ 3. Patients and families not being informed about security or faster response to patient need. Enhanced telemedicine settings of the remote assessment—it is important to and remote assessment training will need to become part of obtain participant/informant agreement/consent to pro- routine workforce training. ceed with the remote interview. Exposure to, and infection with, SARS-CoV-2 and 4. Recording sessions without the knowledge of the other its potential short and long-term impacts on ADHD and party (patient or clinician/provider), or not informing other mental health disorders has not been adequately patient about the presence of others who are not visible explored and more evidence is needed to understand how on the screen. viral exposure causes short term changes in mental health 5. Using the same link for different patients can lead to and what the longer-term impact of this will be. Moving breach of confidentiality and unacceptable practice. forward in the post-COVID era, remote diagnostic assess- 6. Performing telemedicine services while the patient is in ment of ADHD for young people can form a vital com- a moving vehicle, for safety and liability reasons. ponent of the ADHD assessment ecosystem. However, as 13 European Child & Adolescent Psychiatry clinicians, we would need to be cognisant of the challenges • Experience with remote ADHD assessment may also of working in a virtual world, especially when it comes to provide a useful template/paradigm for the assessment clinical decision-making for young people with ADHD. of other childhood psychopathology. Barriers to the use of telehealth platforms include the • While remote assessments are valuable in allowing work impact of the complexity and symptoms of illness, lack of to continue despite restrictions and may have benefits for face-to-face training, and clinician preference for training routine care in the post-pandemic world, it is important mediums [65]. Despite these concerns, remote diagnostic to ensure access for groups who are digitally disadvan- assessment of ADHD in young people using telehealth has taged. Those who may not be able to use/access remote the potential of opening new opportunities for assessing, technologies should be prioritized for conventional or managing, and treating ADHD. Web-based assessments other alternative assessments. could facilitate diagnosis and treatment monitoring, and • It is likely that the delivery of medical care will evolve telemedicine could continue to inform ADHD practices and involve blended models of needs-based face-to-face and guidelines once the restrictions begin to loosen. A and remote contacts. hybrid model that implements web-based and semi-struc- tured approaches in a clinical setting could be the way for- ward for facilitating ADHD diagnosis and management in Declarations young people. Successful implementation of such models Conflict of Interest Jan K Buitelaar has been in the past 3 years a con- in medicine may require ongoing organizational support, sultant to/member of the advisory board of/and/or speaker for Takeda/ in-house clinical supervision, and development of tailored Shire, Roche, Medice, Angelini, Janssen, and Servier. He is not an e-health resources, and open training opportunities on how employee of any of these companies, and not a stock shareholder of any of these companies. He has no other financial or material sup- to operate and effectively utilize these resources [65]. port, including expert testimony, patents, royalties. Paramala Santosh is the CEO and shareholder of HealthTracker Ltd. He has also received research funds and honoraria from Anavex Scientific Corporation, Ne- wron Pharma, and GW Pharma, and research funds from Reverse Rett, a charity. Samuele Cortese declares honoraria and reimbursement for Conclusions travel and accommodation expenses for lectures from the following non-profit associations: Association for Child and Adolescent Central Taking together all the above considerations we may Health (ACAMH), Canadian ADHD Alliance Resource (CADDRA), conclude: British Association of Pharmacology (BAP), and from Healthcare Convention for educational activity on ADHD. Professor Daley has provided educational talks for Medice and Shire/Takeda, attended • With appropriate adaptations, ADHD assessments can be advisory boards for Shire/Takeda. Received support for educational undertaken either remotely or by using personal protec- travel from Shire/Takeda, QbTech and Medice. He has also received tive equipment for in-person work. It is important that royalties from the sale of a self-help version of the New Forest Parent- ing Programme and research funding from NIHR, ESRC and Shire/ we continue to complete standard components of ADHD Takeda. David Coghill served in an advisory or consultancy role for assessment. Medice, Novartis, and Takeda. He received conference support or • The preferences of patients, families and clinicians speaker’s fee from Medice, Servier, and Takeda. He received royal- should be considered when deciding which approach to ties from Cambridge University Press and Oxford University Press; the present work is unrelated to these relationships. Martin Holt- take. mann served in an advisory role for Shire, Takeda and Medice and • The clinician will have insight into the need for a face- received conference attendance support or was paid for public speak- to-face assessment for a particular individual, knowledge ing by Medice, Shire and Neuroconn. He received research support about the current covid-related risks to patients and clini- from the German Research Foundation and the German Ministry of Education and Research. He received royalties as Editor-in-Chief of cians, both of which should be considered when deciding the German Journal for Child and Adolescent Psychiatry and for text- on appointment type. books from Hogrefe. Diane Purper Ouakil reports in the past 3 years • If a traditional face-to-face assessment cannot be done honoraria and non-financial support from Medice and Shire/Takeda, due to restrictions, ADHD assessment should not be and non-financial support from HAC Pharma, outside the submitted work. Edmund Sonuga-Barke has received speaker fees from Takeda/ delayed and a remote assessment should be considered. Shire and Medice, consultancy from Neurotech Solutions and grant • Clinicians should be aware that ADHD may be a risk support from QBTech. Tobias Banaschewski served in an advisory or factor for difficulty complying with social and related consultancy role for ADHS digital, Infectopharm, Lundbeck, Medice, restrictions, and this should be addressed during the diag- Neurim Pharmaceuticals, Oberberg GmbH, Roche, and Takeda. He received conference support or speaker’s fee by Janssen, Medice and nostic assessment. Such restrictions, including changes Takeda. He received royalties from Hogrefe, Kohlhammer, CIP Me- in education can either mask or exacerbate features asso- dien, Oxford University Press; the present work is unrelated to these ciated with ADHD and, therefore, assessment needs to relationships. Cesar A. Soutullo is a Full Time Employee of The Uni- carefully chart symptomatic manifestations prior to as versity of Texas Health-Houston. In the past three years, he has served in advisory board/consultancy roles for Editorial Medica Panamerica- well as during the pandemic. 13 European Child & Adolescent Psychiatry na, Innosphere (Germany), Limbix (USA), MEDEA (Spain), Medice 5. Bemanalizadeh M, Yazdi M, Yaghini O, Kelishadi R (2021) A (Germany), and NeuroTech Solutions Ltd (Israel). He served on the meta-analysis on the effect of telemedicine on the management of Speaker’s Bureau/CME Talks for Bial (Portugal), Cuquerella Medical attention deficit and hyperactivity disorder in children and adoles- Consulting (Spain), Medice (Germany), Rubio (Spain), Tecnofarma cents. J Telemed Telecare. https://​doi.​org/​10.​1177/​13576​33X21​ (Peru). Has received royalties from Editorial Médica Panamericana 10451​86. (Epub ahead of print) and Mayo Ediciones, Springer. His research is supported in part by 6. Bobo E, Lin L, Acquaviva E, Caci H, Franc N, Gamon L et al the Texas Child Mental Health Care Consortium. Anita Thapar’s text- (2020) Comment les enfants et adolescents avec le trouble déficit book royalties are paid to Cardiff University. Maite Ferrin has received d’attention/hyperactivité (TDAH) vivent-ils le confinement durant honoraria from Medice for one congress in 2019 and has contributed to la pandémie COVID-19? [How do children and adolescents Novartis advisory board in 2019. Peter Nagy has received consultancy with Attention Deficit Hyperactivity Disorder (ADHD) experi- fees from Lilly and Medice and conference support from Egis Pharma- ence lockdown during the COVID-19 outbreak?]. Encephale ceuticals. Saskia van der Oord has no conflicts of interest. Sara Carucci 46(3S):S85–S92 had collaborations with projects from the European Union (7th Frame- 7. Breaux R, Dvorsky MR, Marsh NP, Green CD, Cash AR, Shroff work Program) and in sponsored clinical trials by Lundbeck, Otsuka, DM, Buchen N, Langberg JM, Becker SP (2021) Prospective Janssen-Cilag, Acadia and Angelini. Chris Hollis was a member of impact of COVID-19 on mental health functioning in adolescents the NICE ADHD Guideline [NG87] Committee. He has conducted re- with and without ADHD: protective role of emotion regulation search on QbTest funded by the National Institute of Health Research abilities. J Child Psychol Psychiatry. https://d​ oi.​org/​10.​1111/j​ cpp.​ (NIHR). Sven Bölte discloses has in the last 3 years acted as an author, 13382 consultant or lecturer for Medice and Roche. He receives royalties for 8. Bruni O, Giallonardo M, Sacco R, Ferri R, Melegari MG (2021) textbooks and diagnostic tools from Hogrefe, and Liber. Bölte is share- The impact of lockdown on sleep patterns of children and adoles- holder in SB Education/Psychological Consulting AB and NeuroSup- cents with ADHD. J Clin Sleep Med 17(9):1759–1765 portSolutions International AB. Barbara van den Hoofdakker receives 9. Buchen N, Langberg JM, Becker SP (2021) Prospective impact of royalties from Van Gorcum. Alessandro Zuddas served in an advisory COVID-19 on mental health functioning in adolescents with and or consultancy role for Angelini, Janssen, Servier, Takeda, INCIPIT, without ADHD: protective role of emotion regulation abilities. and grant support from Lundbeck, Janssen, Otsuka, Servier, and the J Child Psychol Psychiatry 62(9):1132–1139. https://​doi.​org/​10.​ European Union (Innovative Medicine Initiative 2), He also received 1111/​jcpp.​13382. (Epub 2021 Feb 4) royalities from Giunti Psychometrics, Hoegrefe and Oxford University 10. CADDRA (2020) ADHD and COVID-19 frequently asked ques- Press. tions. https://​www.​caddra.​ca/​wp-​conte​nt/​uploa​ds/​CADDRA-​ ADHD-​and-​Virtu​al-​Care-​FAQ.​pdf. Accessed 30th Apr 2022 Open Access This article is licensed under a Creative Commons Attri- 11. Chandra P, Kar N, Yahia A (2021) Experience of tele-psychiatry bution 4.0 International License, which permits use, sharing, adapta- during COVID-19 amongst doctors working in a mental health tion, distribution and reproduction in any medium or format, as long trust: a survey. BJPsych Open 7(Suppl 1):S13–S14. https://​doi.​ as you give appropriate credit to the original author(s) and the source, org/​10.​1192/​bjo.​2021.​94 provide a link to the Creative Commons licence, and indicate if changes 12. Coghill D, Banaschewski T, Cortese S, Asherson P, Brandeis D, were made. The images or other third party material in this article are Buitelaar J, Daley D, Danckaerts M, Dittmann RW, Doepfner M, included in the article's Creative Commons licence, unless indicated Ferrin M, Hollis C, Holtmann M, Santosh P, Sonuga-Barke E, otherwise in a credit line to the material. 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Soutullo41 · A. Thapar42 · I. C. K. Wong43,44 · A. Zuddas27,28 · C. Galera45,46,47 · E. Simonoff1 1 20 Department of Child and Adolescent Psychiatry, Institute Karakter Child and Adolescent Psychiatry University Centre, of Psychology, Psychiatry and Neuroscience, King’s College Nijmegen, The Netherlands London, London, UK 21 Department of Child and Adolescent Psychiatry 2 Centre for Interventional Paediatric Psychopharmacology and Psychotherapy, Medical Faculty, Central Institute and Rare Diseases, South London and Maudsley NHS of Mental Health, Mannheim/Heidelberg University, Foundation Trust, London, UK Mannheim, Germany 3 22 HealthTracker Ltd, Gillingham, Kent, UK Divisions of Psychiatry and Psychology and Language 4 Sciences, University College London, London, UK Centre for Innovation in Mental Health, School 23 of Psychology, Faculty of Environmental and Life Sciences, First Department of Psychiatry, Aigineteion Hospital, University of Southampton, Southampton, UK National and Kapodistrian University of Athens, Athens, 5 Greece Clinical and Experimental Sciences (CNS and Psychiatry), 24 Faculty of Medicine, University of Southampton, Department of Child and Adolescent Psychiatry, Southampton, UK Psychosomatics and Psychotherapy, Faculty of Medicine, 6 University Hospital Cologne, University of Cologne, Solent NHS Trust, Southampton, UK Cologne, Germany 7 Hassenfeld Children’s Hospital at NYU Langone, New York 25 School of Child and Adolescent Cognitive Behavior Therapy University Child Study Center, New York City, NY, USA (AKiP), Faculty of Medicine, University Hospital Cologne, 8 Mental Health and Clinical Neurosciences, School University of Cologne, Cologne, Germany of Medicine, University of Nottingham, Nottingham, UK 26 Clinical Psychology, KU Leuven, Louvain, Belgium 9 School of Medicine, National Institute for Health Research 27 Department of Biomedical Sciences, Sect. Neuroscience (NIHR) MindTech Mental Health MedTech Cooperative, and Clinical Pharmacology, University of Cagliari, Cagliari, NIHR Nottingham Biomedical Research Centre, Institute Italy of Mental Health, Mental Health and Clinical Neurosciences, 28 University of Nottingham, Nottingham, UK Child and Adolescent Neuropsychiatry Unit, “A. Cao” 10 Paediatric Hospital, ASL Cagliari, Cagliari, Italy Center of Neurodevelopmental Disorders (KIND), 29 Centre for Psychiatry Research, Department of Women’s Department of Child and Adolescent Psychiatry and Children’s Health, Karolinska Institute and Stockholm and Psychotherapy, University Hospital of Psychiatry, Health Care Services, Region Stockholm, Stockholm, Sweden University of Zurich, Zurich, Switzerland 11 30 Child and Adolescent Psychiatry, Stockholm Health Care Neuroscience Center Zurich, University of Zurich, Zurich, Services, Region Stockholm, Stockholm, Sweden Switzerland 12 31 Curtin Autism Research Group, Curtin School of Allied ETH Zurich, Zurich, Switzerland Health, Curtin University, Perth, WA, Australia 32 Bethesda Children’s Hospital, Budapest, Hungary 13 NTU Psychology, School of Social Science, Nottingham 33 Barnet, Enfield and Haringey NHS Trust, ReCognition Trent University, Nottingham, UK Health, London, UK 14 Departments of Paediatrics and Psychiatry, University 34 Department of Child and Adolescent Psychiatry, University of Melbourne, Melbourne, VIC, Australia of Groningen, University Medical Center Groningen, 15 Murdoch Children’s Research Institute, Melbourne, VIC, Groningen, The Netherlands Australia 35 Department of Clinical Psychology and Experimental 16 Royal Children’s Hospital, Melbourne, Melbourne, VIC, Psychopathology, University of Groningen, Groningen, Australia The Netherlands 17 36 LWL-University Hospital for Child and Adolescent Accare Child Study Center, Groningen, The Netherlands Psychiatry, Ruhr University, Bochum, Germany 37 Unit of Child and Adolescent Psychiatry (MPEA1), CHU 18 Department of Child and Adolescent Psychiatry, Aarhus Montpellier-Saint Eloi Hospital, University of Montpellier, University, Aarhus, Denmark 80 Avenue Augustin Fliche, 34000 Montpellier, France 19 38 Department of Cognitive Neuroscience, Donders Institute Team Psychiatry, Development and Trajectories, INSERM for Brain, Cognition and BehaviourRadboudumc, Nijmegen, CESP U 1018, University Paris Saclay, Gif‑sur‑Yvette, The Netherlands France 13 European Child & Adolescent Psychiatry 39 43 Vall d’Hebron Research Institute (VHIR), Universitat Department of Pharmacology and Pharmacy, The University Autònoma de Barcelona, Barcelona, Spain of Hong Kong, Hong Kong, SAR, China 40 44 Department of Child and Adolescent, Center of Mental Research Department of Practice and Policy, UCL School Health, University Hospital of Wurzburg, Wurzburg, of Pharmacy, London, UK Germany 45 University of Bordeaux, Bordeaux, France 41 Louis A Faillace Department of Psychiatry and Behavioral 46 Bordeaux Population Health Centre, INSERM U1219, Science, University of Texas (UT) Health, Houston, TX, Bordeaux, France USA 47 42 Child and Adolescent Psychiatry Department, Charles Division of Psychological Medicine and Clinical Perrens Hospital, Bordeaux, France Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Wolfson Centre for Young People’s Mental Health, Cardiff University School of Medicine, Wales, UK 13