Parents were asked, “Has a doctor or health professional ever told you that (sample child) had Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?” If parents answered “Yes,” the child was categorized as having diagnosed ADHD. Parent-reported diagnosis of ADHD has not been directly validated against a clinical standard for a national sample of US children. However, a comparison of the prevalence of diagnosed ADHD using parent-reported data from the 2007 National Survey of Children’s Health with an estimate from a recent study using medical records for a large administrative sample of children indicated similar results, providing convergent validity for the survey estimate.³²

The parents of all children were asked, “During the past six months, was (sample child) prescribed medication or taking prescription medication for difficulties with emotions, concentration, behavior, or being able to get along with others?” If the parent responded “Yes” to the medication question, the following question was asked: “Who first prescribed the medication. Was it … A pediatrician or other family doctor? … A psychiatrist, psychologist, or other mental health professional? … A neurologist? … Someone else?” In the remainder of this analysis, medication use refers only to medication use for EBD. The category “emotional and behavioral difficulties” refers to the terminology used in the survey and is not equivalent to the educational classification of “emotional and behavioral disturbance.”

The parents of all children were asked the following questions about health care contacts: (1) “During the past 12 months, have you seen or talked to any of the following health care providers about (sample child’s) health? … A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker? (2) Did you see or talk to a general doctor (a doctor in general practice, pediatrics, family medicine, or internal medicine) because of an emotional or behavioral problem that (sample child) may have?” Parents were also asked (1) if the child received special education or early intervention services and (2) if these services were received because of an emotional or behavioral problem. Throughout this analysis, the terms “difficulties” and “problems” are used interchangeably. Special education services for emotional and behavioral difficulties were included because previous research shows the increasing use of these services among children with diagnosed ADHD.^33,34 Use of nonmedication services, as a group, was defined as providing an affirmative answer to either questions about having seen or talked to a mental health professional or a general doctor because of child’s emotional and behavioral difficulties, or receiving special education or early intervention services specifically for emotional and behavioral difficulties.

Based on answers to the questions on the use of medication and nonmedication services for EBD, children with diagnosed ADHD were classified into 3 mutually exclusive service groups: (1) use of medication (with or without use of nonmedication services), (2) use of nonmedication services only, and (3) no service use. Service use was classified into these 3 categories to describe the characteristics of children using the most prevalent kind of treatment (medication use) and to isolate differences in the use of only nonmedication services and no services by insurance coverage.

Children were categorized by the child’s health insurance at the time of interview (any private, public only, and uninsured). Children with both public and private health insurance are categorized as having private coverage. The covariates in the analysis included the child’s age, sex, race and Hispanic origin, and whether the child had a comorbid condition(s). If a parent reported that a child had any of the following diagnosed conditions—Down syndrome, intellectual disability, developmental delay, autism or autism spectrum disorder, learning disability, or current symptoms of seizures, frequent headaches, or stuttering—the child was classified as having a comorbid condition. The conditions selected as comorbidities were chosen because of the inclusion of these conditions in the survey and their association with diagnosed ADHD.⁷ The item nonresponse was 1% to 2% for study variables.

Among all children aged 4 to 17 with diagnosed ADHD, 56.0% had used medication for EBD during the past 6 months (Table 2). Among children 4 to 17 years of age without ADHD, 1.3% (confidence interval = 1.2% to 1.5%) had used medication for EBD during the past 6 months (data not shown). Medication use was higher among privately and publicly insured children than uninsured children (57.3% and 57.0% vs 33.1%, P < .001 for both).

For nearly three quarters of all children with ADHD (72.9%), the physician who first prescribed medication for a child’s EBD was a pediatrician or other family doctor, and for a quarter (24.5%) the first prescriber was a psychiatrist, psychologist, or other mental health professional (Table 2). Having a psychiatrist, psychologist, or other mental health professional as the first prescriber of EBD medication was more common among publicly insured children than privately insured and uninsured children (28.1% vs 22.0% and 14.8%, P < .05 for both).

Among children with diagnosed ADHD, 39.8% had contact with a mental health professional during the past 12 months and 32.2% had contact with a general doctor about the child’s EBD during the past 12 months, with 20.4% currently receiving special education services (Table 3). Among children with diagnosed ADHD, contacting a mental health professional was more often reported for children having public insurance than private insurance or no insurance (47.2% vs 34.6% and 24.6%, P < .001 for both). Contacting a general doctor about the child’s EBD was associated with health insurance coverage in a similar way. Publicly insured children, compared to privately insured and uninsured children, more often had a parent-report of contact with a general doctor about the child’s EBD (38.0% vs 27.5% and 25.7%, P < .001 and P < .05, respectively).

Special education services for EBD were reported more often for publicly insured children (28.0%) compared to both privately insured (13.7%, P < .001) and uninsured children (19.1%, P < .05; Table 3).

Table 4 shows the distribution of all children with diagnosed ADHD across 3 mutually exclusive categories: children using medication for EBD (with or without use of nonmedication services; 56.0%), children only using nonmedication services for EBD (15.1%), and children with no service use (28.9%). A higher percentage of publicly insured (18.7%, P < .001), but not uninsured (18.1%), children used only nonmedication services compared to privately insured children (11.6%). Uninsured children were the most likely to have a report of no service use and publicly insured children were the least likely (48.4% vs 24.3%, P < .001). Nearly a third (31.1%) of privately insured children received no services (P < .001 compared to publicly insured and uninsured children).