ADHD: Insurance and Mental Health Service Use.

We describe mental health service use by insurance among children aged 4 to 17 with diagnosed attention-deficit/ hyperactivity disorder (ADHD). Using parent reports from 2010-2013 National Health Interview Survey, we estimate the percentage that received services for emotional and behavioral difficulties (EBD): medication, other nonmedication services, and none (neither medication nor other nonmedication services). Among children with diagnosed ADHD, 56.0% had used medication for EBD, 39.8% had contact with a mental health professional, 32.2% had contact with a general doctor about the child's EBD, and 20.4% received special education services for EBD. Medication use was more often reported for privately or publicly insured children than uninsured children ( P < .001), and uninsured children more often received no services ( P < .001). Publicly insured children were more likely than privately insured children to receive other nonmedication services ( P < .001). Less than a third (28.9%) of all children received no services as compared to almost half (48.8%) of uninsured children.

Reported Child Health Status, Hispanic Ethnicity, and Language of Interview: United States, 2011-2012.

OBJECTIVES: This report has three objectives: a) to describe the reported health status of four subgroups of school-age children: Hispanic children with a Spanish interview (Hispanic­Spanish interview), Hispanic children with an English interview (Hispanic­English interview), non-Hispanic black children, and non-Hispanic white children; b) to describe selected characteristics of children in the four subgroups; and c) to consider whether the characteristics of children account for subgroup variations in reported health status. DATA SOURCE AND METHODS: Data from the 2011­2012 National Survey of Children's Health were used to describe the health status of children aged 5­17 years using three categories: a) poor or fair, b) good, and c) very good or excellent health. The reported health status of children in the four subgroups was examined using multinomial logistic regression, controlling for the effects of demographic and socioeconomic characteristics and a measure of acculturation. RESULTS: Compared with children in the other subgroups, Hispanic­Spanish interview children were more likely to have reports of poor or fair health (10.6% compared with 1.8%­4.4%) and good health (39.7% compared with 7.7%­ 14.4%). Controlling for demographic and socioeconomic characteristics and a measure of acculturation eliminated the subgroup differences in poor or fair health, but not good health. Even after adjustment for confounders, Hispanic­Spanish interview children more often were reported to have good health rather than very good or excellent health compared with children in the other subgroups. CONCLUSIONS: Worse reported health status of Hispanic­Spanish interview children, compared with children in other subgroups, could not be explained completely by the confounders in the analysis. Additional research is needed to determine whether the worse reported health status of Hispanic children with Spanish interviews reflects the actual health conditions of these children or difficulties in translating the health status question.

Use of Mental Health Services by Children Ages Six to 11 With Emotional or Behavioral Difficulties.

OBJECTIVE: The authors reported use of mental health services among children in the United States between ages six and 11 who were described by their parents as having emotional or behavioral difficulties (EBDs). METHODS: Using data from the 2010-2012 National Health Interview Survey, the authors estimated the national percentage of children ages six to 11 with serious or minor EBDs (N=2,500) who received treatment for their difficulties, including only mental health services other than medication (psychosocial services), only medication, both psychosocial services and medication, and neither type of service. They calculated the percentage of children who received school-based and non-school-based psychosocial services in 2011-2012 and who had unmet need for psychosocial services in 2010-2012. RESULTS: In 2010-2012, 5.8% of U.S. children ages six to 11 had serious EBDs and 17.3% had minor EBDs. Among children with EBDs, 17.8% were receiving both medication and psychosocial services, 28.8% psychosocial services only, 6.8% medication only, and 46.6% neither medication nor psychosocial services. Among children with EBDs in 2011-2012, 18.6% received school-based psychosocial services only, 11.4% non-school-based psychosocial services only, and 17.3% both school- and non-school-based psychosocial services. In 2010-2012, 8.2% of children with EBDs had unmet need for psychosocial services. CONCLUSIONS: School-age children with EBDs received a range of mental health services, but nearly half received neither medication nor psychosocial services. School-based providers played a role in delivering psychosocial services, but parents reported an unmet need for psychosocial services among some children.

Trends in parent-reported emotional and behavioral problems among children using special education services.

OBJECTIVE: This report describes trends in health conditions reported by parents as the limitations leading to special education services for their children. METHODS: Data are reported for children ages 6-17 (N=182,998) surveyed in households in the 2001-2012 National Health Interview Survey. RESULTS: Between 2001 and 2012, the overall percentage of U.S. children ages 6-17 who were receiving special education services increased from 7.2% to 8.7%. Between 2001 and 2012, the leading causes of activity limitations among children receiving special education services included emotional or behavioral problems, which increased from 36% to 43%; speech problems, which increased from 16% to 22%; and learning disability, which decreased from 41% to 27%. There were no significant trends in any of the other conditions considered as possible sources of activity limitations. CONCLUSIONS: Emotional and behavioral problems have become the most frequently reported source of activity limitations among children receiving special education services.

Functional difficulties and school limitations of children with epilepsy: findings from the 2009-2010 National Survey of Children with Special Health Care Needs.

BACKGROUND: Epilepsy is a common serious neurologic disorder in children. However, most studies of children's functional difficulties and school limitations have used samples from tertiary care or other clinical settings. OBJECTIVE: To compare functional difficulties and school limitations of a national sample of US children with special health care needs (CSHCN) with and without epilepsy. METHODS: Data from the 2009-2010 National Survey of CSHCN for 31,897 children aged 6-17 years with and without epilepsy were analyzed for CSHCN in two groups: 1) CSHCN with selected comorbid conditions (intellectual disability, cerebral palsy, autism, or traumatic brain injury) and 2) CSHCN without these conditions. Functional difficulties and school limitations, adjusted for the effect of sociodemographic characteristics, were examined by epilepsy and comorbid conditions. RESULTS: Three percent of CSHCN had epilepsy. Among CSHCN with epilepsy 53% had comorbid conditions. Overall CSHCN with epilepsy, both with and without comorbid conditions, had more functional difficulties than CSHCN without epilepsy. For example, after adjustment for sociodemographic characteristics a higher percentage of children with epilepsy, compared to children without epilepsy, had difficulty with communication (with conditions: 53% vs. 37%, without conditions: 13% vs. 5%). Results for school limitations were similar. After adjustment, a higher percentage of children with epilepsy, compared to children without epilepsy, missed 11 + school days in the past year (with conditions: 36% vs. 18%, without conditions: 21% vs. 15%). CONCLUSION: CSHCN with epilepsy, compared to CSHCN without epilepsy, were more likely to have functional difficulties and limitations in school attendance regardless of comorbid conditions.

Use of selected nonmedication mental health services by adolescent boys and girls with serious emotional or behavioral difficulties: United States, 2010-2012.

Mental health is a key component of a child's overall wellbeing. Previous research using data from the National Health Interview Survey (NHIS) found that about 6% of adolescents have serious emotional or behavioral difficulties. Both medication and nonmedication services have been found to be effective for treatment. Two recent reports from the National Center for Health Statistics have presented estimates of medication use among U.S. adolescents. The use of prescription medication for emotional or behavioral difficulties was higher among boys than girls. This report describes differences between boys and girls in the use of nonmedication mental health services in various school and nonschool settings among adolescents aged 12-17 with serious emotional or behavioral difficulties.

The effect of special health care needs and health status on school functioning.

BACKGROUND: Past studies have shown that specific child conditions are associated with poor school outcomes. A national health survey with noncategorical measures of health and indicators of school functioning offers the opportunity to examine this association. OBJECTIVES: To compare links between two health measures (children with special health care needs and general health status) and multiple school outcomes. METHODS: The analysis was based on 59,440 children aged 6-17 years from the 2007 National Survey of Children's Health. Child health was assessed using the Children with Special Health Care Needs (CSHCN) screener and a question on general health status. CSHCN were classified by the complexity of their health care needs. Indicators of school functioning included special education use, many problem reports, repeated a grade, lack of school engagement, and many missed school days. RESULTS: Overall 22% of children were identified as CSHCN: 13% with more complex needs (C-CSHCN) and 9% with medication use only (CSHCN-RX). Approximately 17% of children were in less than optimal health. After controlling for a child's sociodemographic characteristics C-CSHCN had an increased risk of all of the negative school outcomes compared to children without SHCN, while CSHCN-RX had an increased risk of only one school outcome (many missed school days). Children in less than optimal health were at an increased risk of all negative school outcomes compared to children in optimal health. CONCLUSIONS: The CSHCN screener and health status question identify related, but distinct, groups of children with worse outcomes on the indicators of school functioning.

Identifying emotional and behavioral problems in children aged 4-17 years: United States, 2001-2007.

OBJECTIVES: This report examines two measures that identify children with emotional and behavioral problems: high scores based on questions in the brief version of the Strengths and Difficulties Questionnaire (SDQ) and a single question about serious (definite or severe) overall emotional and behavioral difficulties. Children were classified into four groups, those with: only high scores on the brief SDQ, only serious overall difficulties, both high scores on the brief SDQ and serious overall difficulties, and neither high scores on brief SDQ nor serious overall difficulties. Children's characteristics, conditions, and service use in these four groups were compared. METHODS: Data from the 2001-2007 National Health Interview Survey identified the emotional and behavioral problems, characteristics, conditions, and service use of children aged 4-17 years. RESULTS: Approximately 7% of children had either high scores on the brief SDQ or serious overall difficulties, with 2% having only high scores on the brief SDQ, 3% having only serious overall difficulties, and 2% having both high scores on the brief SDQ and serious overall difficulties. Characteristics of the three groups of children identified with emotional and behavioral problems differed from each other and from children without problems. Children in each of the groups with emotional and behavioral problems, compared with children without problems, were more likely to have developmental conditions and to have used services. Additionally, children with serious overall difficulties (either with or without high scores on the brief SDQ) were more likely to have developmental conditions, receive special education, and use mental health services than children with only high scores on the brief SDQ.

The association between major depressive disorder and obesity in US adolescents: results from the 2001-2004 National Health and Nutrition Examination Survey.

The association between major depressive disorder (MDD) and obesity was assessed in 4,150 US adolescents aged 12-19 years from the 2001-2004 National Health and Nutrition Examination Survey. Weight and height were measured by health professionals and MDD was based on a structured diagnostic interview. The prevalence of MDD in the past year among US adolescents was 3.2% and 16.8% of US adolescents were obese. After adjustment for sex, age, race/ethnicity and poverty, MDD was not significantly associated with obesity among adolescents overall (adjusted odds ratio (adjOR) = 1.6, 95% confidence interval (CI) = 0.9-2.9), but an increased odds of obesity was observed among males (adjOR = 2.7, 95% CI = 1.1-7.1) and non-Hispanic blacks (adjOR = 3.1, 95% CI = 1.1-8.3) with MDD. Future research on strategies that might reduce the risk of obesity in males and non-Hispanic black adolescents with MDD may be warranted.

Attention deficit hyperactivity disorder among children aged 5-17 years in the United States, 1998-2009.

Attention deficit hyperactivity disorder (ADHD) is one of the most common mental health disorders of childhood. The symptoms of ADHD (inattention, impulsive behavior, and hyperactivity) begin in childhood and often persist into adulthood. These symptoms frequently lead to functional impairment in academic, family, and social settings. The causes and risk factors for ADHD are unknown, but genetic factors likely play a role. Diagnosis of ADHD involves several steps, including a medical exam; a checklist for rating ADHD symptoms based on reports from parents, teachers, and sometimes the child; and an evaluation for coexisting conditions. Recent national surveys have documented an increase in the prevalence of ADHD during the past decade. This report presents recent trends in prevalence and differences between population subgroups of children aged 5-17 years.

Maternal reports of child health status and health conditions: the influence of self-reported maternal health status.

OBJECTIVE: The aim of this study was to examine the influence of maternal health status (MHS) on the relationship between child health conditions and child health status (CHS). METHODS: The study sample included 38 207 children aged 5 to 17 years in the 2001 to 2008 National Health Interview Surveys whose mothers were the survey respondent for the child and herself. Information was collected about CHS, MHS, diagnosed child health conditions, and sociodemographic characteristics. Responses to a question on general health status were used to rate CHS and MHS as "better" (excellent/very good health) or "worse" (good/fair/poor health). The percentage of children with worse CHS, adjusted for sociodemographic characteristics, was estimated using logistic regression. RESULTS: Adjusting for child and family sociodemographic characteristics had a negligible effect on the association between CHS and a 4-level variable that classified children by both MHS and child health conditions. The adjusted percentage of children with worse CHS was higher among children whose mothers had worse MHS compared with children whose mothers had better MHS. Moreover, among children whose mothers had worse MHS, there was a weak relationship between child health conditions and worse CHS. Among children whose mothers had better MHS, there was a strong relationship between child health conditions and worse CHS. CONCLUSION: Because mother-reported CHS is used widely in epidemiological studies as a measure of a child's actual state of health, it is important to consider how maternal characteristics may influence a mother's report of a child's status. In particular, CHS reported by mothers with worse health status merits further investigation.

Emotional/behavioral difficulties and adolescent obesity: effect of sex and Hispanic origin/race.

This study examines the relationship between emotional/behavioral difficulties and obesity among US adolescents aged 12-17 using parent-reported data for 11,042 adolescents in the National Health Interview Survey. Obesity was defined as body mass index (BMI) ≥sex/age-specific 95th percentile BMI cut-points from the 2000 CDC Growth Charts. Types of emotional/behavioral difficulties were identified using the Strengths and Difficulties Questionnaire. Among females, emotional/behavioral difficulties were associated with obesity among non-Hispanic (NH) white and Hispanic adolescents (both those with interviews in English and interviews in Spanish). Among males, emotional/behavioral difficulties were associated with obesity among NH white adolescents and Hispanic males with interviews in English. No association between any difficulties and obesity was found among NH black adolescents, either male or female, or Hispanic males with interviews in Spanish. Awareness of the differing association between emotional/behavioral difficulties and obesity among subgroups of adolescents may aid in the development of targeted obesity interventions.

Participation in activities outside of school hours in relation to problem behavior and social skills in middle childhood.

BACKGROUND: Research has shown that participating in activities outside of school hours is associated with lower dropout rates, enhanced school performance, improved social skills, and reduced problem behaviors. However, most prior studies have been limited to small populations of older children (>12 years). This analysis focuses on children aged 6 to 11 to assess the potential association between participation in activities outside of school hours and behavior in middle childhood in a nationally representative survey. METHODS: Estimates were based on 25,797 children from the 2003-2004 National Survey of Children's Health. Outside of school activity was defined as participating in sports teams/lessons, clubs/organizations, or both at least once in the past year. Analysis of variance was used to evaluate the differences in behavior problems and social skills adjusting for sociodemographic factors, among children classified by participation in outside of school activities. RESULTS: Seventy-five percent of children participated in outside of school activities: 23% in sports, 16% in clubs, and 36% in both clubs and sports. Activity participation differed by gender, race/ethnicity, type of school, poverty status, family structure, household education, and school and community safety. Children participating in both sports and clubs had higher social skills index scores, but no significant difference in problem behavior scores compared with children who did not participate in any outside of school activity. CONCLUSION: Children participating in both sports and clubs had greater social competence during middle childhood compared with children who did not participate in any outside of school activities.

Emotional/Behavioral difficulties and mental health service contacts of students in special education for non-mental health problems.

BACKGROUND: Emotional/behavioral difficulties and mental health (MH) service contacts of 3 groups of youth were compared: students in special education for non-MH problems, students in special education for MH problems, and youth not in special education. METHODS: Parents reported the characteristics, special education placement, emotional/behavioral difficulties, and MH service contacts of 25,122 youth aged 6-17 years in the National Health Interview Survey. RESULTS: Two thirds of students in special education received special education services for non-MH problems. Among students in special education for non-MH problems, 17% had serious emotional/behavioral difficulties compared with 51% of students in special education for MH problems and 4% of youth not in special education. MH service contacts were examined only for youth whose difficulties significantly interfered with their ability to function in or out of school. Among youth with serious difficulties, the percentage of youth without a recent MH service contact was greater for students in special education for non-MH problems (40%) and youth not in special education (47%) compared with students in special education for MH problems (13%). CONCLUSIONS: Compared with youth not in special education, students in special education for non-MH problems were 4 times more likely to have serious emotional/behavioral difficulties but were just as likely as youth not in special education to lack a recent MH service contact. Study findings provide a national context for considering the MH screening/evaluation needs of students receiving special education for non-MH problems.

Functional difficulties among school-aged children: United States, 2001-2007.

OBJECTIVE: This report presents estimates of basic actions difficulty, which includes difficulties related to sensory, motor, cognitive, and emotional or behavioral functioning, in U.S. children aged 5-17 years based on questions from the National Health Interview Survey (NHIS). Selected estimates are shown for the educational and health care service use of children with and without basic actions difficulty. METHODS: Estimates of basic actions difficulty were derived from the Family Core and the Sample Child Core questionnaires of the 2001-2007 NHIS. Estimates were generated and compared using SUDAAN, a statistical package that adjusts for the complex sample design of NHIS. RESULTS: Approximately 18% of children aged 5-17 had basic actions difficulty in one or more of the following domains of functioning: sensory, movement, cognitive, or emotional or behavioral. The percentage of children with difficulty in specific domains varied: 3% had sensory difficulty, 2% movement difficulty, 9% cognitive difficulty, and 10% emotional or behavioral difficulty. From 2001 through 2007, the percentage of children aged 5-17 with basic actions difficulty remained stable at about 18%. Children with and without basic actions difficulty differed greatly in their use of both educational and health care services. One-third of children with basic actions difficulty used special education services compared with 2% of children without basic actions difficulty. A substantially higher percentage of children with basic actions difficulty used health care services, including mental health care, other types of therapy, and prescription medication, than children without basic actions difficulty.

Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004-2006.

OBJECTIVES: This report presents national estimates of the prevalence of diagnosed attention deficit hyperactivity disorder (ADHD) and learning disability (LD) in U.S. children 6-17 years of age and describes the prevalence of these conditions for children with selected characteristics. The use of educational and health care services and the prevalence of other health conditions are contrasted for children with ADHD without LD, LD without ADHD, both conditions, and neither condition. METHODS: Estimates are based on data from the National Health Interview Survey (NHIS), an ongoing national household survey of the civilian noninstitutionalized population of the United States. The analysis focuses on 23,051 children 6-17 years of age in the child sample of the 2004, 2005, and 2006 NHIS. RESULTS: About 5% of children had ADHD without LD, 5% had LD without ADHD, and 4% had both conditions. Boys were more likely than girls to have each of the diagnoses (ADHD without LD, LD without ADHD, and both conditions). Children 12-17 years of age were more likely than children 6-11 years of age to have each of the diagnoses. Hispanic children were less likely than non-Hispanic white and non-Hispanic black children to have ADHD (with and without LD). Children with Medicaid coverage were more likely than uninsured children and privately insured children to have each of the diagnoses. Children with each of the diagnoses were more likely than children with neither ADHD nor LD to have other health conditions. Children with ADHD were more likely than children without ADHD to have contact with a mental health professional, use prescription medication, and have frequent health care visits. Children with LD were more likely than children without LD to use special education services.

Use of mental health services in the past 12 months by children aged 4-17 years: United States, 2005-2006.

KEY FINDINGS: Data from the National Health Interview Survey. In 2005-2006, 15% of U.S. children aged 4-17 years had parents who talked to a health care provider or school staff about their child's emotional or behavioral difficulties. This included 18% of boys and 11% of girls. Approximately 5% of children were prescribed medication for difficulties with emotions or behavior. A large majority of these children (89%) were prescribed medication for difficulties with concentration, hyperactivity, or impulsivity, which are symptoms of attention deficit-hyperactivity disorder (ADHD). Approximately 5% of children received "treatment other than medication" for emotional or behavioral difficulties. Most of these children - 60% - received this treatment from a mental health private practice, clinic, or center. Mental health, which includes emotional and behavioral areas of health, is a critical component of child well-being. It may impact children's physical health, relationships, and learning. Appropriate treatment and intervention for children with emotional or behavioral difficulties has been shown to lessen the impact of mental health problems on school achievement, relationships with family members and peers, and risk for substance abuse. Early mental health screening and the availability and use of appropriate mental health services are among the goals of the President's New Freedom Commission on Mental Health.

Identified attention-deficit/hyperactivity disorder and medically attended, nonfatal injuries: US school-age children, 1997-2002.

OBJECTIVE: To determine the medically attended, nonfatal injury rate among children 6-17 years of age ever and never identified with attention-deficit/hyperactivity disorder (ADHD). METHODS: An analysis was performed of parentally reported injury episodes during the past 3 months and current demographic characteristics of 3,741 sample children ever identified with ADHD and 48,243 never identified with ADHD in the 1997-2002 National Health Interview Surveys. RESULTS: The annualized rate of injury was 204 episodes per 1,000 among children with ADHD compared with 115 episodes per 1,000 among children without ADHD. Injury episode rates were higher for children with ADHD regardless of age, sex, or health insurance. Logistic regression, which controlled for confounding risk factors, showed a robust association between ADHD and injury. The adjusted odds ratio (OR) for ADHD (OR(adj) = 1.83) was similar to the ORs for other important predictors of injury, such as male sex (OR(adj) = 1.45), older age (OR(adj) = 1.50), and private health insurance (OR(adj) = 1.44). Children with other health conditions had an increased odds for injury (OR(adj) = 1.51 for children with other developmental disorders and OR(adj) = 1.53 for children with physical disorders). Characteristics of injury episodes were generally similar for children with and without ADHD. CONCLUSIONS: Results from a large, nationally representative sample indicate that children ever identified with ADHD were more likely to have a medically attended, nonfatal injury than children never identified with ADHD. The increased odds of injury among children with ADHD could not be attributed to other confounding risk factors. Children with ADHD may benefit from targeted injury prevention efforts.

Racial and ethnic differences in ADHD and LD in young school-age children: parental reports in the National Health Interview Survey.

OBJECTIVES: Racial and ethnic disparities have been documented for many physical health outcomes in children. Less is known, however, about disparities in behavioral and learning disorders in children. This study uses data from a national health survey to examine racial and ethnic differences in identified attention deficit hyperactivity disorder (ADHD) and learning disability (LD). METHODS: The 1997-2001 National Health Interview Surveys obtained information from parents about the health and sociodemographic characteristics of children. Using these data, prevalence rates of identified ADHD and/or LD were estimated for Hispanic, African American, and white children 6-11 years of age. Racial and ethnic differences in health conditions, income, and insurance coverage were examined as possible explanations for disparities in parental reports of ADHD and LD, as well as the use of any prescription medication among children with ADHD. RESULTS: Hispanic and African American children, compared to white children, had parental reports of identified ADHD without LD less often, and adjustments for the confounding variables-birthweight, income, and insurance coverage-did not eliminate these differences. Hispanic and African American children, compared to white children, also had parental reports of ADHD with LD less often after adjustments for the effects of confounding variables. By contrast, after adjustments for confounding variables, Hispanic and African American children were as likely as white children to have LD without ADHD. Among children with ADHD, use of any prescription medication was reported less often for Hispanic and African American children than white children. These disparities in medication use persisted after adjustments for confounding variables. CONCLUSIONS: The prevalence of ADHD and the use of any prescription medication among children with ADHD differed among Hispanic, African American, and white children. These disparities could not be explained by racial and ethnic differences in other health conditions and sociodemographic variables.