mental health professionals attempt to empower clients to care for their own problems by supporting client agency. However, i

ADHD Stimulant Addiction Case Study: Junior

Junior is a 14-year-old Hispanic boy of Mexican-American heritage. He lives with his parents in San Bernadino, CA. Junior’s parents (Diego and Francisca) both have successful careers and are very concerned that he should succeed in his studies and with his friends. While Junior has always had difficulty staying focused on any one thing for longer than just a few minutes, it became worse as he entered middle school. At one point, a school counselor contacted Junior’s parents to tell them that they might want to consider having Junior tested for attention-deficit/hyperactivity disorder, or ADHD. After a brief exam and consultation, a doctor prescribed a moderate dosage of dextroamphetamine to help Junior focus. The effects were dramatic and instantaneous. He was pleasantly dedicated to the tasks before him, and his grades improved over the next 6-week period. After a while, the dose was increased because the medication was not working as well. Junior’s doctor was a little hesitant but figured that Junior’s physical build and activity level might have something to do with the change, so he increased the dose to the highest of all of his young patients. Lately, though, Junior’s mother has noticed that his medication seems to be running out before it should. At first she thought little of it because he had lost some pills down the drain before, and it was nothing. A few months ago, however, the pharmacist told her that their insurance would not fill the prescription for at least well over a week. This has now happened three times. Once, she was sure he had been out, and suddenly there were 4 pills in the bottle that looked different than the first set. Junior denied that he switched the pills. She had him take the pills while she was watching, and the effects were perfectly normal. As Junior suggested, she believed she must have dreamt up the difference in the pills. Things have changed very recently. Junior has lost weight, and he looks “wired” but simultaneously “exhausted.” Francisca thinks Junior has been taking his medication incorrectly, maybe even obtaining more somehow. For the last 2 days, he has had nose bleeds and has not been sleeping at night. Francisca decided to act quickly when Junior “broke down” and told her that he had been having “weird things” in his vision. He whispered to her that he did not want to hurt her, though he had a “bad thought” about hitting her when she questioned him. He went to their church on his own after school yesterday to pray about his thoughts of harming his mother and the frightening things he had been seeing. Francisca hopes these things are hallucinations and wants to figure out how to help her son before something bad happens.

© 2014 Laureate Education, Inc. Page 1 of 1

ARTICLEPEDIATRICS Volume 138 , number 3 , September 2016 :e 20160407

Racial and Ethnic Disparities in ADHD Diagnosis and Treatment Tumaini R. Coker, MD, MBA, a, b Marc N. Elliott, PhD, b Sara L. Toomey, MD, MPhil, MPH, MSc, c David C. Schwebel, PhD, d Paula Cuccaro, PhD, e Susan Tortolero Emery, PhD, e Susan L. Davies, PhD, f Susanna N. Visser, DrPH, MS, g Mark A. Schuster, MD, PhDb, c

abstractOBJECTIVES: 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.

aDepartment of Pediatrics, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles,

California; bRAND, Santa Monica, California; cDivision of General Pediatrics, Boston Children’s Hospital and

Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Departments of dPsychology and fHealth Behavior, University of Alabama at Birmingham, Birmingham, Alabama; eCenter for Health Promotion

and Prevention Research, University of Texas–Houston, School of Public Health, Houston, Texas; and gCenters

for Disease Control and Prevention, Atlanta, Georgia

Dr Coker was responsible for study conception and design, data analysis, interpretation of

fi ndings, and writing of the manuscript; Dr Elliott contributed to study conception and survey

development, obtained funding, and participated in study design, analysis, and interpretation;

he also revised manuscript drafts; Dr Schwebel contributed to study conception and survey

development, obtained funding, participated in study design and interpretation, and revised

manuscript drafts; Drs Toomey, Tortolero Emery, Cuccaro, and Davies contributed to study

conception and survey development, obtained funding, participated in study design, and revised

manuscript drafts; Dr Visser contributed to study conception, study design, and revision of

manuscript drafts; and Dr Schuster contributed to study conception and survey development,

To cite: Coker TR, Elliott MN, Toomey SL, et al. Racial and Ethnic Disparities in ADHD Diagnosis and Treatment.

Pediatrics. 2016;138(3):e20160407

WHAT’S KNOWN ON THIS SUBJECT: There are racial/ethnic disparities in medication use for

attention-defi cit/hyperactivity disorder (ADHD), but

it is unknown if the disparity is more likely due to

an underdiagnosis or undertreatment of African-

American and Latino children, or an overdiagnosis

or overtreatment of white children.

WHAT THIS STUDY ADDS: Racial/ethnic disparities in medication use for ADHD are robust, persist

from fi fth to 10th grade, and seem to be more

related to underdiagnosis and undertreatment of

African-American and Latino children as opposed to

overdiagnosis or overtreatment of white children.

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COKER et al

Attention-deficit/hyperactivity

disorder (ADHD) diagnoses have

been increasing in the United States.

Parent-reported rates of ever

receiving a diagnosis for children

aged 4 to 17 years increased from

7.8% in 2003 to 11.0% in 2011,

and rates of ADHD medication use

increased from 4.8% in 2007 to

6.1% in 2011. 1 Studies also describe

racial/ethnic disparities in diagnosis

and medical treatment of ADHD,

indicating that African-American

and Latino children may have lower

rates of receiving a diagnosis and

medication compared with white

children. 2 – 7

These differences in diagnosis and

treatment are generally interpreted

as reflecting underdiagnosis and

undertreatment of African-American

and Latino children. 5, 6 In light of

the increasing prevalence, however,

researchers have recognized that

overdiagnosis or overtreatment

of white children is a possible

alternative explanation for the

disparity, 3, 8 although previous

studies have not examined which

explanation is most likely.

The current study was conducted

to help address this question: Is

the disparity in ADHD diagnosis

and medication treatment more

likely due to an underdiagnosis

or undertreatment of African-

American and Latino children or

an overdiagnosis or overtreatment

of white children? A population-

based, multisite longitudinal survey

was used to examine racial/ethnic

disparities in the diagnosis of ADHD

and in ADHD medication treatment

among children. We also examined

whether the disparity and the likely

main drivers of the disparity changed

from fifth grade to 10th grade.

METHODS

Healthy Passages is a longitudinal

study of a cohort of 5147 fifth-

graders and their parents (2004–

2006), with follow-up in seventh

grade (2006–2008) and 10th grade

(2009–2011). 9, 10 Institutional review

board approval was obtained at each

study site and the Centers for Disease

Prevention and Control.

Study Population and Sampling Procedure

Participants were recruited from

public schools in the following

districts: 10 contiguous public school

districts in and around Birmingham,

Alabama; 25 contiguous public school

districts in Los Angeles County,

California; and the largest public

school district in Houston, Texas.

Eligible schools had an enrollment

of ≥25 fifth-graders, representing >99% of students enrolled in regular

classrooms. To ensure adequate

sample sizes of African-American,

Latino, and white students, a 2-stage

probability sampling procedure,

detailed elsewhere, 9 was used. The

sampling procedure included the

following: (1) random sampling of

schools using probabilities that were

a function of how closely a school’s

racial/ethnic mix corresponded to

the site’s racial/ethnic target; and (2)

invitation to participate to all fifth-

grade students in regular classrooms

of sampled schools.

The 118 sampled schools had 11 532

enrolled fifth-graders. A primary

caregiver (henceforth referred to as

“parent”) for each student received

a letter requesting permission for

contact by study personnel. Of the

11 532 parents, 6663 who either

agreed to be contacted or who were

unsure were invited to participate;

5147 completed an interview at

baseline (fifth grade), and 4297

parent–child dyads participated in

all 3 waves (at fifth grade and ∼2 and 5 years later, when most children

were in seventh and 10th grades,

respectively).

Our sample size reached the

predetermined sample size targets;

details of statistical power are

described elsewhere. 9 Interviews

were conducted at the home, a study

center, or another preferred location.

Parents provided informed consent

for participation, and children gave

assent.

Measures

ADHD Symptoms

Questions from the Diagnostic

Interview Schedule for Children

Predictive Scales (DPS) were used

to assess the presence of parent-

reported symptoms of ADHD and

other mental health conditions that

may be comorbidities which could

affect whether a child receives a

diagnosis or medication for ADHD.

These comorbidities included

oppositional defiant disorder,

conduct disorder, and depression.

The DPS is a screening tool based on

the Diagnostic Interview Schedule

for Children; it relies on parent-

reported symptoms (reported as

present or not) of ADHD (7 yes/

no items), oppositional defiant

disorder (12 yes/no items), and

conduct disorder (8 yes/no items),

as well as child-reported symptoms

of depression (6 yes/no items)

during the previous 12 months

(sensitivities and specificities for

ADHD, oppositional defiant disorder,

conduct disorder, and depression,

≥0.89). 11 The 7 ADHD symptoms in the DPS align with 5 inattentive

symptoms (eg, Has your child often

had trouble finishing his or her

homework or other things he or she

is supposed to?) and 2 hyperactivity/

impulsivity symptoms (eg, Has your

child often left his or her seat when

he or she was not supposed to?) on

the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 12 A dichotomous variable was created

for symptoms consistent with

ADHD, defined by a score (sum of

symptoms) above the sample 90th

percentile. We used this cutoff value,

which was more stringent than cutoff

values used in a previously studied

community sample, 11 because data

on level of impairment or symptom

severity were not collected. For

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PEDIATRICS Volume 138 , number 3 , September 2016

fifth- and seventh-grade surveys,

the 90th percentile corresponds

to positive responses on ≥6 of 7 possible ADHD symptoms. For

the 10th-grade surveys, the 90th

percentile corresponds to ≥5 of 7 possible symptoms. Of note, the

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, requires ≥6 symptoms of inattention and/or hyperactivity-impulsivity for

youth aged ≤16 years or ≥5 for youth aged ≥17 years. 12 We also created a continuous variable for symptoms

consistent with ADHD and each of

the other mental health disorders,

defined by the total symptom score

for each scale. Higher symptom

scores reflect more symptoms.

ADHD Diagnosis

In survey waves 1 and 3, parents

were asked if a physician or health

professional had ever told them

that their child had hyperactivity or

attention-deficit disorder (wave 1

question) or hyperactivity, attention-

deficit disorder, or ADHD (wave 3

question) (response options, yes or

no). This question was not asked in

wave 2.

ADHD Medication Use

In waves 1 through 3, parents were

asked if during the last year (wave 1)

or past 12 months (waves 2 and 3)

their child had taken medication for

being overactive, being hyperactive,

or having trouble paying attention

(yes or no).

Other Variables

Data were collected on several child

and parent wave 1 characteristics

previously hypothesized to influence

mental health care use. 13 – 15 Child

sociodemographic covariates

included study city (Birmingham,

Houston, and Los Angeles), child

race/ethnicity (non-Latino black

[henceforth, African-American],

Latino, non-Latino white, and other

race/ethnicity), age at fifth grade

survey (<11, 11, and ≥12 years), sex (male or female), insurance status

(uninsured or insured), annual

household income (less than $20 000,

$20 000–$34 000, $35 000–$69 999,

$70 000 or higher), and household

composition (2-parent, 1-parent, or

other). Parent sociodemographic

covariates included highest

household education level (no high

school diploma, high school diploma,

some college, and college degree

or greater) and English language

proficiency (speaks English very well

versus less than very well). Because

no significant differences were

found in results when accounting for

household size in the income variable

(by using the federal poverty level),

we used annual household income.

We also included child symptoms

of oppositional defiant disorder,

conduct disorder, and depression

(each as continuous variables),

and the child’s school functioning,

using the Pediatric Quality of Life

Inventory version 4.0 at each wave.

This inventory tool is a well-validated

instrument designed to measure

health-related quality of life in 2- to

18-year-olds. 16 It measures school

functioning by using 5 child-reported

items (hard to pay attention in class,

forgets things, trouble keeping up

with school work, missed school

because not feeling well, and missed

school to go to physician/hospital);

respondents report how much of a

problem each item has been during

the past month, with 5 response

options (never, almost never,

sometimes, often, and almost always

a problem). Items are reverse scored

(ie, higher scores represent better

school functioning) and linearly

transformed to a 0 to 100 range.

We included a dichotomous measure

of receipt of family-centered care

(FCC) collected by wave 3 parental

report. FCC is a key element of

the medical home, is less likely to

be reported by African-American

and Latino parents, and may be

associated with having fewer unmet

medical needs. 17 – 19 Although FCC

was only measured in wave 3, it was

used as a covariate in analyses of

all waves, as a general indicator of

access to FCC. FCC was indicated as

received if the parent reported that

their child’s physicians “always”

or “usually” spent enough time,

listened carefully, were sensitive

to the family’s values and customs,

provided specific information that

the parent needed, and helped

the parent feel like a partner in

their child’s care; this method of

assessing FCC has been used in

multiple studies. FCC is included in

the National Survey of Children’s

Health and the National Survey of

Children with Special Health Care

Needs, 20, 21 and it has been shown

to be stable over multiple waves of

these national surveys. 22 However,

because we cannot know whether

FCC measured at wave 3 is indicative

of care received at waves 1 and 2, a

sensitivity analysis was conducted

to determine whether inclusion of

FCC as a covariate in adjusted models

significantly changed our results.

Statistical Methods

All analyses use design and

nonresponse weights and account

for the effects of weights and

clustering of children within sites by

using Stata SE 10. 23 – 25 Our sample

included 4297 parent–child dyads

that participated in all 3 waves.

We used χ2 tests of homogeneity and t tests to describe the wave 1 characteristics of children and

parents in the study sample. Bivariate

analyses were also used to describe

the proportion of children with

symptoms consistent with ADHD,

parent-reported diagnosis of ADHD,

and a history of parent-reported

medication for ADHD according to

child race/ethnicity and survey wave.

The proportion of children receiving

ADHD medication was examined

according to race/ethnicity at each

wave, stratified according to number

of ADHD symptoms (0 symptoms,

1–2 symptoms, 3–5 symptoms, and

6–7 symptoms). Logistic regression

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COKER et al

was used to examine the unadjusted

and adjusted odds of ADHD diagnosis

and medication use according to

race/ethnicity over the 3 survey

waves. To determine the disparity

in medication use among children

who had received a diagnosis, odds

of medication use were calculated

according to race/ethnicity among

children with a diagnosis of ADHD

(with or without symptoms).

Finally, we looked for racial/ethnic

disparities in medication use among

2 groups of children: (1) those with a

presumed need for ADHD medication

(either an ADHD diagnosis or

symptoms suspicious for ADHD); and

(2) those with no presumed need

for ADHD medication (no diagnosis

of or symptoms consistent with

ADHD by fifth grade). Racial ethnic/

disparities in medication use that

persist in this first group of children

would suggest underdiagnosis or

undertreatment of African-American

and Latino children. Disparities

that persist in the second group of

children would suggest overdiagnosis

or overtreatment of white children,

which could be the result of multiple

factors (eg, differential provider or

parental expectations for medication

use among children based on child

race/ethnicity).

RESULTS

Table 1 describes the sample. In fifth

grade, parents reported that 8% of

children had symptoms of ADHD, 8%

had ever received an ADHD diagnosis,

and 7% had taken medication for

ADHD over the past year. By 10th

grade, those percentages increased

to 9%, 9%, and 8%, respectively. In

fifth, seventh, and 10th grades, higher

percentages of African-American

children compared with white

children had symptoms suggestive

of ADHD (fifth grade, 12% vs 7%;

seventh grade, 11% vs 6%; and 10th

grade, 13% vs 9%). Latino children

were just as likely to have ADHD

symptoms as white children at each

wave ( Table 2).

In fifth and 10th grades, white

children were much more likely

to have ever received a diagnosis

of ADHD (16% in fifth grade and

19% in 10th grade) than African-

American children (9% and 10%,

respectively), Latino children (4%

and 4%), and children of other race/

ethnicity (10% and 10%) ( Tables

2 and 3). White children were also

more likely to have a parental report

of taking medication for ADHD in the

last year at all 3 waves, compared

with African-American, Latino, and

other children ( Table 3). Results for

differences in medication use were

similar when stratified according

to number of ADHD symptoms. At

all symptom levels above zero, a

higher proportion of white children,

compared with African-American

and Latino children, had a parental

report of ADHD medication (see

Supplemental Table 6). This disparity

persisted even among children at

the highest symptom levels. For

example, among 10th grade children

at the highest symptom level, 65%

4

TABLE 1 Fifth Grade Characteristics

Characteristic Unweighted N Weighted % or Mean ± SD

Child race/ethnicity

African-American 1497 29.1

Latino 1512 44.4

Othera 248 4.4

White 1039 22.1

Male sex 2097 51.1

Age (child age at fi fth grade)

≤10 y (most aged 10; n = 16 are 8–9 y) 1989 44.0 11 y 2048 48.9

≥12 y 260 7.1 Highest household education

Some high school 755 23.5

High school graduate 850 21.8

Some college 1159 25.2

College graduate 1474 29.5

Household income, $

<20 000 1306 35.4

20 000–34 000 865 23.0

35 000–69 000 857 20.1

≥70 000 1059 21.5 Family household composition

Two-parent 2400 58.1

Single-parent 1685 37.7

Other (nonparent, foster) 190 4.2

Insurance type (child)

Private 2063 42.5

Medicaid/CHIP 1664 42.3

Other insurance type (military, IHS) 80 2.0

Uninsured 472 13.2

Study site

Birmingham, AL 1350 31.0

Houston, TX 1462 34.6

Los Angeles, CA 1485 34.4

Mental health symptoms

Oppositional defi ant disorder 329 7.8

Conduct disorder 350 8.2

Depression 307 7.5

FCC 2176 48.9

School functioning (PedsQL subscale) — 75.0 ± 20.6

CHIP, Children’s Health Insurance Program; IHS, Indian Health Service; PedsQL, Pediatric Quality of Life Inventory; —,

continuous variable. a The other category includes multiracial (n = 131), American Indian/Alaska Native (n = 7), and Asian or Pacifi c Islander

(n = 110).

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PEDIATRICS Volume 138 , number 3 , September 2016

of white children were taking ADHD

medication according to parental

report, compared with 36% of

African-American children and 30%

of Latino children.

Across all waves, African-American

children had significantly lower

adjusted odds of both ever having

a diagnosis of ADHD (fifth grade

adjusted odds ratio [aOR], 0.40 [95%

confidence interval (CI), 0.27–0.59];

10th grade aOR, 0.42 [95% CI,

0.27–0.67]) and of taking ADHD

medication in the past year (fifth

grade aOR, 0.43 [95% CI, 0.29–0.65];

seventh grade aOR, 0.41 [95% CI,

0.28–0.62]; 10th grade aOR, 0.44

[95% CI, 0.28–0.71]) compared with

white children. A similar pattern was

observed when comparing Latino

children versus white children

on adjusted odds of ever having a

diagnosis of ADHD (fifth grade aOR,

0.37 [95% CI, 0.22–0.60]; 10th grade

aOR, 0.46 [95% CI, 0.26–0.79]) and

of taking ADHD medication (fifth

grade aOR, 0.40 [95% CI, 0.23–0.70];

seventh grade aOR, 0.43 [95% CI,

0.25–0.74]; 10th grade aOR, 0.41

[95% CI, 0.21–0.79]) ( Table 3). Of

note, male sex was consistently

associated in these models with

receiving an ADHD diagnosis and

medication.

Disparities in Medication Rates Among Children With ADHD According to Symptoms or Diagnosis

Among children ever having a

diagnosis of ADHD or past-year

symptoms of ADHD, African-American

children had lower adjusted odds

of past-year ADHD medication,

compared with white children at

fifth grade (aOR, 0.33 [95% CI,

0.17–0.62]), seventh grade (aOR,

0.34 [95% CI, 0.18–0.64]), and 10th

grade (aOR, 0.41 [95% CI, 0.22–0.75]).

Latino children had decreased odds

compared with white children at fifth

grade (aOR, 0.38 [95% CI, 0.16–0.90])

and 10th grade (aOR, 0.42 [95% CI,

0.20-0.86]) only ( Table 4).

When examining disparities in

medication use among children who

had been diagnosed with ADHD

(whether they had symptoms),

African-American children (fifth

grade odds ratio [OR], 0.46 [95% CI,

0.22–0.97]; 10th grade OR, 0.42 [95%

CI, 0.24–0.74]) and Latino children

(fifth grade OR, 0.17 [95% CI, 0.07–

0.39]; 10th grade OR, 0.28 [95% CI,

0.14–0.57]) had lower unadjusted

5

TABLE 2 ADHD Symptoms, Diagnosis, and Medication Use According to Race/Ethnicity Over 3 Waves

Variable Fifth Grade Seventh Grade 10th Grade

ADHD, by symptoms

Total 8 (350) 7 (324) 9 (400)

White 7 (68) 6 (67) 9 (87)

African-American 12 (176) 11 (154) 13 (195)

Latino 6 (90) 6 (89) 6 (95)

Other 7 (16) 6 (14) 9 (23)

P <.001 <.001 <.001 ADHD, by diagnosis

Total 8 (368) NA 9 (422)

White 16 (152) NA 19 (191)

African-American 9 (131) NA 10 (139)

Latino 4 (62) NA 4 (69)

Other 10 (23) NA 10 (23)

P <.001 <.001 Took medication for ADHD (past 12 mo)

Total 7 (314) 7 (336) 8 (341)

White 14 (132) 14 (142) 16 (155)

African-American 9 (123) 9 (124) 8 (110)

Latino 3 (44) 3 (55) 4 (60)

Other 7 (15) 6 (15) 7 (16)

P <.001 <.001 <.001

Unless otherwise indicated, data are presented as n (%). NA, not applicable.

TABLE 3 Unadjusted ORs and aORs of ADHD Diagnosis and Medication Use According to Race/ Ethnicity Over 3 Waves

Variable Fifth Grade Seventh Grade 10th Grade

ADHD, diagnosis

White Ref NA Ref

African-American

OR (95% CI) 0.54 (0.43–0.69)*** NA 0.46 (0.36-0.60)***

aOR (95% CI) 0.40 (0.27–0.59)*** NA 0.42 (0.27–0.67)***

Latino

OR (95% CI) 0.21 (0.15–0.30)*** NA 0.18 (0.13–0.26)***

aOR (95% CI) 0.37 (0.22–0.60)*** NA 0.46 (0.26–0.79)**

Other

OR (95% CI) 0.63 (0.38–1.03) NA 0.45 (0.29–0.72)**

aOR (95% CI) 0.76 (0.40–1.41) NA 0.56 (0.30–1.03)

ADHD, medication

White Ref Ref Ref

African-American

OR (95% CI) 0.57 (0.43–0.75)*** 0.58 (0.45–0.75)*** 0.48 (0.35–0.66)***

aOR (95% CI) 0.43 (0.29–0.65)*** 0.41 (0.28–0.62)*** 0.44 (0.28–0.71)**

Latino

OR (95% CI) 0.18 (0.12–0.25)*** 0.21 (0.15–0.29)*** 0.23 (0.17–0.31)***

aOR (95% CI) 0.40 (0.23–0.70)** 0.43 (0.25–0.74)** 0.41 (0.21–0.79)**

Other

OR (95% CI) 0.45 (0.25–0.80)** 0.39 (0.23–0.67)** 0.42 (0.22–0.79)**

aOR (95% CI) 0.60 (0.31–1.18) 0.46 (0.25–0.86)* 0.45 (0.21–0.98)*

Adjusted for child age, sex, health insurance, mental health symptoms, and school functioning;

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