ADHD and Psychiatric Comorbidity: Functional Outcomes in a School-Based Sample of Children

Objective: Investigate the prevalence and impact of psychiatric comorbidities in community-based samples of schoolchildren with/without ADHD. Method: Teachers and parents screened children in South Carolina (SC; n = 4,604) and Oklahoma (OK; n = 12,626) for ADHD. Parents of high-screen and selected low-screen children received diagnostic interviews (SC: n = 479; OK: n = 577). Results: Psychiatric disorders were increased among children with ADHD and were associated with low academic performance. Conduct disorder/oppositional defiant disorder (CD/ODD) were associated with grade retention (ODD/CD + ADHD: odds ratio [OR] = 3.0; confidence interval [CI] = [1.5, 5.9]; ODD/CD without ADHD: OR = 4.0; CI = [1.7, 9.7]). School discipline/police involvement was associated with ADHD alone (OR = 3.2; CI = [1.5, 6.8]), ADHD + CD/ODD (OR = 14.1, CI = [7.3, 27.1]), ADHD + anxiety/depression (OR = 4.8, CI = [1.6, 14.8]), and CD/ODD alone (OR = 2.8, CI = [1.2, 6.4]). Children with ADHD + anxiety/depression had tenfold risk for poor academic performance (OR = 10.8; CI = [2.4, 49.1]) compared to children with ADHD alone. This should be interpreted with caution due to the wide confidence interval. Conclusion: Most children with ADHD have psychiatric comorbidities, which worsens functional outcomes. The pattern of outcomes varies by type of comorbidity.

ADHD Medication Use During Pregnancy and Risk for Selected Birth Defects: National Birth Defects Prevention Study, 1998-2011

Objective: The objective of this study was to examine the prevalence of, and maternal characteristics associated with, ADHD medication use before and during pregnancy, and associations between early pregnancy ADHD medication use and risk for 12 selected birth defects. Method: We used data from the National Birth Defects Prevention Study (1998-2011), a U.S. population-based case-control study examining risk factors for major structural birth defects. Results: There was an increase in ADHD medication use from 1998-1999 (0.2%) to 2010-2011 (0.5%; p < .001). Early pregnancy ADHD medication use was more commonly reported by mothers of infants/fetuses with gastroschisis (crude odds ratio [cOR]: 2.9, 95% confidence interval [CI] = [1.2, 6.9]), omphalocele (cOR: 4.0, 95% CI = [1.2, 13.6]), and transverse limb deficiency (cOR: 3.3, 95% CI = [1.1, 9.6]). Conclusion: ADHD medication use before and during pregnancy was rare, but the prevalence of use has increased over time. In this analysis, early pregnancy ADHD medication use was associated with three of 12 selected birth defects.

Combatting the Increasing Threat of Vector-Borne Disease in the United States with a National Vector-Borne Disease Prevention and Control System

Reported cases of vector-borne diseases in the United States have more than tripled since 2004, characterized by steadily increasing incidence of tick-borne diseases and sporadic outbreaks of domestic and invasive mosquito-borne diseases. An effective public health response to these trends relies on public health surveillance and laboratory systems, proven prevention and mitigation measures, scalable capacity to implement these measures, sensitive and specific diagnostics, and effective therapeutics. However, significant obstacles hinder successful implementation of these public health strategies. The recent emergence of Haemaphysalis longicornis, the first invasive tick to emerge in the United States in approximately 80 years, serves as the most recent example of the need for a coordinated public health response. Addressing the dual needs for innovation and discovery and for building state and local capacities may overcome current challenges in vector-borne disease prevention and control, but will require coordination across a national network of collaborators operating under a national strategy. Such an effort should reduce the impact of emerging vectors and could reverse the increasing trend of vector-borne disease incidence and associated morbidity and mortality.

The Need for a National Strategy to Address Vector-Borne Disease Threats in the United States

Vector-borne diseases (VBDs) cause significant morbidity and mortality each year in the United States. Over the last 14 yr, over 700,000 cases of diseases carried by ticks, mosquitoes, and fleas have been reported from U.S. states and territories to the Centers for Disease Control and Prevention. The number of reported cases has been increasing annually with two major trends: a steady increase in tick-borne diseases and increasing intermittent outbreaks of mosquito-borne arboviruses. The factors that are driving VBD introduction and emergence vary among diseases but are not likely to disappear, indicating that current trends will continue and probably worsen in the absence of effective prevention and control tools and implementation capacity. There are a number of challenges to preventing VBDs, including the lack of vaccines and effective vector control tools, insecticide resistance, and eroding technical capacities in public health entomology at federal, state, and local levels. For these reasons, a national strategy is needed to address VBD threats and to reverse the alarming trend in morbidity and mortality associated with these diseases.

Predictors of Receipt of School Services in a National Sample of Youth With ADHD

Objective: The objective of the study is to describe the extent to which students with ADHD received school-based intervention services and identify demographic, diagnostic, and impairment-related variables that are associated with service receipt in a large, nationally drawn sample. Method: Parent-reported data were obtained for 2,495 children with ADHD aged 4 to 17 years from the National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (NS-DATA). Results: The majority (69.3%) of students with ADHD currently receive one or more school services. Educational support (62.3%) was nearly twice as prevalent as classroom behavior management (32.0%). More than 3 times as many students with ADHD had an individualized education program (IEP; 42.9%) as a Section 504 plan (13.6%). Conclusion: At least one in five students with ADHD do not receive school services despite experiencing significant academic and social impairment, a gap that is particularly evident for adolescents and youth from non-English-speaking and/or lower income families.

Student-Perceived School Climate Is Associated With ADHD Medication Treatment Among Adolescents in Medicaid

OBJECTIVE

The objective of this study was to evaluate the relationship between school climate and ADHD medication treatment among adolescents in Medicaid in Georgia.

METHOD

School climate and Medicaid claims data were aggregated for 159 GA counties. County-level school climate percentile and medicated ADHD prevalence were calculated. The t tests and regression models evaluated the relationship between school climate, medicated ADHD, and demographics, weighted by county population. Poorer 2008 school climate (<25th percentile) was regressed on 2011 medicated ADHD prevalence, controlling for potential confounders.

RESULTS

The prevalence of medicated ADHD was 7.8% among Medicaid-enrolled GA adolescents. The average county-level prevalence of medicated ADHD was 10.0% ( SD = 2.9%). Poorer school climate was associated with lower rates of medicated ADHD ( p < .0001); along with demographics, these factors accounted for 50% of the county variation in medicated ADHD.

CONCLUSION

School climate is associated with medicated ADHD among adolescents in Medicaid. Additional research may reveal whether high medicated ADHD may reflect a lack of access to non-pharmacological therapies in some communities.

Vital Signs: Trends in Reported Vectorborne Disease Cases - United States and Territories, 2004-2016

Introduction

Vectorborne diseases are major causes of death and illness worldwide. In the United States, the most common vectorborne pathogens are transmitted by ticks or mosquitoes, including those causing Lyme disease; Rocky Mountain spotted fever; and West Nile, dengue, and Zika virus diseases. This report examines trends in occurrence of nationally reportable vectorborne diseases during 2004–2016.

Methods

Data reported to the National Notifiable Diseases Surveillance System for 16 notifiable vectorborne diseases during 2004–2016 were analyzed; findings were tabulated by disease, vector type, location, and year.

Results

A total 642,602 cases were reported. The number of annual reports of tickborne bacterial and protozoan diseases more than doubled during this period, from >22,000 in 2004 to >48,000 in 2016. Lyme disease accounted for 82% of all tickborne disease reports during 2004–2016. The occurrence of mosquitoborne diseases was marked by virus epidemics. Transmission in Puerto Rico, the U.S. Virgin Islands, and American Samoa accounted for most reports of dengue, chikungunya, and Zika virus diseases; West Nile virus was endemic, and periodically epidemic, in the continental United States.

Conclusions and Implications for Public Health Practice

Vectorborne diseases are a large and growing public health problem in the United States, characterized by geographic specificity and frequent pathogen emergence and introduction. Differences in distribution and transmission dynamics of tickborne and mosquitoborne diseases are often rooted in biologic differences of the vectors. To effectively reduce transmission and respond to outbreaks will require major national improvement of surveillance, diagnostics, reporting, and vector control, as well as new tools, including vaccines.

A National Description of Treatment among United States Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To characterize lifetime and current rates of attention-deficit/hyperactivity disorder (ADHD) treatments among US children and adolescents with current ADHD and describe the association of these treatments with demographic and clinical factors.

STUDY DESIGN

Data are from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome, a follow-back survey of parents from the 2011-2012 National Survey of Children's Health. Weighted analyses focused on receipt of ADHD treatment among children aged 4-17 years with current ADHD (n = 2495) by 4 treatment types: medication, school supports, psychosocial interventions, and alternative treatments.

RESULTS

Medication and school supports were the most common treatments received, with two-thirds of children and adolescents with ADHD currently receiving each treatment. Social skills training was the most common psychosocial treatment ever received (39%), followed by parent training (31%), peer intervention (30%), and cognitive behavioral therapy (20%). Among alternative treatments, 9% were currently taking dietary supplements, and 11% had ever received neurofeedback. Most children (67%) had received at least 2 of the following: current medication treatment, current school supports, or lifetime psychosocial treatment; 7% had received none of these 3 treatment types.

CONCLUSIONS

A majority of school-aged children and adolescents with ADHD received medication treatment and school supports, whereas fewer received recommended psychosocial interventions. Efforts to increase access to psychosocial treatments may help close gaps in service use by groups currently less likely to receive treatment, which is important to ensure that the millions of school-aged US children diagnosed with ADHD receive quality treatment.

Medicaid Prior Authorization Policies for Medication Treatment of Attention-Deficit/Hyperactivity Disorder in Young Children, United States, 2015

OBJECTIVES

In 2011, the American Academy of Pediatrics updated its guidelines for the diagnosis and treatment of children with attention-deficit/hyperactivity disorder (ADHD) to recommend that clinicians refer parents of preschoolers (aged 4-5) for training in behavior therapy and subsequently treat with medication if behavior therapy fails to sufficiently improve functioning. Data available from just before the release of the guidelines suggest that fewer than half of preschoolers with ADHD received behavior therapy and about half received medication. About half of those who received medication also received behavior therapy. Prior authorization policies for ADHD medication may guide physicians toward recommended behavior therapy. Characterizing existing prior authorization policies is an important step toward evaluating the impact of these policies on treatment patterns. We inventoried existing prior authorization policies and characterized policy components to inform future evaluation efforts.

METHODS

A 50-state legal assessment characterized ADHD prior authorization policies in state Medicaid programs. We designed a database to capture data on policy characteristics and authorization criteria, including data on age restrictions and fail-first behavior therapy requirements.

RESULTS

In 2015, 27 states had Medicaid policies that prevented approval of pediatric ADHD medication payment without additional provider involvement. Seven states required that prescribers indicate whether nonmedication treatments were considered before Medicaid payment for ADHD medication could be approved.

CONCLUSION

Medicaid policies on ADHD medication treatment are diverse; some policies are tied to the diagnosis and treatment guidelines of the American Academy of Pediatrics. Evaluations are needed to determine if certain policy interventions guide families toward the use of behavior therapy as the first-line ADHD treatment for young children.

Treated Prevalence of Attention-Deficit/Hyperactivity Disorder Increased from 2009 to 2015 Among School-Aged Children and Adolescents in the United States

OBJECTIVES

The purpose of this brief is to describe changes in the treated prevalence of medically managed attention-deficit/hyperactivity disorder (ADHD) among insured school-aged children and adolescents in the United States from 2009 to 2015. We examine the differences between those with employer-sponsored insurance (ESI) and with Medicaid insurance.

METHODS

We utilized two large longitudinal administrative datasets containing medical and drug claims data on individuals with ESI and Medicaid insurance from Truven Health MarketScan^® Administrative Claims Databases. Treated prevalence was measured as the percentage of school-aged children and adolescents enrolled in a calendar year who met the criteria for medically managed ADHD in the same calendar year. Subjects were eligible for inclusion if they were aged 6-17 years and were continuously enrolled during a calendar year.

RESULTS

The annual prevalence of treated ADHD among school-aged children and adolescents with ESI increased from 4.5% in 2009 to 6.7% in 2015. Among those with Medicaid it increased from 11.3% in 2009 to 13.3% in 2012, and fell after 2012, remaining steady from 2013 through 2015.

CONCLUSION

Treated prevalence of ADHD increased continuously over time among school-aged children and adolescents with ESI, but declined slightly after 2012 among those in the Medicaid sample.

A National Profile of Attention-Deficit Hyperactivity Disorder Diagnosis and Treatment Among US Children Aged 2 to 5 Years

OBJECTIVE

Clinical guidelines provide recommendations for diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD), with specific guidance on caring for children younger than 6 years. This exploratory study describes ADHD diagnosis and treatment patterns among young children in the United States using 2 nationally representative parent surveys.

METHODS

The National Survey of Children's Health (2007-2008, 2011-2012) was used to produce weighted prevalence estimates of current ADHD and ADHD medication treatment among US children aged 2 to 5 years. The National Survey of Children with Special Health Care Needs (2009-2010) provided additional estimates on types of medication treatment and receipt of behavioral treatment among young children with special health care needs (CSHCN) with ADHD.

RESULTS

In 2011 to 2012, 1.5% of young children (approximately 237,000) had current ADHD compared to 1.0% in 2007 to 2008. In 2011 to 2012, 43.7% of young children with current ADHD were taking medication for ADHD (approximately 104,000). In young CSHCN with ADHD, central nervous system stimulants were the most common medication type used to treat ADHD, and 52.8% of young CSHCN with current ADHD had received behavioral treatment for ADHD in the past year.

CONCLUSION

Nearly a quarter million In young CSHCN have current ADHD, with a prevalence that has increased by 57% from 2007 to 2008 to 2011 to 2012. The demographic patterns of diagnosis and treatment described in this study can serve as a benchmark to monitor service use patterns of young children diagnosed with ADHD over time.

Interpreting the Prevalence of Mental Disorders in Children: Tribulation and Triangulation

Knowledge on the prevalence of mental disorders among children informs the work of many health care providers, public health researchers, educators, and policy makers, and any single data source and study methodology can provide valuable insight. However, it is only after prevalence estimates from complementary studies are considered together that distinctions can be made to more deeply inform an assessment of community needs, including diagnosed prevalence versus underlying prevalence, differences between insured and uninsured populations, and how estimates change over time. National surveys, community-based studies, and administrative claims data each provide a different type of information that builds broad understanding. This article presents some of the overarching complexities of the issue, discusses strengths and weaknesses of some common data sources and methodologies used to generate epidemiological estimates, and describes ways in which these data sources complement one another and contribute to a better understanding of the prevalence of pediatric mental disorders.

Racial and Ethnic Disparities in ADHD Diagnosis and Treatment

OBJECTIVES

We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities were more likely due to underdiagnosis or undertreatment of African-American and Latino children, or overdiagnosis or overtreatment of white children.

METHODS

We used a population-based, multisite sample of 4297 children and parents surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression examined disparities in parent-reported ADHD diagnosis and medication use in the following analyses: (1) using the total sample; (2) limited to children with an ADHD diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms.

RESULTS

Across all waves, African-American and Latino children, compared with white children, had lower odds of having an ADHD diagnosis and of taking ADHD medication, controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental health symptoms. Among children with an ADHD diagnosis or symptoms, African-American children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino children had lower odds at fifth and 10th grades. Among children who had neither ADHD symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted analysis.

CONCLUSIONS

Racial/ethnic disparities in parent-reported medication use for ADHD are robust, persisting from fifth grade to 10th grade. These findings suggest that disparities may be more likely related to underdiagnosis and undertreatment of African-American and Latino children as opposed to overdiagnosis or overtreatment of white children.

Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among Insured Children Aged 2-5 Years - United States, 2008-2014

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is associated with adverse outcomes and elevated societal costs. The American Academy of Pediatrics (AAP) 2011 guidelines recommend "behavior therapy" over medication as first-line treatment for children aged 4-5 years with ADHD; these recommendations are consistent with current guidelines from the American Academy of Child and Adolescent Psychiatry for younger children. CDC analyzed claims data to assess national and state-level ADHD treatment patterns among young children.

METHODS

CDC compared Medicaid and employer-sponsored insurance (ESI) claims for "psychological services" (the procedure code category that includes behavior therapy) and ADHD medication among children aged 2-5 years receiving clinical care for ADHD, using the MarketScan commercial database (2008-2014) and Medicaid (2008-2011) data. Among children with ESI, ADHD indicators were compared during periods preceding and following the 2011 AAP guidelines.

RESULTS

In both Medicaid and ESI populations, the percentage of children aged 2-5 years receiving clinical care for ADHD increased over time; however, during 2008-2011, the percentage of Medicaid beneficiaries receiving clinical care was double that of ESI beneficiaries. Although state percentages varied, overall nationally no more than 55% of children with ADHD received psychological services annually, regardless of insurance type, whereas approximately three fourths received medication. Among children with ESI, the percentage receiving psychological services following release of the guidelines decreased significantly by 5%, from 44% in 2011 to 42% in 2014; the change in medication treatment rates (77% in 2011 compared with 76% in 2014) was not significant.

CONCLUSIONS AND COMMENTS

Among insured children aged 2-5 years receiving clinical care for ADHD, medication treatment was more common than receipt of recommended first-line treatment with psychological services. Among children with ADHD who had ESI, receipt of psychological services did not increase after release of the 2011 guidelines. Scaling up evidence-based behavior therapy might lead to increased delivery of effective ADHD management without the side effects of ADHD medications.

Persistence of Parent-Reported ADHD Symptoms From Childhood Through Adolescence in a Community Sample

OBJECTIVE

To examine ADHD symptom persistence and factors associated with elevated symptom counts in a diverse, longitudinal community-based sample.

METHOD

Parents reported demographics and completed a diagnostic interview repeatedly over a 6-year period. At Time 1, 481 interviews were completed about children (5-13 years); all participants were invited to four annual follow-up interviews, and 379 (79%) completed at least one. Inattentive (IA) and hyperactive-impulsive (HI) symptom counts were modeled with logistic quantile regression, while accounting for study design complexities.

RESULTS

The prevalence of seven IA symptoms remained stable from early childhood through late adolescence. The prevalence of eight HI symptoms decreased by more than half over time. After demographic adjustment, the upper quartile of HI symptom counts decreased with age (p < .01). High HI symptom counts persisted more among those with high IA symptom counts (p = .05).

CONCLUSION

This study further characterizes and provides insights into ADHD symptom trajectory through adolescence.

Diagnostic Experiences of Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

This report describes the diagnostic experiences of a sample of children in the United States diagnosed with attention-deficit/hyperactivity disorder (ADHD) as of 2011–2012.

DATA SOURCES

Data were drawn from the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome, a follow-up to the 2011–2012 National Survey of Children’s Health.

RESULTS

The median age at which children with ADHD were first diagnosed with the disorder was 7 years; one-third were diagnosed before age 6. Children with ADHD were diagnosed by a wide variety of health care providers, including primary care physicians and specialists. Regardless of age at diagnosis, the majority of children (53.1%) were first diagnosed by primary care physicians. Notable differences were found by age at diagnosis for two types of specialists. Children diagnosed before age 6 were more likely to have been diagnosed by a psychiatrist, and those diagnosed at ages 6 and over were more likely to have been diagnosed by a psychologist. Among children diagnosed with ADHD, the initial concern about a child’s behavior was most commonly expressed by a family member (64.7%), but someone from school or daycare first expressed concern for about one-third of children later diagnosed with ADHD (30.1%). For approximately one out of five children (18.1%), only family members provided information to the child’s doctor during the ADHD assessment.

The association between youth violence exposure and attention-deficit/hyperactivity disorder (ADHD) symptoms in a sample of fifth-graders

The purpose of the current study was to examine the association between violence exposures (no exposure, witness or victim only, and both witness and victim) and attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as the potential moderating role of gender. Data from 4,745 5th graders and their primary caregivers were drawn from the Healthy Passages study of adolescent health. Parent respondents completed the DISC Predictive Scales for ADHD, and youth provided information about exposure to violence. Results indicated that youth who reported both witnessing and victimization had more parent-reported ADHD symptoms and were more likely to meet predictive criteria for ADHD. Among those with both exposures, girls exhibited a steeper increase in ADHD symptoms and higher probability of meeting predictive criteria than did boys. Findings indicate that being both victim-of and witness-to violence is significantly associated with ADHD symptoms particularly among girls.

Cost-effectiveness of Legacy for Children™ for Reducing Behavioral Problems and Risk for ADHD among Children Living in Poverty

This paper describes the programmatic costs required for implementation of the Legacy for Children™ (Legacy) program at two sites (Miami and Los Angeles) and enumerate the cost-effectiveness of the program. Legacy provided group-based parenting intervention for mothers and children living in poverty. This cost-effectiveness analysis included two behavioral outcomes, behavioral problems, and attention-deficit/hyperactivity disorder (ADHD), and programmatic costs collected prospectively (2008 US$). Incremental costs, effects, the incremental cost-effectiveness ratio (ICER), and cost-effectiveness acceptability curves were estimated for the intervention groups relative to a comparison group with a 5 year analytic horizon. The intervention costs per family for Miami and Los Angeles were $16,900 and $14,100, respectively. For behavioral problems, the incremental effects were marginally significant (p=0.11) for Miami with an ICER of $178,000 per child at high risk for severe behavioral problems avoided. For ADHD, the incremental effects were significant (p=0.03) for Los Angeles with an ICER of $91,100 per child at high risk for ADHD avoided. Legacy was related to improvements in behavioral outcomes within two community-drawn sites and the costs and effects are reasonable considering the associated economic costs.

The impact of case definition on attention-deficit/hyperactivity disorder prevalence estimates in community-based samples of school-aged children

OBJECTIVE

To determine the impact of varying attention-deficit/hyperactivity disorder (ADHD) diagnostic criteria, including new DSM-5 criteria, on prevalence estimates.

METHOD

Parent and teacher reports identified high- and low-screen children with ADHD from elementary schools in 2 states that produced a diverse overall sample. The parent interview stage included the Diagnostic Interview Schedule for Children-IV (DISC-IV), and up to 4 additional follow-up interviews. Weighted prevalence estimates, accounting for complex sampling, quantified the impact of varying ADHD criteria using baseline and the final follow-up interview data.

RESULTS

At baseline 1,060 caregivers were interviewed; 656 had at least 1 follow-up interview. Teachers and parents reported 6 or more ADHD symptoms for 20.5% (95% CI = 18.1%-23.2%) and 29.8% (CI = 24.5%-35.6%) of children respectively, with criteria for impairment and onset by age 7 years (DSM-IV) reducing these proportions to 16.3% (CI = 14.7%-18.0%) and 17.5% (CI = 13.3%-22.8%); requiring at least 4 teacher-reported symptoms reduced the parent-reported prevalence to 8.9% (CI = 7.4%-10.6%). Revising age of onset to 12 years per DSM-5 increased the 8.9% estimate to 11.3% (CI = 9.5%-13.3%), with a similar increase seen at follow-up: 8.2% with age 7 onset (CI = 5.9%-11.2%) versus 13.0% (CI = 7.6%-21.4%) with onset by age 12. Reducing the number of symptoms required for those aged 17 and older increased the overall estimate to 13.1% (CI = 7.7%-21.5%).

CONCLUSION

These findings quantify the impact on prevalence estimates of varying case definition criteria for ADHD. Further research of impairment ratings and data from multiple informants is required to better inform clinicians conducting diagnostic assessments. DSM-5 changes in age of onset and number of symptoms required for older adolescents appear to increase prevalence estimates, although the full impact is uncertain due to the age of our sample.

The prevalence of ADHD: its diagnosis and treatment in four school districts across two states

OBJECTIVE

To describe the epidemiology of ADHD in communities using a DSM-IVTR case definition.

METHOD

This community-based study used multiple informants to develop and apply a DSM -IVTR-based case definition of ADHD to screening and diagnostic interview data collected for children 5-13 years of age. Teachers screened 10,427 children (66.4%) in four school districts across two states (SC and OK). ADHD ratings by teachers and parent reports of diagnosis and medication treatment were used to stratify children into high and low risk for ADHD. Parents (n = 855) of high risk and gender frequency-matched low risk children completed structured diagnostic interviews. The case definition was applied to generate community prevalence estimates, weighted to reflect the complex sampling design.

RESULTS

ADHD prevalence was 8.7% in SC and 10.6% in OK. The prevalence of ADHD medication use was 10.1% (SC) and 7.4% (OK). Of those medicated, 39.5% (SC) and 28.3% (OK) met the case definition. Comparison children taking medication had higher mean symptom counts than other comparison children.

CONCLUSIONS

Our ADHD estimates are at the upper end of those from previous studies. The identification of a large proportion of comparison children taking ADHD medication suggests that our estimates may be conservative; these children were not included as cases in the case definition, although some might be effectively treated.

A national profile of Tourette syndrome, 2011-2012

OBJECTIVE

To provide recent estimates of the prevalence of Tourette syndrome among a nationally representative sample of US children and to describe the association of Tourette syndrome with indicators of health and functioning.

METHODS

Data on 65,540 US children aged 6 to 17 years from the 2011-2012 National Survey of Children's Health were analyzed. Parents reported whether a health care provider had ever told them their child had Tourette syndrome or other neurobehavioral or chronic health conditions and whether their child had current Tourette syndrome.

RESULTS

Based on parents' report, 0.19% of US children had Tourette syndrome; the average age of diagnosis was 8.1 years. Children with Tourette syndrome, compared with those without, were more likely to have co-occurring neurobehavioral and other health conditions, meet criteria for designation as having a special health care need, receive mental health treatment, have unmet mental health care needs, and have parents with high parenting aggravation and parents who were contacted about school problems; they were less likely to receive effective care coordination or have a medical home. After controlling for co-occurring neurobehavioral conditions, the findings on parents being contacted about school problems and children having unmet mental health care needs were no longer significant.

CONCLUSIONS

Tourette syndrome is characterized by co-occurring neurobehavioral and other health conditions, and poorer health, education, and family relationships. The findings support previous recommendations to consider co-occurring conditions in the diagnosis and treatment of Tourette syndrome. Future research may explore whether having a medical home improves outcomes among children with Tourette syndrome.

Vital signs: disability and physical activity--United States, 2009-2012

BACKGROUND

Adults with disabilities are less active and have higher rates of chronic disease than the general population. Given the health benefits of physical activity, understanding physical activity, its relationship with chronic disease, and health professional recommendations for physical activity among young to middle-age adults with disabilities could help increase the effectiveness of health promotion efforts.

METHODS

Data from the 2009-2012 National Health Interview Survey (NHIS) were used to estimate the prevalence of, and association between, aerobic physical activity (inactive, insufficiently active, or active) and chronic diseases (heart disease, stroke, diabetes, and cancer) among adults aged 18-64 years by disability status and type (hearing, vision, cognitive, and mobility). The prevalence of, and association between, receiving a health professional recommendation for physical activity and level of aerobic physical activity was assessed using 2010 data.

RESULTS

Overall, 11.6% of U.S. adults aged 18-64 years reported a disability, with estimates for disability type ranging from 1.7% (vision) to 5.8% (mobility). Compared with adults without disabilities, inactivity was more prevalent among adults with any disability (47.1% versus 26.1%) and for adults with each type of disability. Inactive adults with disabilities were 50% more likely to report one or more chronic diseases than those who were physically active. Approximately 44% of adults with disabilities received a recommendation from a health professional for physical activity in the past 12 months.

CONCLUSIONS

Almost half of adults with disabilities are physically inactive and are more likely to have a chronic disease. Among adults with disabilities who visited a health professional in the past 12 months, the majority (56%) did not receive a recommendation for physical activity.

IMPLICATIONS FOR PUBLIC HEALTH

These data highlight the need for increased physical activity among persons with disabilities, which might require support across societal sectors, including government and health care.

Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011

OBJECTIVE

Data from the 2003 and 2007 National Survey of Children's Health (NSCH) reflect the increasing prevalence of parent-reported attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment by health care providers. This report updates these prevalence estimates for 2011 and describes temporal trends.

METHOD

Weighted analyses were conducted with 2011 NSCH data to estimate prevalence of parent-reported ADHD diagnosis, current ADHD, current medication treatment, ADHD severity, and mean age of diagnosis for U.S. children/adolescents aged 4 to 17 years and among demographic subgroups. A history of ADHD diagnosis (2003-2011), as well as current ADHD and medication treatment prevalence (2007-2011), were compared using prevalence ratios and 95% confidence intervals.

RESULTS

In 2011, 11% of children/adolescents aged 4 to 17 years had ever received an ADHD diagnosis (6.4 million children). Among those with a history of ADHD diagnosis, 83% were reported as currently having ADHD (8.8%); 69% of children with current ADHD were taking medication for ADHD (6.1%, 3.5 million children). A parent-reported history of ADHD increased by 42% from 2003 to 2011. Prevalence of a history of ADHD, current ADHD, medicated ADHD, and moderate/severe ADHD increased significantly from 2007 estimates. Prevalence of medicated ADHD increased by 28% from 2007 to 2011.

CONCLUSIONS

Approximately 2 million more U.S. children/adolescents aged 4 to 17 years had been diagnosed with ADHD in 2011, compared to 2003. More than two-thirds of those with current ADHD were taking medication for treatment in 2011. This suggests an increasing burden of ADHD on the U.S. health care system. Efforts to further understand ADHD diagnostic and treatment patterns are warranted.

Health care needs of children with Tourette syndrome

To document the impact of Tourette syndrome on the health care needs of children and access to health care among youth with Tourette syndrome, parent-reported data from the 2007-2008 National Survey of Children's Health were analyzed. Children with Tourette syndrome had more co-occurring mental disorders than children with asthma or children without Tourette syndrome or asthma and had health care needs that were equal to or greater than children with asthma (no Tourette syndrome) or children with neither asthma nor Tourette syndrome. Health care needs were greatest among children with Tourette syndrome and co-occurring mental disorders, and these children were least likely to receive effective care coordination. Addressing co-occurring conditions may improve the health and well-being of children with Tourette syndrome. Strategies such as integration of behavioral health and primary care may be needed to improve care coordination.

State-based and demographic variation in parent-reported medication rates for attention-deficit/hyperactivity disorder, 2007-2008

Medication is the most effective treatment of attention-deficit/hyperactivity disorder (ADHD), a common neurobehavioral disorder of childhood. We used data from the 2007-2008 National Survey of Children’s Health to calculate weighted estimates of parent-reported ADHD and medication treatment among US children aged 4 to 17 years, by state and sex-stratified age. State-based rates of ADHD medication treatment ranged from 33% in Nevada to 79% in Mississippi; rates of medicated ADHD were higher among boys than girls at every age. State-based investigations of ADHD medication treatment factors are needed, and our findings may inform these public health efforts.

Mental health surveillance among children--United States, 2005-2011

Mental disorders among children are described as "serious deviations from expected cognitive, social, and emotional development" (US Department of Health and Human Services Health Resources and Services Administration, Maternal and Child Health Bureau. Mental health: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, and National Institutes of Health, National Institute of Mental Health; 1999). These disorders are an important public health issue in the United States because of their prevalence, early onset, and impact on the child, family, and community, with an estimated total annual cost of $247 billion. A total of 13%-20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994-2011 has shown the prevalence of these conditions to be increasing. Suicide, which can result from the interaction of mental disorders and other factors, was the second leading cause of death among children aged 12-17 years in 2010. Surveillance efforts are critical for documenting the impact of mental disorders and for informing policy, prevention, and resource allocation. This report summarizes information about ongoing federal surveillance systems that can provide estimates of the prevalence of mental disorders and indicators of mental health among children living in the United States, presents estimates of childhood mental disorders and indicators from these systems during 2005-2011, explains limitations, and identifies gaps in information while presenting strategies to bridge those gaps.

Behavioral and socioemotional outcomes through age 5 years of the legacy for children public health approach to improving developmental outcomes among children born into poverty

OBJECTIVES

We evaluated Legacy for Children, a public health strategy to improve child health and development among low-income families.

METHODS

Mothers were recruited prenatally or at the birth of a child to participate in Legacy parenting groups for 3 to 5 years. A set of 2 randomized trials in Miami, Florida, and Los Angeles, California, between 2001 and 2009 assessed 574 mother-child pairs when the children were 6, 12, 24, 36, 48, and 60 months old. Intent-to-treat analyses from 12 to 60 months compared groups on child behavioral and socioemotional outcomes.

RESULTS

Children of mothers in the intervention group were at lower risk for behavioral concerns at 24 months and socioemotional problems at 48 months in Miami, and lower risk for hyperactive behavior at 60 months in Los Angeles. Longitudinal analyses indicated that children of intervention mothers in Miami were at lower risk for behavior problems from 24 to 60 months of age.

CONCLUSIONS

Randomized controlled trials documented effectiveness of the Legacy model over time while allowing for implementation adaptations by 2 different sites. Broadly disseminable, parent-focused prevention models such as Legacy have potential for public health impact. These investments in prevention might reduce the need for later intervention strategies.

Tourette syndrome, parenting aggravation, and the contribution of co-occurring conditions among a nationally representative sample

BACKGROUND

Previous research suggests that parents of a child with Tourette Syndrome (TS) have lower self-concepts, higher caregiver burden, and more difficulties with home activities. However, the contributions of TS and mental, emotional, or behavioral (MEB) conditions to family functioning are difficult to identify from previous research due to relatively small TS sample sizes and high rates of co-occurring conditions within samples of children with TS.

OBJECTIVE

The current study hypothesized that families of children with TS would report significantly more family functioning difficulties (more parenting aggravation, more difficulty with coping with the child's care, less parent-child communication, and less consistent family routines). Specifically, co-occurring conditions would contribute substantially to reported parenting aggravation.

METHOD

Parent-reported data from the 2007 National Survey of Children's Health were analyzed, including whether the child had been diagnosed with TS or an MEB. Weighted analyses were restricted to US children 6-17 years of age (n = 64,034) and adjusted for child age, sex, race and ethnicity.

RESULTS

Parents of children with TS were more likely to fall into the high parenting aggravation index category compared with parents of children without TS (aPR = 3.8, 95% CI: 2.2-6.6). Controlling for the co-occurring MEB conditions attenuated the relations between TS and parenting aggravation; however, a significant effect for TS remained in some cases.

CONCLUSION

Parents of children with TS may face significant challenges in raising their children, leading to increased parenting aggravation; these challenges appear to be primarily associated with the presence of co-occurring MEB conditions.

Legacy for ChildrenTM: a pair of randomized controlled trials of a public health model to improve developmental outcomes among children in poverty

Background

One in five Americans under age 18 lives in a family below the Federal poverty threshold. These more than 15 million children are at increased risk of a wide variety of adverse long-term health and developmental outcomes. The early years of life are critical to short- and long-term health and well-being. The Legacy for Children^TM model was developed in response to this need and marries the perspectives of epidemiology and public health to developmental psychology theory in order to better address the needs of children at environmental risk for poor developmental outcomes.

Methods/design

The Legacy for Children^TM group-based parenting intervention model was evaluated as a pair of randomized controlled trials among low-income families in Miami and Los Angeles. The study was designed to allow for site-stratified analysis in order to evaluate each model implementation separately. Evaluation domains include comprehensive assessments of family, maternal, and child characteristics, process outcomes, and prospective programmatic cost. Data collection began prenatally or at birth and continues into school-age.

Discussion

The societal costs of poor developmental outcomes are substantial. A concerted effort from multiple sectors and disciplines, including public health, is necessary to address these societal concerns. Legacy uses a public health model to engage parents and promote overall child well-being in families in poverty through rigorous evaluation methodologies and evidence-based intervention strategies. This study collects rich and modular information on maternal and child outcomes, process, and cost that will enable a detailed understanding of how Legacy works, how it can be refined and improved, and how it can be translated and disseminated. Taken together, these results will inform public policy and help to address issues of health disparities among at-risk populations.

Trial registration

NCT00164697

Pediatric primary care physicians' practices regarding newborn hearing screening

OBJECTIVE

Approximately 2 to 3 out of 1000 infants are born with hearing loss in the United States each year. Pediatric primary care physicians (PCPs) can play an important role in ensuring that infants with hearing loss are identified early and provided appropriate services. In this study, pediatric PCPs were surveyed about their practices regarding early hearing detection and intervention.

METHODS

Responses from the 2008 DocStyles survey were used to examine patient, physician, and practice variables associated with actions consistent with the 2007 Joint Committee on Infant Hearing position statement, which includes follow-up protocols for medical home providers.

RESULTS

Pediatricians working in a group setting were more likely to receive hearing screening results than were those in individual practices or hospitals and clinics. Family/general physicians with heavier caseloads were more likely to receive hearing screening results for their pediatric patients than were those with lighter caseloads. Few pediatric PCPs reported contacting their state's early hearing detection and intervention program if they knew that an infant failed the newborn hearing screening. Although high proportions of pediatric PCPs reported referring an infant with hearing loss to an otolaryngologist, only about half reported referring a child with risk factors for hearing loss for audiological and speech-language assessment, even if the parents expressed concern or if the results of a developmental screening indicated a possible delay. Few respondents reported referring an infant with hearing loss under their care to an ophthalmologist.

CONCLUSIONS

This study highlights the need to improve infrastructure for pediatric PCPs to receive and request infant hearing screening results to facilitate reporting and coordinate follow-up services for infants identified with hearing loss.

Concurrent medical conditions and health care use and needs among children with learning and behavioral developmental disabilities, National Health Interview Survey, 2006-2010

Studies document various associated health risks for children with developmental disabilities (DDs). Further study is needed by disability type. Using the 2006-2010 National Health Interview Surveys, we assessed the prevalence of numerous medical conditions (e.g. asthma, frequent diarrhea/colitis, seizures), health care use measures (e.g. seeing a medical specialist and >9 office visits in past year), health impact measures (e.g. needing help with personal care), and selected indicators of unmet health needs (e.g. unable to afford needed prescription medications) among a nationally representative sample of children ages 3-17 years, with and without DDs. Children in four mutually exclusive developmental disability groups: autism (N = 375), intellectual disability (ID) without autism (N = 238); attention-deficit/hyperactivity disorder (ADHD) without autism or ID (N = 2901); and learning disability (LD) or other developmental delay without ADHD, autism, or ID (N = 1955); were compared to children without DDs (N = 35,775) on each condition or health care measure of interest. Adjusted odds ratios (aORs) were calculated from weighted logistic regression models that accounted for the complex sample design. Prevalence estimates for most medical conditions examined were moderately to markedly higher for children in all four DD groups than children without DDs. Most differences were statistically significant after adjustment for child sex, age, race/ethnicity, and maternal education. Children in all DD groups also had significantly higher estimates for health care use, impact, and unmet needs measures than children without DDs. This study provides empirical evidence that children with DDs require increased pediatric and specialist services, both for their core functional deficits and concurrent medical conditions.

Association between parental nativity and autism spectrum disorder among US-born non-Hispanic white and Hispanic children, 2007 National Survey of Children's Health

BACKGROUND

Limited studies suggest the prevalence of autism spectrum disorders (ASD) varies by whether maternal and child birth country are discordant.

OBJECTIVE/HYPOTHESIS

We explored associations between ASD and maternal and paternal nativity in a sample of US-born non-Hispanic white (NHW, n = 37,265) and US-born Hispanic (n = 4,690) children in the 2007 National Survey of Children's Health (NSCH).

METHODS

We assessed ASD prevalence within race-ethnicity and parental nativity subgroups. Prevalence ratios (aPR), comparing each group to NHW children with 2 US-born parents, were adjusted for child age, sex, and receipt of care in a medical home. Estimates were weighted to reflect US noninstitutionalized children. Standard errors were adjusted to account for the complex sample design.

RESULTS

In NHW children with 2 US-born parents, ASD prevalence was 1.19%; estimates were similar for NHW children with a foreign-born mother or father. There was a striking heterogeneity between Hispanic children with 2 US-born versus 2 foreign-born parents (ASD prevalence 2.39% versus 0.31%, p = .05). Even after adjustment, PRs comparing ASD prevalence in Hispanic versus NHW children were vastly different for Hispanic subgroups, suggesting a substantially lower prevalence for Hispanic children with both parents foreign-born (aPR 0.2, 95% confidence interval 0.1-0.5) and a higher prevalence for Hispanic children with both parents US-born (aPR 2.0 [0.8-4.6]).

CONCLUSIONS

Previous studies comparing ASD prevalence between NHW and Hispanic children based on a composite Hispanic grouping without consideration of parental nativity likely missed important differences between these racial-ethnic groups. Continuing efforts toward improving early identification in Hispanic children are needed.

Association of externalizing behavior disorder symptoms and injury among fifth graders

OBJECTIVE

Injury is the leading cause of death among American youth, killing more 11-year-olds than all other causes combined. Children with symptoms of externalizing behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) may have increased risk. Our aims were to determine: (1) whether increasing symptoms of ADHD and CD associate positively with injuries among a community sample of fifth graders; and (2) whether symptoms of ADHD and CD have a multiplicative rather than additive association with injuries among the sample.

METHODS

Data were collected from 4745 fifth graders and their primary caregivers participating in Healthy Passages, a multisite, community-based study of pediatric health risk behaviors and health outcomes. The primary outcome was injury frequency. Primary independent variables were ADHD and CD symptoms. Additional covariates included gender, race/ethnicity, and household income. Ordinal logistic regression examined correlates of injury frequency. The interaction between ADHD and CD symptoms also was examined.

RESULTS

In bivariate analyses, the odds of injury increased as ADHD symptoms (odds ratio [OR] 1.29; 95% confidence interval [95% CI] 1.18-1.41) and CD symptoms (OR 1.18; 95% CI 1.07-1.31) increased. However, in multivariate analysis, only ADHD symptoms were significantly associated with injury (OR 1.22; 95% CI 1.10-1.35). There was no statistically significant interaction between ADHD and CD symptoms.

CONCLUSIONS

ADHD symptoms are associated with increased odds of injury in fifth graders. Findings have implications for potential injury prevention strategies for mental health practitioners (for example, cognitive training with at-risk youth), pediatricians (ADHD screening), and parents (improved supervision).

Unmet health care needs among CSHCN with neurologic conditions

OBJECTIVE

Children with neurologic conditions require a variety of services. With this study we examined health care needs and unmet needs among children with neurologic conditions.

METHODS

Cross-sectional data reported by parents of 3- to 17-year-olds in the 2005-2006 National Survey of Children With Special Health Care Needs were analyzed. Demographic characteristics, health care needs, and unmet needs of children with special health care needs (CSHCN) and neurologic conditions were descriptively compared with an independent referent group of children without special health care needs; statistical contrasts were performed as a function of the type (conditions included in the Diagnostic and Statistical Manual of Mental Disorders [DSM] or not) and number of reported neurologic conditions.

RESULTS

Compared with the parents of children without special health care needs, parents of CSHCN with neurologic conditions were more likely to report unmet health care needs for their child. After adjustment for demographic factors and severity of functional limitation, CSHCN with at least 2 conditions had more visits to a health care provider, needed more services, and reported more unmet needs than CSHCN with a single DSM condition. The magnitude of need among CSHCN was greatest among those with at least 1 of each type of neurologic condition.

CONCLUSIONS

Unmet health care needs exist among CSHCN with neurologic conditions and are particularly pronounced among children with a combination of both DSM and non-DSM disorders. The health care needs among CSHCN with multiple neurologic conditions may be better served by targeted efforts to improve care coordination.

Social support networks and maternal mental health and well-being

The link between social networks and mental health has increasingly been recognized by public health as an important topic of interest. In this paper, we explore this association among a specific group: mothers. Specifically, we discuss how maternal mental health can be understood in the context of social networks, the influence of specific social relationships, and how the type and quality of support can mediate maternal mental health outcomes. We review interventions that foster social networks to address maternal mental health as well as other related health outcomes. Findings suggest that interventions that combine multiple treatment approaches may be more effective in addressing mental health. Also, traditional measures of social networks may not be appropriate for vulnerable populations, with qualitative, rather than quantitative, indicators of social networks being more predictive of maternal health and well-being. The implications of these findings and future research directions are discussed.

The relationship between autism and parenting stress

OBJECTIVE

We assessed associations between parenting a child with autism and stress indicators.

METHODS

In the 2003 National Survey of Children's Health, parents or other knowledgeable adult respondents for children aged 4 to 17 years reported their recent feelings about their life sacrifices to care for their child, difficulty caring for their child, frustration with their child's actions, and anger toward their child. Responses were compiled in the Aggravation in Parenting Scale. Parents of children reported to have autism (N = 459) were compared with parents of: (1) children with special health care needs including emotional, developmental, or behavioral problems other than autism that necessitated treatment (children with other developmental problems [N = 4545]); (2) children with special health care needs without developmental problems (N = 11475); and (3) children without special health care needs (N = 61826). Weighted estimates are presented.

RESULTS

Parents of children with autism were more likely to score in the high aggravation range (55%) than parents of children with developmental problems other than autism (44%), parents of children with special health care needs without developmental problems (12%), and parents of children without special health care needs (11%). However, within the autism group, the proportion of parents with high aggravation was 66% for those whose child recently needed special services and 28% for those whose child did not. The parents of children with autism and recent special service needs were substantially more likely to have high aggravation than parents of children with recent special service needs in each of the 3 comparison groups. Conversely, parents of children with autism but without recent special service needs were not more likely to have high aggravation than parents of children with other developmental problems.

CONCLUSIONS

Parenting a child with autism with recent special service needs seems to be associated with unique stresses.

National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder

OBJECTIVE

In this study we identified child and family-level characteristics that were associated with medication treatment for attention-deficit/hyperactivity disorder using nationally representative survey data.

METHODS

National Survey of Children's Health data from 79264 youth 4 to 17 years of age were used. Data were weighted to adjust for the complex survey design of the National Survey of Children's Health. Gender-specific logistic regression models were generated to identify child and family-level characteristics that were collectively associated with current medication status among youth with a reported diagnosis of attention-deficit/hyperactivity disorder.

RESULTS

Nationally, 7.8% of youth aged 4 to 17 years had a reported attention-deficit/hyperactivity disorder diagnosis, and 4.3% had both a disorder diagnosis and were currently taking medication for the disorder. Current medication treatment among youth with attention-deficit/hyperactivity disorder was associated with white race, younger age, English spoken in the home, health care coverage, a health care contact within the last year, and reported psychological difficulties. Gender-specific logistic regression models revealed that, together, younger age, higher income, health care coverage, having psychological difficulties, and a health care contact in the past year were associated with medication use among boys with attention-deficit/hyperactivity disorder. Among girls with the disorder, younger age, psychological difficulties, fair-to-poor paternal mental health status, and a health care contact within the last year were collectively associated with current medication use. CONCLUSIONS. Regardless of gender, younger age, the presence of psychological difficulties, and a recent health care contact were significantly associated with medication treatment for attention-deficit/hyperactivity disorder. However, additional health care access and income variables among boys and paternal mental health status among girls represented gender-specific factors that were also associated with medication treatment for the disorder. Future studies should characterize how and when the burden associated with attention-deficit/hyperactivity disorder leads to treatment, support, or services for this prevalent and impairing neurobehavioral disorder.

Attention-deficit/hyperactivity disorder in school-aged children: association with maternal mental health and use of health care resources

OBJECTIVE

To investigate the association between the mental health status of mothers and attention-deficit/hyperactivity disorder (ADHD) in their school-aged children and to characterize the health care access and utilization of families affected by ADHD.

METHODS

Survey logistic regression procedures were used to investigate the association between activity-limiting mental health conditions in mothers and ADHD in their school-aged children using 1998 National Health Interview Survey data. A total of 9529 mother-child dyads were included in the final analysis.

RESULTS

The prevalence of ADHD among children aged 4 to 17 years was 6.3%. Survey logistic regression statistics revealed an association between an activity-limiting depression, anxiety, or emotional problem in mothers and ADHD in their children. This association persisted after controlling for the gender, age, and race of the child; household income (as a function of the 1997 poverty level); and type of family structure as reported by the mother (adjusted odds ratio [OR]: 4.2; 95% confidence interval [CI]: 2.2-8.1). Mothers of a child with ADHD were 13 times more likely to have consulted with a mental health professional about their child's health within the past year despite reporting an inability to afford prescription medications (OR: 3.3; 95% CI: 2.2-4.9) and mental health care (OR: 7.4; 95% CI: 4.6, 11.8) for the child.

CONCLUSIONS

Maternal mental health is significantly associated with the presence of ADHD in school-aged children. This finding further supports a link between maternal mental health and behavioral outcomes in children. Health care utilization and access findings support a family-oriented system of care.