OBJECTIVES: To visualize heterogeneity in treatment pathways and outcomes among children and adolescents with ADHD in Europe.  METHODS: Retrospective chart review of 779 ADHD patients (aged 6–17 years) diagnosed by 340 clinicians between 2004 and 2007 in six European countries. Receipt of ADHD medication and/or behavioural therapy (BT) was evaluated across the study period. Patient characteristics, treatment patterns, physician-reported satisfaction and symptom control were analysed in the total population and among patients with at least one switch in ADHD therapy during follow-up (switchers). Optimal treatment success (OTS) was defined as high satisfaction and complete symptom control at chart review.  RESULTS: Most patients treated with ADHD medication (89.5%) received methylphenidate. Among 386 patients (49.6%) who remained on their initial treatment throughout the chart review period, the majority (86.3%) were treated with ADHD medication alone or in combination with BT. Switchers (n=393; 50.4%) did not differ significantly at baseline from non-switchers. Few patients (n=98; 12.6%) switched more than once. The most common types of switch (first and last treatments considered) were from one monotherapy to another (n=91; 23.2%) or change of medication co-administered with BT (n=54; 13.7%). The most common reasons for last switch were suboptimal response (40.2%), duration of action (18.1%) or both (14.5%). At review, among those who switched, 11.7% discontinued all ADHD treatment and 5.1% received only BT. Overall, OTS was 27.4% with no significant difference between switchers and non-switchers (29.1% vs 25.5%; p=0.281). CONCLUSIONS: About half the patients switched from their initial treatment during chart review, mostly due to suboptimal response, with many (16.8%) discontinuing ADHD medications. Furthermore, OTS remained low regardless of whether a patient switched ADHD therapies. Together, these observations suggest currently available ADHD treatments are inadequate for achieving OTS among children and adolescents in Europe.