Susanna N. Visser

Trends in the Prevalence of Developmental Disabilities in US Children, 1997–2008

OBJECTIVE: To fill gaps in crucial data needed for health and educational planning, we determined the prevalence of developmental disabilities in US children and in selected populations for a recent 12-year period. PARTICIPANTS AND METHODS: We used data on children aged 3 to 17 years from the 1997–2008 National Health Interview Surveys, which are ongoing nationally representative samples of US households. Parent-reported diagnoses of the following were included: attention deficit hyperactivity disorder; intellectual disability; cerebral palsy; autism; seizures; stuttering or stammering; moderate to profound hearing loss; blindness; learning disorders; and/or other developmental delays. RESULTS: Boys had a higher prevalence overall and for a number of select disabilities compared with girls. Hispanic children had the lowest prevalence for a number of disabilities compared with non-Hispanic white and black children. Low income and public health insurance were associated with a higher prevalence of many disabilities. Prevalence of any developmental disability increased from 12.84% to 15.04% over 12 years. Autism, attention deficit hyperactivity disorder, and other developmental delays increased, whereas hearing loss showed a significant decline. These trends were found in all of the sociodemographic subgroups, except for autism in non-Hispanic black children. CONCLUSIONS: Developmental disabilities are common and were reported in ∼1 in 6 children in the United States in 2006–2008. The number of children with select developmental disabilities (autism, attention deficit hyperactivity disorder, and other developmental delays) has increased, requiring more health and education services. Additional study of the influence of risk-factor shifts, changes in acceptance, and benefits of early services is needed.

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.

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.

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 Childrens 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 Childrens 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.

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.

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.

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.

Convergent Validity of Parent-Reported Attention-Deficit/Hyperactivity Disorder Diagnosis: A Cross-Study Comparison

Author Contributions: All authors had full access to the data used in analysis and take full responsibility for the integrity and accuracy of the results. Study concept and design: Hanks, Just, and Wansink. Acquisition of data: Hanks and Just. Analysis and interpretation of data: Hanks, Just, and Wansink. Drafting of the manuscript: Hanks, Just, and Wansink. Critical revision of the manuscript for important intellectual content: Hanks, Just, and Wansink. Statistical analysis: Hanks and Just. Obtained funding: Just and Wansink. Administrative, technical, and material support: Wansink. Study supervision: Just and Wansink.

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 Childrens 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).