453169

ournal of Attention DisordersWolraich et al.

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Current Perspectives
Journal of Attention Disorders

The Prevalence of ADHD:  Its Diagnosis

2014, V
  ol. 18(7) 563­–575
© 2012 SAGE Publications
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DOI: 10.1177/1087054712453169
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Across Two States

Mark L. Wolraich1, Robert E. McKeown2, Susanna N.Visser3, David Bard1,

Steven Cuffe4, Barbara Neas1, Lorie L. Geryk2, Melissa Doffing5, Matteo Bottai2,
Ann J. Abramowitz6, Laoma Beck1, Joseph R. Holbrook2, and Melissa Danielson3

Abstract
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. (J. of Att. Dis. 2014; 18(7) 563-575)

Keywords
ADHD, prevalence rate, school sample, community-based sample, epidemiology

Monitoring the prevalence of attention-deficit/hyperactivity
disorder (ADHD) is an important public health activity as
public awareness has increased and treatment options have
expanded across the globe. A metaregression analysis com-
prised of over 102 studies revealed a worldwide ADHD
prevalence rate of 5.3% for studies published between 1978
and 2005 (Polanczyk, de Lima, Horta, Biederman, &
Rohde, 2007). The pooled prevalence rate in North America
was higher than those of Africa or the Middle East, but was
comparable to those of Europe, South American, Oceania,
and Asia.
Conclusions about the epidemiology of ADHD within
the US are complicated by ongoing reports of limited
access to care (Burns et al., 1995), conflicting evidence of
over- and under-diagnosis, and clinical debates about the
appropriateness of medication use (Angier, 1994; Bussing
et al., 2005; Diller, 1996; McGinnis, 1997). Nevertheless,
parent-reported rates of ADHD diagnosis have increased
steadily since 1998 (Akinbami, Liu, Pastor, & Reuben,
2011; Centers for Disease Control and Prevention, 2010;
Pastor & Reuben, 2008). A recent parent survey revealed
that 9.5% of those 4-17 years of age (approximately 5.4
million American children) had an ADHD diagnosis by
2007, representing a 22% increase in four years (Centers
for Disease Control and Prevention, 2010). Although par-
ent surveys reveal important trends, they lack clinical vali-
dation and are predicated on access to health care.
Application of DSM-IVTR criteria for ADHD requires
“some impairment from the symptoms be present in two or
more settings (e.g., at school and home)” and clear evi-
dence of significant impairment in social, academic, or
1
2
University of Oklahoma Health Sciences Center, USA
University of South Carolina, Columbia, USA
3
Centers for Disease Control and Prevention, Atlanta, GA, USA
4
University of Florida College of Medicine, Jacksonville, USA
5
University of Colorado Colorado Springs, USA
6
Emory University, Atlanta, GA, USA
Corresponding Author:
Mark L. Wolraich, University Oklahoma Health Sciences Center, OU
Child Study Center, 1100 NE 13th Street, Oklahoma City, OK 73117,
USA.
Email: mark-wolraich@ouhsc.edu

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564 Journal of Attention Disorders 18(7)
occupational functioning (APA, 2000). Thus, the diagnosis
requires a degree of impairment (“some” and “clinically
significant”) and multiple (“two or more”) settings but
does not direct application of these criteria. The lack of
explicit in impairment criteria likely contributes to vari-
able prevalence rates (Gathje, Lewandowski, & Gordon,
2008) and is compounded by the lack of clarity regarding
the inclusion of multiple informants (American Academy
of Pediatrics [AAP] Committee on Quality Improvement
and Subcommittee on Attention-Deficit/Hyperactivity
Disorder, 2000); AAP’s practice guidelines recommend
using information from parents and teachers (AAP’s
Subcommittee on Attention-Deficit/Hyperactivity Disorder
Steering Committee on Quality Improvement and
Management, 2011), although the correlation between par-
ent and teacher ratings is often low (Lahey et al., 1987;
Newcorn et al., 1994; Wolraich et al., 2004) with no clear
recommendation for resolving these conflicts.
Many previous population-based estimates of ADHD
have relied on a single reporter or existing clinical diagnoses
(Barbaresi et al., 2002; Burd, Klug, Coumbe, & Kerbeshian,
2003; Mandell, Thompson, Weintraub, Destefano, & Blank,
2005)—methods that are insufficient to evaluate DSM-IVTR
diagnostic criteria. Nationally representative cross-sectional
surveys that are used to estimate ADHD prevalence have
relied solely on parental report of the diagnosis (Pastor &
Reuben, 2008; Visser, Lesesne, & Perou, 2007) or have oth-
erwise used less than the full DSM-IVTR criteria (Hargreaves,
Shumway, Tei-Wei, & Cuffel, 1998). Thus, very few studies
have documented symptoms in multiple settings, using infor-
mation from multiple sources, possibly resulting in inaccu-
rate estimates of prevalence (Barkley, 2006). Although
clinical studies allow for more rigorous application of diag-
nostic criteria, community-based epidemiological studies
that include participants regardless of health care access
promise greater generalizability of findings to the popula-
tion (Eaton et al., 2008; Goldberg, 1995; Susser, Schwartz,
Morabia, & Bromet, 2006).
Given the upward trend in parent-reported ADHD and
the complicated nature of DSM-IVTR diagnostic require-
ments, community-based studies that apply strict diagnos-
tic criteria (APA, 2000) are clearly needed. Such work has
great potential to provide important information for
resource management and efficient delivery of services in
school and health care. The objectives of this study were to
describe the epidemiology of ADHD, using a DSM-IVTR
case definition that includes multiple informants and mul-
tiple settings, among community-drawn samples of ele-
mentary-age children.
Method
To directly address the DSM-IVTR criteria for ADHD, this
study used a two-phase design. In the first phase, school
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district-wide behavioral screenings were conducted by ele-
mentary school teachers within four school districts in
South Carolina (SC) and Oklahoma (OK). In the second
phase, parents (or caregivers) of children who met high- or
low-screen criteria were invited to participate in direct,
structured interview assessments of ADHD, co-occurring
conditions, treatment history, demographics, and health-
risk behaviors. A strict, DSM-IVTR-based case definition
was developed and applied to generate weighted estimates
of ADHD within each of the two sites. A detailed descrip-
tion of each phase is included below.
Phase I
Sampling population. Four school districts were targeted:
one large district in SC (15 schools) and three districts in OK
(20 schools). All elementary schools in three of the districts
participated; in one large OK district, 8 of the 65 schools in
the district were systematically selected to participate, and
7 schools participated. The communities included rural,
suburban, and urban neighborhoods, and reflect a diverse
student population.
The sampling universe included children in mainstream
elementary classrooms (8,487 in SC; 7,212 in OK), target-
ing kindergarten through fifth grade. Screening included a
small number of elementary schools that offered a sixth
grade (OK only), and preK programs. Demographic charac-
teristics are presented for the district and the screened popu-
lations in Table 1.
Screening procedures. Participating teachers rated each
classroom student on the presence of ADHD core symp-
toms (Vanderbilt ADHD Diagnostic Teacher Rating Scale
[VADTRS]; Wolraich et al., 2003), general behavior and
associated functioning (the Strength and Difficulties Ques-
tionnaire [SDQ]; Goodman, 2001), and two questions about
previous ADHD diagnosis (“Has this child been diagnosed
with ADHD or ADD?”) and current ADHD medication
treatment (“Is the child on medication for ADHD or
ADD?”). A screening form was sent home by teachers, ask-
ing parents the same two questions about diagnosis and
treatment. Research staff received research numbers, but no
identifying information; school personnel retained names
and research numbers, but no assessment results.
Data from teachers and parents were used to divide the
children into two strata from which eligible Phase II partici-
pants were drawn: those likely to have ADHD (high screen)
and those not likely to have ADHD (low screen). Children
were categorized as high screen if they (a) had six or more
ADHD core symptoms in either or both ADHD dimensions
on the Vanderbilt scale and intermediate impairment ratings
on the SDQ or (b) received an ADHD diagnosis or were
taking medication for ADHD, based on either the parent or
teacher report. The remaining children were categorized as
low screen.
Wolraich et al. 565

Table 1. Characteristics of the Project to Learn About ADHD in Youth School Population and Screened Sample, by Site.

Participating school population Screened sample

South Carolina Oklahoma South Carolina Oklahoma

(n = 8,694)a (n = 7,212) (n = 4,606) (n = 5,851)

  n % n % n % n %
Gender
 Male 4,411 51 3,730 52 2,332 51 2,993 52
 Female 4,283 49 3,482 48 2,272 49 2,780 48
Race/ethnicity
  African American (NH) 4,573 53 969 11 2,172 51 611 10
  American Indian (NH) 22 <1 1,166 16 9 <1 708 12
  Caucasian (NH) 3,226 37 3,369b 48b 1,736 41 2,755 47
 Hispanic 411 5 1,708 24 200 5 1,574 27
b b
  Others (NH) 462 5 102 2 126 2
Grade level
 PreK 262 3 589 8 183 4 465 8
 K 1,284 15 1,152 16 824 18 907 16
 1st 1,424 16 1,188 16 667 15 959 16
 2nd 1,359 16 1,094 15 745 16 881 15
 3rd 1,397 16 1,064 15 746 16 802 14
 4th 1,459 17 1,073 15 865 19 854 15
 5th 1,509 17 1,052 15 566 12 953 16
a
Demographic characteristics were not available at the district level by special education classification. Therefore, the population total includes those
children in self-contained classrooms. NH = non Hispanic.
b
Population estimates were only available for a combined Caucasian/Other classification.

Sampling procedures. Both sites used representative sam-
pling procedures. An eligible subsample was selected from
the two screening strata by taking all high screens and a
sample of low screens, proportionally (in OK) or frequency
(in SC) matched on gender. The school districts required a
process in which school staff contacted eligible families and
requested permission to release their information to study
staff. Families expressing an interest in study participation
(n = 1,167) were invited into the diagnostic phase (Phase II)
in which parents (n = 844; 73.3% of those invited) com-
pleted the diagnostic interview. Site-specific participation
rates are documented in Figure 1.
Phase II
Case ascertainment. Following screening, consenting
families were interviewed after a median 13 months in SC
(interquartile range [IQR] = 8-16 months) and 10 months in
OK (IQR = 6-12 months), using modules of the parent
DISC-IV (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone,
2000) parent report (generalized anxiety disorder, obsessive
compulsive disorder, posttraumatic stress disorder, major
depression/dysthymic disorder, mania/hypomania, ADHD,
oppositional defiant disorder, conduct disorder), a health-
risk behavior survey, and a demographic survey. In most
cases, the participating caregiver was the child’s mother
(94% SC and 86% OK). DISC-IV interviews completed in
OK were primarily conducted via telephone with most other
measures returned by mail, due to large catchment size; in-
person interviews were conducted to accommodate hearing
difficulties or Spanish translation. SC interviews were com-
pleted primarily in person; written measures were collected
during the interview or returned by mail. Participants were
given an incentive (gift cards or checks) for participation.
Demographic characteristics of the interviewed sample
are presented in Table 2. Parents were notified of probable
diagnoses and given referral information when requested,
following review of the DISC reports by a clinician. Triage
protocols were in place for timely response to identified
risks of harm to self or others or reported abuse. All study
procedures were reviewed and approved by the Institutional
Review Boards of the Centers for Disease Control and
Prevention, and respective universities.
ADHD Study Case Definition
The DSM-IVTR case definition was based on ADHD symp-
tom counts (at least six of nine symptoms in either or both
of the inattentive or hyperactive/impulsive subscales),
impairment ratings (at least one DISC-IV impairment

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566 Journal of Attention Disorders 18(7)

South Carolina Oklahoma

Teacher and/or
Parent Screen

8487 7212

45.7% 54.3% 18.9% 81.1%

(Catchment)
Population
Screening

3881 1361
4606 5851
Children not Children not
Screened Screened
Screened Screened

52.1% 47.9% 71.4% 28.6%

Interview
Eligible*

2400 2206 4180 1671

Ineligible Eligible Ineligible Eligible

71.3% 28.7% 67.9% 32.1%

21.8% 22.4%
Recruitment
Interview

1573 1134
633 537
Not Not
Recruited Recruited
Recruited Recruited

24.0% 76.0% 30.4% 69.6%

Diagnostic
Interview

152 Parents 163 Parents

Parent

481 Parents 374 Parents

Not Not
Interviewed Interviewed
Interviewed Interviewed

Figure 1. Project to Learn about ADHD in Youth screening and case ascertainment flowchart.
a
All high screens and a gender frequency-matched sample of low screens were eligible for recruitment into the diagnostic interview phase. Eligible
families were approached for an interview if a letter was returned, indicating consent to be contacted for the study.

domain rated severe, or two rated moderate), and a report of • Six or more symptoms plus positive impairment
age of onset from the diagnostic interview of parents (Figure rating and age of onset before 7 years, as reported
2). Case criteria were met through endorsement of the fol- by parents during the interview phase, and four or
lowing criteria: five screening symptoms, as reported by teachers
(Figure 2, case inclusion Group g).
High-screen children (six or more symptoms plus
some impairment, as reported by teachers) Low-screen children (fewer than six symptoms and/or
no impairment due to reported symptoms, as reported
• Six or more symptoms plus positive impairment by teachers; no report of ADHD diagnosis or current
rating and age of onset before 7 years, as reported ADHD medication by the teacher or parent)
by parents during the interview phase (Figure 2,
case inclusion Group h). • Six or more symptom plus positive impairment rat-
ing and age of onset before 7 years, as reported by
High-screen children (report of ADHD diagnosis parents during the interview phase; and four or five
or current ADHD medication by the teacher or symptoms and some SDQ impairment, as reported
parent) by teachers (Figure 2, case inclusion Group f).

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Wolraich et al. 567

Table 2. Characteristics of the Project to Learn About ADHD in Youth Interview Participants, by Site.

Interviewed sample

South Carolina (n = 481) Oklahoma (n = 374)

n Weighted % 95% CI n Weighted % 95% CI

Gender
 Male 323 49.1 [46.1, 52.1] 264 53.2 [47.8, 58.5]
 Female 158 50.9 [48.0, 53.9] 110 46.8 [41.5, 52.2]
Ethnicity/race
  African American (NH) 184 50.6 [44.3, 56.9] 41 8.5 [4.7, 14.9]
  American Indian (NH) 0 0.0 — 40 8.7 [5.4, 13.6]
  Caucasian (NH) 269 44.2 [38.1, 50.5] 225 50.5 [41.5, 59.6]
 Hispanic 21 3.4 [1.8, 6.2] 44 26.1 [17.3, 37.2]
  Others (NH) 7 1.8 [0.4, 7.6] 24 6.3 [3.0, 12.7]
Grade level
 PreK 21 7.1 [4.2, 11.7] 26 7.1 [3.3, 14.4]
 K 69 19.1 [13.8, 25.8] 45 16.1 [9.9, 25.0]
 1st 68 12.3 [9.2, 16.4] 68 19.7 [13.4, 28.0]
 2nd 89 15.0 [11.4, 19.4] 49 9.4 [5.6, 15.4]
 3rd 96 20.3 [15.6, 26.1] 47 10.4 [6.7, 15.9]
 4th 87 17.5 [13.4, 22.5] 64 16.6 [8.7, 29.5]
 5th 51 8.7 [6.1, 12.2] 75 20.7 [13.1, 31.3]
Age
  5-7 years old 140 32.5 [26.5, 39.2] 102 30.0 [21.4, 40.3]
  8-10 years old 235 45.9 [39.7, 52.3] 146 42.1 [31.8, 53.2]
  11-13 years old 106 21.6 [17.1, 26.8] 126 27.9 [19.9, 37.5]
Insurance
  Private insurance 335 76.4 [70.8, 81.2] 117 35.8 [28.9, 43.4]
 Medicaid 100 18.3 [14.2, 23.2] 235 53.0 [42.3, 63.4]
No insurance  17 3.2 [1.8, 5.6] 30   16.6 [8.7, 29.4]
Caregiver education
  <High school 10 1.5 [0.8, 3.1] 83 31.4 [22.8, 41.7]
  High school grade 54 10.9 [7.5, 15.6] 85 21.6 [13.9, 32.1]
  Some college 209 38.7 [32.9, 44.8] 176 35.4 [27.0, 44.8]
  College graduate+ 192 48.9 [42.5, 55.4] 30 11.6 [6.7,19.3]
Annual income
 <US$20,000 53 8.8 [6.2, 12.2] 149 41.4 [31.6, 51.9]
 US$20,000-US$45,000 120 25.7 [20.7, 31.5] 174 41.0 [31.5, 51.2]
 US$45,000-US$70,000 107 27.0 [21.3, 33.7] 29 8.6 [5.1, 13.9]
 >US$70,000 170 38.5 [32.3, 45.1] 22 9.1 [4.9, 16.1]
Note: CI = confidence interval.

Children who were medicated at the time of the DISC-IV
were excluded as cases if they did not otherwise meet the
preceding case criteria.
Analysis
Selection of participants was by a multistage sampling strati-
fied design by district. Therefore, sampling weights were cal-
culated to account for the differential sampling design
(screening status and gender) as well as adjustments for nonre-
sponse. When applied, the weights produce estimates that more
closely reflect the demographic characteristics of the sampled
district populations. Consideration of the complex design fea-
tures in the analytic phase results in asymptotically unbiased
estimates and standard errors. This sampling design was devel-
oped and executed within each of the school districts sepa-
rately, and district-level estimates therefore best represent the
population of children in that district.
SAS version 9.2 was used for data management; analy-
ses were conducted using SAS-callable SUDAAN 10.0.

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568 Journal of Attention Disorders 18(7)

Figure 2. Project to Learn about ADHD in youth case definition diagram.

Note: DISC = Diagnostic Interview Schedule for Children.

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Wolraich et al. 569
Confidence intervals (CIs) are presented alongside weighted
point estimates as an indicator of precision; a relative stan-
dard error greater than 30% was used as an indicator of sta-
tistical instability. Inferential tests of association for weighted
analyses were based on Fellegi-adjusted Wald F statistics
(Fellegi, 1980). More details on the design can be found in
the appendix.
Results
Site participation rates can be found in Figure 1. The SC
screened sample included 4,606 children (54.3% of the dis-
trict’s population). The OK screened sample included 5,851
children (81% of the three districts’ population). Children were
not screened for one of three reasons: (a) The teachers did not
complete the screener, (b) the children were not included in the
screening universe (i.e., self-contained special education class-
rooms), and (c) the parents indicated that they did not want their
child screened. Of those meeting eligibility requirements,
28.7% in SC (633) and 32.1% in OK (537) returned a letter sent
by their school, indicating interest in participating in the study.
Ultimately, of those volunteering for the study, 76% of SC and
70% of OK were interviewed.
Overall, 8.7% (95% CI = [7.2, 10.5]) of the children in
SC (99 cases) and 10.6% (95% CI = [7.5, 14.9]) of the chil-
dren in OK (117 cases) met the case definition. In OK, the
weighted prevalence was 15.3% (95% CI = [9.4, 23.8]) for
the suburban/rural district (54 cases), 9.0% (95% CI = [4.2,
18.5]) for the urban district (29 cases), and 9.1% (95% CI =
[6.3, 13.0]) for the rural district (34 cases). The OK district
estimates were not significantly different, nor were they
explained by variations in within-stratum teacher screening
scores. Combining the SC and OK samples, the district indi-
cator was not statistically significant, nor were any of the dis-
trict pairwise comparisons (all multiple-comparison adjusted
p values > .17). Of the 258 high screens for SC, 36.8% met
the case definition, whereas of the 223 low screens, only
1.8% met the case definition.
Among children meeting the case definition, the percent-
age of parent-reported ADHD medication use in the last
month in SC was 46.7%, compared with 19.3% for OK.
Overall, the percentage of children taking ADHD medica-
tion was 10.1% in SC and 7.4% in OK; 4.0% in SC and
2.1% in OK met the case definition despite medication, and
6.1% in SC and 5.4% in OK were on medication and did not
meet the case definition.
The two sites exhibited comparable differences in preva-
lence across most sociodemographic factors (Table 3).
Thus, the data were pooled across sites for the purpose of
making demographic comparisons. Pooled prevalence esti-
mates were higher among males (13.6% vs. 5.3%), F(1,
835) = 20.8, p < .01, children covered under Medicaid
(13.7% vs. 6.5%), F(1, 808) = 13.1, p < .01, and families
earning less than US$45,000 per year (12.1% vs. 5.1%),
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F(1, 804) = 16.4, p < .01. Small race/ethnic group sample
sizes limited race/ethnicity comparisons within the OK
sample and race/ethnic group comparisons across sites. A
comparison of prevalence among the largest racial groups
in SC (Caucasian and African American) was not statisti-
cally significant, nor was the cross-site difference in preva-
lence among Caucasians. At both sites, the mean symptom
counts for medicated comparison children were signifi-
cantly higher than for unmedicated comparison children
(pooled M = 5.6 vs. 2.2), F(1, 619) = 40.6, p < .01.
Discussion
This study provides ADHD prevalence estimates in com-
munities (school districts) based on a multistage screening
and a DSM-IVTR diagnostic interview process, including
multiple reporters (parents and teachers). The percentage
of children meeting the case definition for ADHD was
8.7% in SC and 10.6% in OK. Our overall prevalence
rates were higher than previous community-based esti-
mates and were at the middle to upper end of the range
found in a 2001 systematic review (Brown et al., 2001).
The creation of subtypes in DSM-IVTR could be a contrib-
uting factor; however, parent-reported rates have increased
steadily since 1998 (Akinbami et al., 2011), suggesting
that other factors may be influencing the epidemiology of
ADHD, including changes in the cultural acceptance of
ADHD and health care provider characteristics (Eiraldi,
Mazzuca, Clarke, & Power, 2006; Fulton et al., 2009).
Other hypothesized contributing factors include changes
in access to care, increased awareness of the condition,
changing sociodemographic patterns within the United
States, and changes to state-based policy and screening
program efforts (Berry, Bloom, Foley, & Palfrey, 2010).
Our prevalence estimates may be conservative because
we did not include self-contained special education class-
rooms in our sampling design. Furthermore, 5.7% of sam-
ple children were taking ADHD medication but did not
meet our study’s case definition. Some of the medicated
children were likely cases who were adequately managed
with medication. These children were not included in the
case definition because those adequately managed and
those inappropriately treated were indistinguishable.
Notably, medicated comparison children had roughly dou-
ble the number of core symptoms than unmedicated com-
parison children; however, their symptom counts were less
than half those of cases.
The SC and OK sites differed demographically, with the
OK samples having lower incomes, less parental education,
a higher rate of Medicaid coverage, and a lower rate of pri-
vate insurance, all suggesting a lower socioeconomic level
among the OK sample. These demographic differences
could contribute to the higher prevalence of ADHD found
in OK and higher medication use in SC.
570 Journal of Attention Disorders 18(7)

Table 3. Project to Learn About ADHD in Youth Case Prevalence by Site and Demographic Factors.

South Carolina Oklahoma

Prevalence rates Weighted % 95% CI Weighted % 95% CI

Gender
 Male 13.0 [10.4, 16.1] 14.1 [9.5, 20.4]
 Female 4.6 [3.2, 6.8] 6.8a [3.3, 13.3]
Ethnicity/race
  African American (NH) 8.9 [6.4, 12.3] 12.0a [5.7, 23.8]
  Caucasian (NH) 7.9 [6.1, 10.2] 9.4 [7.3, 11.9]
Age
  5-10 years old 8.5 [6.9, 10.5] 8.8 [5.9, 12.9]
  11-13 years old 9.5 [5.6, 15.7] 15.4a [7.7, 28.4]
Insurance
  Any insurance 8.2 [6.7, 10.0] 11.8 [8.1, 16.9]
  Private insurance 8.0 [6.3, 10.1] 6.3 [4.6, 8.8]
 Medicaid 13.5 [9.2, 19.5] 14.6 [9.0, 22.9]
  No insurance 17.8a [6.8, 39.2] 3.8a [1.5, 9.1]
Caregiver education
  HS degree or less 15.2 [9.3, 23.9] 10.8a [5.6, 19.6]
 Some college or technical training 7.6 [6.0, 9.6] 10.5 [8.2, 13.4]
  or more
Annual income
 <US$20,000 14.9 [8.7, 24.3] 9.1 [6.1, 13.2]
 US$20,000-US$45,000 12.3 [8.2, 17.9] 14.8 [8.1, 25.3]
 >US$45,000 5.5 [3.9, 7.6] 4.8 [2.7, 8.4]
Note: CI = confidence interval.
a
Relative standard error (100% × SE/prevalence) > 30%.

Of the cases, 54.6% in SC and 80.7% in OK had not taken
ADHD medication in the past month. This finding supports
previous national reports of the geographic variability of
ADHD medication treatment (Centers for Disease Control
and Prevention, 2005). Froehlich et al. (2007) reported a
similar rate of ADHD medication; 68% of those who met
ADHD criteria had not taken ADHD medication in the pre-
vious year. Taken together, these data suggest that the major-
ity of children who meet ADHD criteria, independent of
diagnostic status, are not taking ADHD medication.
Study Strengths and Limitations
School-based samples can be used to efficiently collect
behavioral information about children in communities, and
these data are more likely to be generalizable than data from
clinical samples. Teachers are valuable respondents, because
they observe students for up to 6 hours per day; however,
they may not be aware of students’ diagnoses and treat-
ment. Parents usually are aware of diagnoses and treatment,
and observe their children in varying circumstances, but they
can be difficult to access in a defined community-sampling
frame, such as a school district. Therefore, combining
teacher and parent information may yield the strongest psy-
chometric approach for identifying cases in a community.
However, the estimates in this study may not be generaliz-
able to other geographic areas or to children not enrolled in
mainstream public school classrooms.
Importantly for this study, the case definition relied on
parent and teacher reports and did not incorporate clinical
information or judgment. In addition, the interview phase
yielded approximately 30% of all of those who might have
been interviewed (all eligible), due to school district regula-
tions on how personally identifiable information could be
released. Lower response rates among eligible participants
increases the risk of response bias; however, there was no
evidence of systematic biases within our samples. In addi-
tion, nonresponse adjustments were made for lower recruit-
ment of African American students in SC and African
American and Hispanic students in OK, yet the weighting
methods somewhat underestimated race/ethnic group size
in OK. Unmeasured bias is also possible, including bias
introduced by greater participation of parents of children
with ADHD.
Conclusion
Estimates from this community-based study corroborate the
high prevalence (7.8%-9.5%) of ADHD found in recent parent-
reported surveys (Centers for Disease Control and Prevention,

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Wolraich et al. 571
2005, 2010). Although typical gender ratios were found, there
were no differences between Caucasian and African American
children. Many children meeting case criteria had not been
previously identified and were not receiving medication treat-
ment, suggesting that the condition remains underdiagnosed
for some children. In addition, many diagnosed children were
not receiving treatment that adequately reduced their core
symptoms and impairments. The impact of untreated ADHD
is serious, with school failure, dropout, and poor functioning
in adulthood common for these children (Ingram, Hechtman,
& Morgenstern, 1999). This information lends itself to the
development of community or school-based programs that
address the needs of this large, school-age population. In
addition, clinicians should use rigorous assessment proce-
dures such as those recommended by the practice parameters
of the American Academy of Child and Adolescent Psychiatry
and the AAP (AAP’s Subcommittee on Attention-Deficit/
Hyperactivity Disorder Steering Committee on Quality
Improvement and Management, 2011; Pliszka & AACAP
Work Group on Quality Issues, 2007). These parameters call
for thorough assessment, input from parents and teachers,
and the use of standardized behavior rating scales to diag-
nose children with ADHD.
Appendix
Complex Sample Design and Analysis
Study origin and purpose. In 2003, the Centers for Disease
Control and Prevention, National Center on Birth Defects
and Developmental Disabilities, provided funding to the
University of Oklahoma Health Sciences Center and Uni-
versity of South Carolina to conduct a study to determine
the prevalence of ADHD among elementary school-age
children, including preK students and some sixth graders
when present in a qualifying school. This sampling universe
included children and youth of ages 4 to 13. The stated pur-
pose of the study was to determine the prevalence of ADHD
based on DSM-IVTR criteria in school-based samples of
elementary school–age children.
Sampling design. A multistaged, stratified random sam-
pling design was used for selection of the ultimate primary
sampling units (PSU)—students within a select population
of school districts. A stratified sampling design was selected
to ensure all strata segments of the population were repre-
sented and to allow estimation of stratum-specific estimates
of interest with prespecified statistical precision. The four
strata selected for sampling represented cross-segments of
two factors associated with ADHD risk: child gender and
brief reports of ADHD symptoms (child inattention,
hyperactivity, and impaired function). The latter factor was
not readily available and was therefore assessed first within
the populations of interest. Efforts to collect these data from
both teachers and parents were extended to all public schools
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within the population of selected school districts. The Okla-
homa City (OKC) school district was the sole exception,
where, for feasibility reasons, only eight schools were
invited to participate and only seven agreed. The invited
schools within OKC were selected by the school adminis-
tration to reflect the characteristics of that entire district.
To ensure a high response rate, study investigators ini-
tially met with school administrators to gain strong support
for the study. Similar meetings with all teachers in each
school were held to encourage participation. Incentives were
provided to the school to optimize response rates. Ultimately,
the study obtained ratings on 81% and 53% of the children
in the OK and SC schools, respectively. Screening informa-
tion was available from teachers and parents (teachers sent
home a supplemental, brief questionnaire asking whether
their child was diagnosed with ADHD and/or was on a medi-
cation for ADHD) for 53.7% of SC and 27.9 % OK for the
screening sample. ADHD risk status was determined based
on screening information with “High Risk” reflecting
(a) core symptom requirements for ADHD on the VADTRS
and a score of at least 1 (borderline) on a 0-to-6 scale for
associated impairment based on the SDQ, (b) teacher- or
parent-reported diagnosis of ADHD, or (c) teacher or parent
report of current ADHD medication treatment.
Based on stratum factors (gender was also available
from the returned screening instruments), the random selec-
tion of students within each of the four strata was the second
phase of the sampling design. The relative size of the ran-
dom selection within each stratum was based on a priori
expectations of higher variability of prevalence estimates in
high-risk groups and, relatedly, a desire to increase the num-
ber of sampled cases by oversampling high-screen children.
All high-risk individuals were eligible for recruitment for
participation. In OK, a proportionally matched (by gender)
sample of low-screen individuals was selected from a tar-
geted recruitment pool of roughly 500 children. In SC, a
random sample of low-screen children, frequency matched
by gender, were selected for further recruitment. The total
recruitment samples (our “interview-eligible” subsample)
consisted of 1,671 children in OK and 2,206 children in SC.
Staff successfully contacted 32.1% (n = 537) and 28.6% (n =
630) of these individuals (recruitment occurred if partici-
pants agreed to be contacted about the study), and 69.6%
(374) and 76.3% (481) of those contacted participated in an
interview in OK and SC, respectively.
The study aimed to infer all estimates back to school dis-
tricts that were invited to participate in the screening phase
of the design. Population data on student enrollment in all
eligible schools were collected in SC at the start of the study
and retrospectively collected for appropriate years in OK
from each school district’s administrative body. Sampling
weights were calculated in a series of steps to account for the
multistage sampling procedure. First, nonresponse weights
were generated for the initial teacher and parent responses
572 Journal of Attention Disorders 18(7)
based on the inverse of the ratio of returned screens to the
administrative child enrollment counts. Response rates for
schools varied moderately, so separate nonresponse weights
were generated for each participating school. Second, a sam-
pling rate was estimated for the random selection of interview-
eligible comparison (low screen) children from the total
number of low screens returned. The inverse of this selection
rate, stratified by gender and school district, served as the
Stage 2 weight for the comparison children. All of the high-
screen children from the screening sample were included in
the interview-eligible sample and, therefore, each received a
Stage 2 weight of 1. Third, nonresponse rates for recruitment
and successful interview were estimated and multiplied with
the Stage 1 and 2 weights to generate preliminary population-
based weights for each interviewed parent. These preliminary
weights were then passed through a final poststratification
procedure that adjusted for response rate differences between
weighted sample estimates and population estimates of race.
Poststratification adjustments for child gender and grade were
also considered but determined unnecessary (i.e., only minor
differences existed between population and sample estimated
gender and grade distributions). Weights in OK ranged from
2.43 to 327.49, with a median weight of 4.69 and an IQR of
3.70 to 9.13. Weights in SC ranged from 3.34 to 199.58, with
a median weight of 10.73 and an IQR of 6.00 to 25.14.
Statistical analysis. All analyses of these data used the SAS®-
callable version of SUDAAN® (10.0). This specialized soft-
ware allows for a variety of complex sample design
adjustments, which produce asymptotically unbiased sam-
pling-universe inferences with appropriately adjusted standard
errors. A District × Gender × Screening status stratification
variable was used to adjust the estimation of point estimates of
population proportions, means, and measures of association. A
finite population correction term was also used in analysis to
control for the sampling of individuals within these strata with-
out replacement. The children sampled reflect our PSU of
analysis, so our design can be conceptualized as a Stratified
Without Replacement sampling of elementary school-age chil-
dren. Four of the OK parents did not complete the entire inter-
view assessment battery. The case definition of ADHD for the
children of these four parents was scored as missing due to
insufficient Diagnostic Interview Schedule for Children–IV
(DISC-IV) data. The sample weight calculations did consider
these families, however, and all analyses included these indi-
viduals (for population weighting purposes) and treated the
absent DISC-IV outcomes as missing completely at random
within strata (Rubin, 1976) with an appropriate adjustment to
the estimated standard errors.
Disclaimer
The findings and conclusions in this report are those of the authors
and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
Downloaded from jad.sagepub.com at The University of Edinburgh on June 9, 2015
Acknowledgements
The authors wish to acknowledge the early contributions of
those who participated in the collaborative meetings that led to
the development of the screening protocol and design phase of
the Project to Learn about ADHD in Youth. Contributors
included: Dr. Edward Brann, Dr. Sandra Evans, Kurt Heisler,
Dr. Gretchen LeFever, Dr. Catherine Lesesne, Dr. James Paulson,
and Dr. Ruth Perou. We would like to further acknowledge
Dr. Angelika Claussen for her assistance with manuscript for-
matting and the statistical and data management assistance from
Dr. Cheryl Addy, Dr. Charity Moore, Gina Babka-Bryan, and
Donna Wells.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: The lead author has been a consultant to Shire, Lilly,
Shinoghi and Nextwave pharmaceutical companies.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
manuscript was supported by the Centers for Disease Control and
Prevention through cooperative agreements U50/CCU622315-02
and U84/CCU422516-02 and contracts 200-2006-18912 and
200-2006-18949.
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Author Biographies
Mark L. Wolraich, MD, is the Chief of the Section of
Developmental and Behavioral Pediatrics in the Department of
Pediatrics at the University of Oklahoma Health Sciences Center
(UOHSC). He is the CMRI Shaun Walters Professor of Pediatrics
and the Edith Kinney-Gaylord Residential Professor. He is the
UOHSC Principal Investigator for the Project to Learn about
ADHD in Youth.
Robert E. McKeown,PhD, is Distinguished Professor Emeritus
and Past Chair of the Department of Epidemiology and Biostatistics
at the University of South Carolina. He is past president of the
American College of Epidemiology and past chair of the
Epidemiology Section of the American Public Health Association.
His research focuses on psychiatric epidemiology and public
health ethics. He is the University of South Carolina Principal
Investigator for the Project to Learn about ADHD in Youth.
Susanna Visser, MS, is the Lead Epidemiologist for the Child
Development Studies Team within the National Center on Birth
Defects and Developmental Disabilities at the Centers for Disease
Control and Prevention (CDC). Ms. Visser’s expertise includes
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the analysis and design of longitudinal and population-based epi-
demiological studies of neurobehavioral and mental health condi-
tions, including ADHD and Tourette Syndrome. She is the CDC
Principal Investigator for the Project to Learn about ADHD in
Youth.
David Bard, PhD, is an Assistant Professor in the Department of
Pediatrics at the University of Oklahoma Health Sciences Center.
His research interests include medical decision-making, behavior
genetics, clinical trials methodology, longitudinal analyses, and
testing and measurement in the behavioral sciences. He is a
Co-Investigator of the UOHSC Project to Learn about ADHD in
Youth.
Steven P. Cuffe, M.D. is Professor and Chair of the Department
of Psychiatry at the University of Florida College of Medicine-
Jacksonville. He has spent 20 years researching the epidemiology,
risk and protective factors of child and adolescent psychiatric
disorders. He is the Co-Principal Investigator of the University of
South Carolina Project to Learn about ADHD in Youth.
Barbara Neas, PhD is a David Ross Boyd Professor of
Biostatistics in the Biostatistics and Epidemiology Department,
School of Public Health, Oklahoma University Health Sciences
Center. Her expertise is in the area of categorical data analysis of
independent and mixed data obtained from longitudinal and sur-
vey designs. She was a statistician for the OUHSC Project to
Learn about ADHD in Youth.
Lorie L. Geryk, MPH, is the Project Manager for the University
of South Carolina Project to Learn about ADHD in Youth. She is
currently completing her doctoral degree in Public Health at the
University of South Carolina.
Melissa Doffing, MA, was the Project Manager for the University
of Oklahoma Health Sciences Center Project to Learn about
ADHD in Youth. Ms. Doffing has experience in managing multi-
ple federal and state funded community-based research projects
and contributed her expertise in database design and data
management.
Matteo Bottai, ScD, is the Head of the Unit of Biostatistics,
Institute of Environmental Health, Karolinska Institutet,
Stockholm, Sweden. He received his Laurea degree in Mathematics
summa cum laude from University of Pisa, Pisa, Italy, and his
doctoral degree in Biostatistics from the Harvard School of Public
Health, Boston, MA. His current research focuses on statistical
methods for modeling and estimation of conditional percentiles
and served as a statistician for the University of South Carolina
Project to Learn about ADHD in Youth.
Ann J. Abramowitz, PhD, is a Professor of Practice in the
Department of Psychology and an Associate Professor of
Wolraich et al. 575

Psychiatry and Behavioral Sciences at Emory University. She is
the Director of Assessment in Emory’s doctoral program in
Clinical Psychology and is Chair of the Professional Advisory
Board of Children and Adults with ADHD (CHADD). She pro-
vides consultation to the CDC on ADHD and related areas.
Laoma Beck, MD, served as Project Manager during the final
years of data collection for the Project to Learn about ADHD in
Youth. She is the mother of two happy and healthy children.
Joseph R. Holbrook, PhD, is an Associate Service Fellow in the
Child Development Studies Team within the Centers for Disease
Control and Prevention. Prior to this position, he was a student,
graduate assistant, and data manager for the University of South
Carolina Project to Learn about ADHD in Youth (PLAY).
Melissa Danielson, MSPH, is a health scientist with the Child
Development Studies Team within the National Center on Birth
Defects and Developmental Disabilities at the Centers for Disease
Control and Prevention. Her work includes epidemiological
analyses related to ADHD and other mental, emotional and behav-
ioral conditions among children, and the epidemiology of health
outcomes among children with disabilities. She served as the data
manager of the CDC Project to Learn about ADHD in Youth.

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