Children and Youth Services Review 136 (2022) 106441

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Prevalence and correlates of mental health disorders among children &

adolescents in U.S.
Glory Okwori
Department of Health Services Management and Policy, East Tennessee State University, United States

A R T I C L E I N F O A B S T R A C T

Keywords: The purpose of this study was to determine the national prevalence and correlates of currently diagnosed
Prevalence attention deficit/hyperactivity disorder (ADHD), behavioral problems, anxiety and depression among U.S.
Mental health disorders children aged 3–17 years. Data from the 2018 National Survey of Children’s Health (NSCH) was analyzed.
Characteristics
Parents/caregivers reported whether their children currently had each mental health condition. Chi square
analyses and multivariate logistic regressions were utilized to examine the prevalence of conditions and assess
independent associations based on selected sociodemographic characteristics. Weighted prevalence estimates
were calculated for the study population (n = 26,572). The study found that 8.6% currently had ADHD, 6.9%
currently had behavioral disorders, 8.0% currently had anxiety, 3.7% currently had depression and 16.1% had
any of the four conditions. The prevalence of each disorder was higher for older age, Whites (except for
behavioral disorders which were higher for Blacks), public insurance, single parent households, children living
with non-parents, parent/caregiver mental/emotional health, and non-users of medical home when comparing
individuals who had these disorders to those without the disorders. Condition-specific variations were observed.
Children with public and private insurance, single parents/non-parents, mentally ill parents and not receiving
care in a medical home were more likely to be diagnosed with mental health disorders. These findings provide
the latest data on a broad range of mental health disorders in a nationally representative sample of U.S. children
and adolescents and show that these problems are prevalent which highlight the need for prevention and early
intervention.

1. Introduction 2020). Mental health disorders also account for the largest share of
heath care expenditure for health problems in children (Agency for
Mental health disorders in children can be described as critical Healthcare Research and Quality, 2015).
changes in the way children behave, learn, or deal with their emotions A review of the burden of mental health disorders concluded that
which can lead to distress and affect their cognitive functioning and mental health problems often begin at an early age in childhood, thus,
behaviors (Centers for Disease Control and Prevention, 2020). Occa­ early identification and interventions are critical (Kessler et al., 2009).
sionally, children may have problems such as worries and fears or Pre-school aged children with mental health problems may be treated
disruptive behaviors; however, if the symptoms are persistent, severe without a mental health diagnoses because the diagnoses and treatment
and interfere with the activities of children, they may be diagnosed with in this age group are complex (Ali et al., 2018). Mental health problems
mental health disorders. These disorders can also disrupt the ability for persist for a long time, do not go away completely and can continue
children to function properly in terms of cognitive or social behaviors. throughout lifetime into adulthood (van Duin et al., 2019).
It has been estimated that between 13% and 20% of children in the The prevalence and distribution of a wide range of mental health
United States experience a mental health problem every year and the problems in children, which is important for prevention, treatment and
costs to individuals, families and the society has been estimated to be resource allocation, has not been well studied (Ghandour et al., 2019).
approximately $247 billion (Centers for Disease Control and Prevention, Thus, a more comprehensive assessment of mental health disorders in
2020). The most common mental disorders diagnosed in children are children is needed. Furthermore, various mental health issues have been
attention-deficit/hyperactivity disorder (ADHD), behavior disorders, assessed together rather than separately (World Health Organization,
anxiety and depression (Centers for Disease Control and Prevention, 2020). The social ecological model provides a conceptual framework to

E-mail address: [email protected].

https://doi.org/10.1016/j.childyouth.2022.106441
Received 16 July 2021; Received in revised form 9 February 2022; Accepted 21 February 2022
Available online 25 February 2022
0190-7409/© 2022 Elsevier Ltd. All rights reserved.
G. Okwori Children and Youth Services Review 136 (2022) 106441

identify the factors associated with mental health problems such as in­ dichotomous variable measuring whether the child currently has the
dividual, family factors and community or societal factors and their condition was created and coded as (0) does not currently have condi­
interaction with each other. The strong connection between parental tion; or (1) currently has condition. The outcome measures were limited
characteristics and mental health problems in adolescents indicate the to those children whose caretakers provided definite responses and
relevance of the family context within the development of mental health current cases of the mental health outcomes of interest to reduce the
problems (Merikangas et al., 2010). temporal limitations due to the cross-sectional design of the study.
Most national surveys on mental disorders have focused on adoles­
cents or did not evaluate multiple diagnoses. Recent trends suggest that 2.3. Measures of covariates
even though the prevalence of certain childhood mental disorders have
been relatively stable, several have increased (Ghandour et al., 2019). Demographic information such as child sex, age (3–5, 6–11, and
Prior studies that examined adverse childhood experiences (ACEs) and 12–17 years), race/ethnicity, family structure (two married parents, two
internalizing behaviors during childhood did not evaluate depression unmarried parents, single parent, nonparent/other relative), household
and anxiety separately. Only a small number of studies have evaluated educational level (less than high school/or high school diploma and
whether exposure to ACEs differentially affects the outcomes of some college or college degree/higher), insurance type (uninsured,
depression and anxiety (Elmore & Crouch, 2020). The prevalence of private and public insurance, private insurance, and public insurance),
specific mental disorders in children has implications for intervention and family poverty/income level (<100% FPL, 100–199% FPL,
efforts. Four mental health disorders are assessed within this study, 200–399% FPL, and ≥ 400% FPL) were included in the study. The se­
thereby adding relevant findings to the current state of research. lection of these variables is consistent with other studies that examined
This study examines the prevalence of mental disorders (ADHD, ACEs or mental health outcomes (Elmore & Crouch, 2020; Ghandour
behavioral disorder, anxiety and depression) in a nationally represen­ et al., 2019). NSCH provides imputed values that were used for the
tative sample of children, and describes the individual, familial and analysis. Both household poverty level and household educational level
community sociodemographic correlates of these mental disorders. This were imputed using regression methods (US Census Bureau, 2020).
study contributes to the literature by providing current estimates of Child sex, race/ethnicity were missing < 1% observations and were
various mental disorders in children and covers a broader range of ages imputed using hot-deck imputation.
and across multiple levels of influence. These findings are important for Elmore, Crouch, & Kabir Chowdhury (2020) noted that the mental
better understanding the current extent of the mental health disorders health of caregivers could impact exposure to ACEs, resilience factors or
among this population and informing the future program and advocacy mental health outcomes among children. As such, the mental or
efforts. emotional health of the parents or caregivers of the child were assessed
via survey questions that asked caregivers regarding their mental health
2. Methods status and categorized as excellent, very good/good and fair/poor.
Living and playing in safe and equitable environments have been shown
2.1. Study design & study population to be examples of positive childhood experiences or resilient factors
(Sege & Harper Browne, 2017). A response of yes or no to the survey
A cross-sectional study using secondary data from the 2018 National questions, “In your neighborhood is there a park/playground” or “In
Survey of Children’s Health (NSCH) was utilized. The NSCH is con­ your neighborhood is there a recreation center, community center, or
ducted by the United States Census Bureau, and the Maternal and Child boys’ and girls’ club ” were used as responses for the variable ‘oppor­
Health Bureau of the Health Resources and Services Administration to tunities for play and physical activity’. Living in a safe neighborhood
assess the health and well-being of children. was examined as two categories: agree and disagree.
The 2018 NSCH sample was compiled using 176,000 households Medical home initiatives have been identified as an important ser­
from the Census Master Address File nationally. The sample was strati­ vice for children with special needs (American Academy of Pediatrics &
fied at the state level and by a child-presence indicator, which allows for Medical Home Initiatives for Children With Special Needs Project
oversampling of households that were more likely to have children. A Advisory Committee, 2002) and is included in this study. Essential
total of 30,530 surveys were completed via web, paper and phone with qualities of a medical home has been defined as: accessible, continuous,
approximately 600 surveys per state and a response rate of 43.1% (Data coordinated, compassion, comprehensive, culturally effective and
Resource Center for Child and Adolescent Health, 2019). The survey family-centered care (National Resource Center for Patient-Centered
design has been described in detail elsewhere (US Census Bureau, 2019). Medical Home, 2020). The medical home variable criteria as
The study population consisted of noninstitutionalized children be­ measured by the NSCH was based on five components which include
tween the ages of 3 and 17 nationally whose parents or guardians having a personal doctor or nurse who knows the child’s health history
completed the survey. The study excluded children whose parents or well, usual source of care, family-centered care, receiving the necessary
caregivers did not answer survey questions related to mental health help to coordinate the child’s care and obtaining referrals for services.
outcomes ( This is a widely used measure that reflects the description of medical
n = 3,958). The final sample size included 26,572 children. home stated by the American Academy of Pediatrics and approved by
This study was approved by East Tennessee State University’s Insti­ the National Quality Forum (Child and Adolescent Health Measurement
tutional Review Board and was not considered as research that involved Initiative (CAHMI), 2009).
human subjects.
2.4. Statistical analysis
2.2. Measures of mental health disorders
The characteristics and demographics of the study population were
The presence of current mental health conditions was assessed using described by each mental health outcome (ADHD, anxiety, behavior
survey parent/caregiver’s responses to questions asking whether the disorders and depression). Given the study variables are categorical,
doctor had ever told the parent/caregiver that the child had ADHD, descriptive statistics were chi-square analysis used to examine the
anxiety, behavior disorders or depression (yes/no). If yes, a secondary mental health outcomes relative to individual, parental, and community
question asked whether the child currently had the condition (yes/no). or societal contexts of interest. Survey weights provided by the Census
The following response options in the dataset have been recommended Bureau were utilized to account for nonresponse and non-coverage and
to assess prevalence: “does not have the condition”, “ever told, but does reflect the US population of all noninstitutionalized children aged 0–17
not currently have the condition”, and “currently has the condition”. A years. The proportion of characteristics among groups were compared

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G. Okwori Children and Youth Services Review 136 (2022) 106441

using estimates of risk differences. Logistic regressions were performed poor were most likely to experience ADHD (23%), behavior disorders
to obtain unadjusted and adjusted odd ratios to assess associations of (25%) anxiety (29%) and depression (18%) compared to 8%, 6%, 7%
mental health outcomes with sociodemographic characteristics. De­ and 3% respectively of children with caregivers who had excellent, very
mographic variables are potential confounders of mental health out­ good or good health. Anxiety and depression were most common for
comes. All analyses were conducted using SAS Version 9.4. children who did not live in safe neighborhoods (11%, 7% respectively)
compared to children who lived in safe neighborhoods (8%, 3%
3. Results respectively). ADHD, behavior disorders, anxiety and depression were
most common for those who did not receive care in a medical home
The children in this study population were nearly equally divided (10%, 8%, 10% and 5% respectively) compared to children who
between males (51%) and females (49%; Table 1). Across the three age received care in a medical home (7%, 5%, 6% and 2% respectively).
groups, there were 19%, 40% and 41% of children aged 3–5 years, 6–11 Children who were older (12–17) had a greater probability of
years, and 12–17 years respectively. The majority of the sample was having ADHD, behavior disorders, anxiety and depression (13%, 7%,
non-Hispanic White (50%) while 14% were non-Hispanic Black and 26% 14% and 8% respectively) (Table 2). Children living in homes without
were Hispanic. Over one-quarter (30%) of children had public insur­ their parents as caregivers had increased risks of having all four diseases
ance, 57% had private insurance only and 9% were uninsured. Most (16%, 15%,13%,7%). The probabilities of having all four disorders
children lived with both parents who were married (61%) and had a given that caregivers had a high school education compared to those
caregiver respondent who had some college education or higher (70%). without a high school education were 12%, 9%, 10% and 5%. Having a
Approximately twenty percent of children lived below the federal caregiver whose health was fair or poor increases the risk of having all
poverty line and majority (88%) of the caregivers of the children re­ four disorders by 15%, 13%, 11% and 6% .
ported excellent, very good or good health. Nearly half (48%) of study
participants reported the receipt of care in a medical home. Approxi­ 3.1. Logistic regression results
mately 92% of participants reported living in a safe neighborhood and
77% reported having opportunities for physical activity or recreation. Unadjusted odd ratios (OR) and adjusted odd ratios (aOR) of the
Prevalence estimates of mental health outcomes among children in associations between individual, familial and community sociodemo­
the study population are shown in Table 1. Less than ten percent of graphic characteristics for the four mental health outcomes are pre­
children (9%) had current ADHD while 91% did not have current ADHD. sented in Table 3. After adjustment, the strength of most these
Approximately 7% had current behavioral disorders while 93% did not relationships was not attenuated.
have current behavioral disorders. The majority of children did not have In the adjusted models, males compared to females had higher odds
current anxiety (92%) while the remaining (8%) had current anxiety. of ADHD (aOR: 2.26; CI: 1.89–2.71) and behavior disorders (aOR: 1.87;
The vast majority of children did not have current depression (96%) CI: 1.51–2.30). Males compared to females had lesser odds of anxiety
while the remaining (4%) had current depression. Approximately 16% (aOR: 0.76; CI: 0.65–0.90) and depression (aOR: 0.70; CI: 0.54–0.91).
of children had either of the four conditions. Hispanic children had lower odds of ADHD (aOR: 0.56; CI: 0.41–0.76),
Significant differences (p < 0.05) were found for the following behavior disorders (aOR: 0.68; CI: 0.50–0.92), and depression (aOR:
characteristics for all mental health outcomes: sex, race, age, insurance 0.45; CI: 0.31–0.65) relative to White children. Blacks compared to
status, family structure, income, caregiver mental health and medical Whites had lesser odds of anxiety (aOR: 0.36; CI: 0.26–0.50). Children
home. Both ADHD and behavior disorders were most common for males aged 3–5 years had lesser odds of ADHD than children aged 12–17 years
(12%, 9% respectively) compared to females (6%, 5% respectively), (aOR: 0.11; CI: 0.08–0.16) as well as lesser odds of anxiety (aOR: 0.16;
while anxiety and depression were most common for females (9%, 4% CI: 0.11–0.22) and depression (aOR: 0.03; CI: 0.01–0.11). Children aged
respectively) compared to males (7%, 3% respectively). ADHD was most 6–11 years had higher odds of behavioral disorders than children aged
common for ages 12 to 17 (11%) than ages 3 to 5 (1%). Anxiety was most 12–17 years (aOR: 1.63; CI: 1.33–1.99), but lesser odds of anxiety (aOR:
common for ages 12 to 17 (11%) than ages 3 to 5 (2%). Depression was 0.64; CI: 0.54–0.76) and depression (aOR: 0.27; CI: 0.20–0.38). In­
most common for ages 12 to 17 (7%) than ages 3 to 5 (<1%). Behavior dividuals with private insurance alone had lesser odds of ADHD (aOR:
disorders was most common for ages 6–11 (9%) than ages 3 to 5 (4%). 0.70; CI: 0.53–0.93), behavioral disorders (aOR 0.47; CI: 0.37–0.61) and
While ADHD and anxiety were most common for non-Hispanic white depression (aOR 0.52; CI: 0.39–0.69) compared to individuals with
children (10%), non-Hispanic white and non-Hispanic black children public insurance alone. Individuals with public and private insurance
were equally likely to have depression (4%) and among non-Hispanic were more likely to have ADHD (aOR: 1.54; CI: 1.11–2.12), behavioral
black children, 10% reported having behavior disorders. Higher pro­ disorders (aOR: 1.40; CI: 1.01–1.95), anxiety (aOR: 1.62; CI: 1.13–2.30),
portions of children with public and private insurance reported having and depression (aOR: 1.80; CI: 1.09–2.98) compared to individuals with
ADHD (16%) than uninsured children (7%). Behavior disorders (15%) public insurance alone. Individuals without insurance had lesser odds of
were more common among children with public and private insurance ADHD (aOR: 0.58; CI: 0.40–0.86), behavioral disorders (aOR 0.65; CI:
than uninsured children (7%). Children with public and private insur­ 0.43–0.99), and depression (aOR 0.47; CI: 0.26–0.83) compared to in­
ance had higher proportions of children reporting anxiety (14%) than dividuals with public insurance alone.
uninsured children (8%). Children with public and private insurance In the adjusted models, children living with single parents compared
were most likely to report depression (9%) than uninsured children to children living with both married parents remained strongly associ­
(3%). ated with and related to increased odds of behavior disorders (aOR:
ADHD and behavior disorders were most common for children living 1.60; CI: 1.27–2.02), anxiety (aOR: 1.21; CI: 0.97–1.51) and depression
with relatives or non-parents (12%, 12% respectively) compared to (aOR: 1.38; CI: 1.01–1.90). Children living with non-parents or relatives
children with both married parents (8%, 5% respectively), while anxiety compared to children living with both parents had higher odds of being
and depression were most common for children living with single par­ diagnosed with ADHD (aOR: 4.03; CI: 2.41–6.75), behavior disorders
ents (10%, 6% respectively) compared to children with both married (aOR: 4.84; CI: 2.67–8.75) and anxiety (aOR: 2.21; CI: 0.50–9.81).
parents (7%, 3% respectively). Family poverty level was a significant Children whose caregivers’ mental health was excellent, very good or
correlate for behavior disorders and depression. Higher proportions of good had lesser odds of ADHD (aOR: 0.31; CI: 0.21–0.45), behavior
children with a family income below 100% Federal Poverty Level re­ disorders (aOR: 0.26; CI: 0.17–0.39), anxiety (aOR: 0.22; CI: 0.15–0.33)
ported behavior disorders (9%) and depression (5%) compared to chil­ and depression (aOR: 0.23; CI: 0.14–0.36) compared to children whose
dren with a family income above 400% Federal Poverty Level (5%, 3% caregivers’ mental health was fair or poor. Children whose caregivers
respectively). Children with caregivers whose mental health was fair or had high school education had lesser odds of behavioral disorders (aOR:

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G. Okwori Children and Youth Services Review 136 (2022) 106441

Table 1
Characteristics of Study Population in Total and by Current Mental Health Status Among Respondents to the 2018 NSCH.
Characteristic Current ADHD Current Behavior Current Anxiety Current Depression Any Mental Health
Disorder Outcome

Total Yes No Yes No Yes No Yes No Yes

N a(%)b N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%)
Total Sample 26,572 2677 23,895 1901 24,671 2719 23,853 1198 25,374 4989 (16.1)
(8.6) (91.4) (6.9) (93.1) (8.0) (92.0) (3.7) (96.3)
Individual Level
Sex *** *** ** * **
Male 13,892 1845 12,047 1340 12,552 1277 12,615 531 13,361 2879 (17.7)
(51.1) (11.5) (88.5) (8.7) (91.3) (7.1) (92.9) (3.1) (96.9)
Female 12,680 832 (5.6) 11,848 561 12,119 1442 11,238 667 12,013 2110 (14.4)
(48.9) (94.4) (5.0) (95.0) (9.0) (91.0) (4.3) (95.7)
Race/Ethnicity *** ** *** ^ ***
Hispanic 3129 248 (6.4) 2881 221 2908 267 (5.9) 2862 121 3008 504 (12.7)
(25.6) (93.6) (5.8) (94.2) (94.1) (2.6) (97.4)
White, Non– Hispanic 18,388 1981 16,407 1281 17,107 2086 16302 884 17,504 3682 (18.7)
(49.9) (10.0) (90.0) (6.9) (93.1) (10.3) (89.7) (4.2) (95.8)
Black, Hispanic 1739 193 (9.7) 1546 175 1564 122 (5.6) 1617 80 (4.2) 1659 317 (15.5)
(13.8) (90.3) (9.7) (90.3) (94.4) (95.8)
Other, Non-Hispanic 3316 255 (6.2) 3061 224 3092 244 (5.7) 3072 113 3203 486 (12.3)
(10.6) (93.8) (5.7) (94.3) (94.3) (3.1) (96.9)
Age *** *** *** *** ***
3–5 years 4618 65 (1.4) 4553 205 4413 92 (2.1) 4526 8 (0.3) 4610 269 (5.7)
(19.3) (98.6) (4.3) (95.7) (97.9) (99.7)
6–11 years 9367 1024 8343 863 8504 850 (7.6) 8517 187 9180 1713 (16.6)
(40.2) (9.8) (90.2) (9.2) (90.8) (92.4) (2.1) (97.9)
12–17 years 12,587 1588 10,999 833 11,754 1777 10,810 1003 11,584 3007 (20.5)
(40.5) (10.9) (89.1) (5.9) (94.1) (11.3) (88.7) (6.9) (93.1)
Insurance Status *** *** * *** ***
Public only 5333 754 4579 729 4604 714 (8.4) 4619 379 4954 1368 (18.2)
(30.1) (10.2) (89.8) (10.5) (89.5) (91.6) (5.1) (94.9)
Private only 18,629 1577 17,052 880 17,749 1679 19,650 661 17,968 3020 (14.5)
(57.1) (7.6) (92.4) (4.5) (95.5) (7.5) (92.5) (2.7) (97.3)
Public and private 1005 (3.9) 214 791 (84.2) 192 813 (85.5) 197 808 (86.2) 97 (8.8) 908 (91.2) 350 (25.9)
(15.8) (14.5) (13.8)
Uninsured 1605 (8.9) 132 (6.6) 1473 100 1505 129 (8.0) 1476 61 (2.8) 1544 251 (14.1)
(93.4) (6.5) (93.5) (92.0) (97.2)
Family Level
Family Structure *** *** ^ *** ***
Non-Parent/Other 1594 (8.4) 263 1331 241 1353 205 (8.6) 1389 113 1481 437 (20.8)
Relative (12.3) (87.7) (11.9) (88.1) (91.4) (5.1) (94.9)
Single Parent 5268 657 4611 545 4723 690 (9.8) 4578 349 4919 1237 (19.5)
(22.8) (10.1) (89.9) (10.0) (90.0) (90.2) (5.6) (94.4)
Two Parents 1666(8.0) 178 (9.1) 1488 151 1515 174 (8.1) 1492 87 (4.3) 1579 340 (17.4)
Unmarried (91.0) (8.2) (91.8) (91.9) (95.7)
Two Parents Married 18,044 1579 16,465 964 17,080 1650 16,394 649 17,395 2975 (13.9)
(60.7) (7.5) (92.5) (4.8) (95.2) (7.3) (92.7) (2.7) (97.3)
Household Educational ^
Level
<High school/High 4405 416 (7.5) 3989 416 3989 452 (6.8) 3953 236 4169 935 (16.3)
school (29.8) (92.5) (7.5) (92.5) (93.2) (4.4) (95.6)
Some college or more 22167 1485 20,682 1485 20,682 2267 19,900 962 21,205 4054 (15.9)
(70.2) (6.6) (93.4) (6.6) (93.4) (8.5) (91.5) (3.4) (96.6)
Income/Poverty Level *** *
<100% FPL; 3156 366 (9.4) 2790 366 2790 379 (8.3) 2777 208 2948 730 (17.5)
(19.7) (90.6) (9.4) (90.6) (91.7) (5.1) (94.9)
100–199% FPL; 4366 423 (8.0) 3943 423 3943 495 (7.6) 3871 247 4119 923 (16.4)
(22.1) (92.0) (8.0) (92.0) (92.4) (4.2) (95.8)
200–399% FPL; 8129 534 (6.5) 7595 534 7595 807 (8.3) 7322 335 7794 1463 (15.5)
(27.1) (93.5) (6.5) (93.5) (91.7) (2.8) (97.2)
≥400% FPL 10,921 578 (4.8) 10,343 578 10,343 1038 9883 408 10,513 1873 (15.4)
(31.1) (95.2) (4.8) (95.2) (7.9) (92.1) (3.2) (96.8)
Caregiver Mental *** *** *** *** ***
Health
Excellent, very good/ 24,260 2280 21,980 1519 22,741 2332 21,928 974 23,286 4274 (14.8)
good (88.3) (7.9) (92.1) (5.9) (94.1) (7.4) (92.6) (3.0) (97.0)
Fair/poor 672 (2.9) 151 521 (76.8) 163 509 (74.9) 205 467 (71.2) 122 550 (81.7) 306 (44.3)
(23.2) (25.1) (28.8) (18.3)
No response 1640 (8.8) 246 1394 219 1421 182 (7.9) 1458 102 1538 409 (19.6)
(11.1) (88.9) (10.7) (89.3) (92.1) (5.1) (94.9)
Community/Societal
Opportunities for play/
activity
(continued on next page)

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G. Okwori Children and Youth Services Review 136 (2022) 106441

Table 1 (continued )
Characteristic Current ADHD Current Behavior Current Anxiety Current Depression Any Mental Health
Disorder Outcome

Yes 19,965 1944 18,021 1408 18,557 2038 17,927 869 19,096 3672 (15.7)
(77.2) (8.5) (91.5) (6.8) (93.2) (7.9) (92.1) (3.7) (96.3)
No 6607 733 (9.1) 5874 493 6114 681 (8.4) 5926 329 6278 1317 (17.1)
(22.8) (90.9) (7.1) (92.9) (91.6) (3.7) (96.3)
Safe Neighborhood ^ * *
Agree 25,207 2495 22,712 1746 23,461 2518 22,689 1111 24,096 4659 (15.8)
(92.4) (8.5) (91.5) (6.7) (93.3) (7.8) (92.2) (3.4) (96.6)
Disagree 1365 (7.6) 182 1183 155 1210 201 1164 87 (6.5) 1278 330 (19.5)
(10.0) (90.0) (9.0) (91.0) (10.8) (89.2) (93.5)
Medical Home * *** *** *** ***
Yes 14,165 1284 12,881 736 13,429 1192 12,973 437 13,728 2322 (14.1)
(47.8) (7.6) (92.4) (5.3) (94.7) (6.4) (93.6) (2.3) (97.3)
No 12,407 1393 11,014 1165 11,242 1527 10,880 761 11,646 2667 (17.9)
(52.2) (9.5) (90.5) (8.3) (91.7) (9.5) (90.5) (4.6) (95.4)

^p ≤ 0.05 *p ≤ 0.01 **p ≤ 0.001 ***p ≤ 0.0001 a Unweighted frequencies b

Weighted percent (percentages are adjusted for non-response and non-coverage).

0.74; CI: 0.58–0.94) and anxiety (aOR: 0.66; CI: 0.52–0.83) compared to indicates the importance of improving access to care and diagnoses of
children whose caregivers had some college education. these conditions in younger children.
In the adjusted models, children not receiving care in a medical home There were racial/ethnic differences among the four mental health
had higher odds of behavioral disorders (aOR: 1.34; CI: 1.08–1.66), disorders with non-Hispanic White children having the highest per­
anxiety (aOR: 1.54; CI: 1.32–1.81), and depression (aOR: 1.45; CI: centage of children having mental health disorders except for behavioral
1.10–1.91) compared to children who received care in a medical home. disorders which was more prevalent among Black children. These results
suggest that reconsidering prior documented concerns regarding the
4. Discussion under diagnosis of ADHD or other mental disorders in Black children
may be appropriate (Coker et al., 2016; Morgan et al., 2013). Limited
The findings from this study revealed that 9% of children had ADHD, access to care more broadly among Black and Hispanic children may
7% had behavior disorders, 8% had anxiety and 4% had depression. imply that these children are less likely to use health services and thus be
According to the CDC, in 2016, 8.4% of children in the U.S were examined by providers or diagnosed with these conditions (Wang et al.,
currently diagnosed with ADHD, 7.4% were diagnosed with behavioral 2013). Racial disparities in diagnosis such as bias linked to conduct/
disorders, 7.1% were diagnosed with anxiety and 3.2% were diagnosed behavioral problems have been attributed to the disproportionately high
with depression (Centers for Disease Control and Prevention, 2020). The rates of behavioral disorders diagnosed among Black and Hispanic
prevalence estimates for each mental health disorder in this study were children (Mizock & Harkins, 2011). This underscores the importance of
slightly higher (except for that of behavioral disorders) than those re­ assessing factors that contribute to health disparities in terms of
ported by the CDC, although comparable, as well as higher than esti­ engagement and utilization of mental health services as well as
mates from other surveys reported previously (Centers for Disease providing solutions and promising practices to reduce these disparities.
Control and Prevention, 2013; Visser, Deubler, et al., 2016). Estimates Furthermore, the data highlighted significant associations between
from the 2007 National Health Interview Survey data (survey was the mental disorders of children and their caregivers’ mental health,
conducted in-person) and the 2012 NSCH survey data (survey was which could be a results of shared biological and genetic predispositions,
conducted via phone) were only half of those reported here for anxiety environmental factors and relationship between the parent and the
and behavioral disorders, although the estimates for depression were child. The strong association between mental health disorders and
similar to the redesigned NSCH data utilized in this study. The differ­ parent/caregiver characteristics portray the relevance of the family
ences in the mode of data collection, wording of questionnaires, and context in the development of mental health disorders. Divorce has been
changes in diagnoses criteria may explain certain differences. For shown to be associated with mental problems in children particularly,
example, the incorporation of conduct/behavioral diagnoses by educa­ anxiety, behavior disorders and substance abuse (Shanahan et al.,
tors in the current study may have influenced the estimates provided 2008). The mechanisms underlying the effect of non-intact families on
here especially for moderate or mild cases. These estimates present an mental health in children including biological vulnerability and the in­
important baseline from which to assess future annual NSCH data to direct impact on disruptions within the home environment necessitate
determine trends and patterns overtime for these indicators of mental further study.
health disorders by demographic subgroups and overall. The results from this study showed the need for increased use of a
Our study noted that estimates for ADHD, behavior disorders, anxi­ medical care home. Children in this study that received care in a medical
ety and depression among younger children aged 3–5 years were 1.4%, home were less likely to have any of the four mental health disorders.
4.3%, 2.1% and 0.3% respectively. Past estimates for behavior disor­ There has been an emphasis on the use of the medical home models of
ders, anxiety and depression among children aged 3–5 years utilizing care in order to address the social determinants of health and mental
data from the 2016 NSCH were 3.4%, 1.3% and 0.08%, respectively health (Ghandour et al., 2011). The identification of a primary care
(Ghandour et al., 2019). These results suggest an early onset of these provider that enables access to a range of providers has been shown to
disorders in young children. This is comparable to a study of insurance reduce racial disparities in mental health care diagnosis and increase
claims data which showed an increase in the number of children aged preventive care (Rosenthal, 2008). Homer et al. showed that care co­
2–5 years that received clinical care for mental health disorders from ordination improved mental health outcomes (Homer et al., 2008). In a
2008 to 2014 (Visser, Danielson, et al., 2016) as well as a study of different study which was a randomized trial of children who had
electronic health record data showing increased pediatric visits associ­ ADHD, the authors found that implementing coordinated care between
ated with mental health care for children aged 4–5 years from 2008 to medical care and mental health was linked to increased rates of mental
2014 (Fiks et al., 2016). The findings, coupled with other research have health treatment inception and completion, improved behavioral out­
noted increase in the prevalence of younger children experiencing comes of children and decreased parental stress (Kolko et al., 2014). The
mental health outcomes over time (Danielson et al., 2017). This collaboration between mental health care providers and the receipt of

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G. Okwori Children and Youth Services Review 136 (2022) 106441

Table 2
Difference in Probabilities of Having Mental Health Disorders Among Respondents to the 2018 NSCH.
Characteristic Current ADHD Current Behavior Disorder Current Anxiety Current Depression

Yes Yes Yes Yes

Risk (95% CI) Risk (95% CI) Risk (95% CI) Risk (95% CI)
Individual Level
Sex *** *** *** ***
Male 0.13 (0.13–0.14) 0.10 (0.09–0.10) 0.09 (0.09–0.10) 0.04 (0.03–0.04)
Female 0.06 (0.06–0.07) 0.04 (0.04–0.05) 0.11 (0.11–0.12) 0.05 (0.05–0.06)
Race/Ethnicity *** *** *** **
Hispanic 0.08 (0.08–0.09) 0.07 (0.06–0.08) 0.09 (0.09–0.10) 0.04 (0.04–0.05)
White, Non– Hispanic 0.11 (0.10-0.0.12) 0.07 (0.07–0.08) 0.11 (0.11–0.12) 0.05 (0.05–0.06)
Black, Hispanic 0.11 (0.10-0.0.12) 0.10 (0.10–0.11) 0.07 (0.06–0.08) 0.05 (0.04–0.05)
Other, Non-Hispanic 0.08 (0.08–0.09) 0.07 (0.06–0.08) 0.07 (0.07–0.08) 0.03 (0.02–0.03)
Age *** *** *** ***
3–5 years 0.01 (0.01–0.02) 0.04 (0.04–0.05) 0.02 (0.02–0.03) 0.01 (0.01–0.02)
6–11 years 0.11 (0.11–0.12) 0.09 (0.08–0.10) 0.09 (0.09–0.10) 0.02 (0.01–0.02)
12–17 years 0.13 (0.12–0.14) 0.07 (0.07–0.08) 0.14 (0.13–0.14) 0.08 (0.08–0.09)
Insurance Status *** *** *** ***
Public only 0.08 (0.07.0.09) 0.14 (0.13–0.15) 0.13 (0.12–0.13) 0.07 (0.06–0.07)
Private only 0.21 (0.20–0.22) 0.05 (0.04–0.05) 0.09 (0.09–0.10) 0.04 (0.04–0.0)
Public and private 0.08 (0.08–0.09) 0.19 (0.18–0.20) 0.20 (0.19–0.20) 0.10 (0.10–0.20)
Uninsured 0.14 (0.13–0.14) 0.06 (0.05–0.06) 0.08 (0.07–0.08) 0.04 (0.03–0.04)
Family Level
Family Structure *** *** *** ***
Non-Parent/Other Relative 0.16 (0.15–0.17) 0.15 (0.14–0.15) 0.13 (0.12–0.14) 0.07 (0.06–0.07)
Single Parent 0.12 (0.12–0.13) 0.10 (0.10–0.11) 0.13 (0.13–0.14) 0.07 (0.06–0.07)
Two Parents Unmarried 0.11 (0.10–0.12) 0.09 (0.09–0.10) 0.10 (0.10–0.11) 0.05 (0.04–0.05)
Two Parents Married 0.09 (0.09–0.10) 0.05 (0.05–0.06) 0.09 (0.09–0.10) 0.04 (0.04–0.05)
Household Educational Level *** *** *
<High school/ High school 0.12 (0.11–0.13) 0.09 (0.09–0.10) 0.10 (0.09–0.11) 0.05 (0.05–0.06)
Some college or more 0.10 (0.09–0.0.10) 0.07 (0.06–0.07) 0.10 (0.10–0.11) 0.04 (0.04–0.0.05)
Income/Poverty Level *** *** *** ***
<100% FPL; 0.13 (0.12–0.14) 0.12 (0.12–0.13) 0.12 (0.12–0.13) 0.07 (0.06–0.07)
100–199% FPL; 0.11 (0.10–0.12) 0.10 (0.10–0.11) 0.11 (0.10–0.11) 0.06 (0.05–0.06)
200–399% FPL; 0.10 (0.10–0.11) 0.07 (0.07–0.08) 0.10 (0.10–0.11) 0.04 (0.03–0.04)
≥ 400% FPL 0.09 (0.08–0.10) 0.05 (0.05–0.06) 0.10 (0.10–0.11) 0.04 (0.04–0.05)
Caregiver Mental Health *** *** *** ***
Excellent, very good/good 0.15 (0.15–0.16) 0.06 (0.05–0.06) 0.11 (0.10–0.11) 0.04 (0.04–0.05)
Fair/poor 0.22 (0.21–0.22) 0.24 (0.23–0.24) 0.31 (0.30–0.31) 0.18 (0.17–0.18)
No response 0.15 (0.14–0.16) 0.13 (0.12–0.14) 0.11 (0.10–0.11) 0.06 (0.05–0.06)
Community/Societal
Opportunities for play/activity ** *
Yes 0.10 (0.09–0.10) 0.07 (0.06.0.07) 0.10 (0.10–0.11) 0.04 (0.04–0.05)
No 0.11 (0.10–0.12) 0.07 (0.07–0.08) 0.10 (0.10–0.11) 0.05 (0.04–0.06)
Safe Neighborhood *** *** *** **
Agree 0.10 (0.09.1.10) 0.07(0.06–0.07) 0.10 (0.09–0.10) 0.04 (0.04–0.05)
Disagree 0.13 (0.12–0.15) 0.11 (0.10–0.13) 0.15 (0.13–0.17) 0.06 (0.05–0.08)
Medical Home *** *** *** ***
Yes 0.09 (0.09–0.10) 0.05 (0.05–0.06) 0.08 (0.08–0.09) 0.03 (0.02–0.03)
No 0.11 (0.11–0.12) 0.09 (0.09–0.10) 0.12 (0.12–0.13) 0.06 (0.06–0.07)

needed referrals has also been shown to improve outcomes (Rosenthal, children were less likely to have all four mental health outcomes
2008). The findings demonstrate the need for research on best ways to compared to children with public insurance alone, while children with
optimize the efficacy of the medical home to address mental health. public and private insurance were more likely to have mental health
The differences in the receipt of treatment between these disorders disorders compared to children with public insurance alone. These
have been described where behavioral problems and anxiety are findings are comparable to a different study which showed that children
sometimes treated in primary care or educational settings with a focus with public insurance (either combined with private coverage or used
on behavioral management techniques and parental behaviors rather alone) were more likely to have these disorders compared to privately
than direct treatment provided to the child (Cheung et al., 2013). These insured children (Merikangas et al., 2010). Uninsured or poor children
differences as well as the severity of the disorder, comorbidity of dis­ are unable to have access to a provider who can diagnose these disor­
orders, and income of the household could also predict the receipt of ders, thus making them less likely to obtain mental health treatment.
mental health treatment, highlighting the complexity of provision of Further studies are needed to ascertain mental health problems in poor
mental health treatment and utilization of mental health services by or uninsured children.
children with mental health disorders. Busch and Horwitz (2004) showed that children without insurance
The results from this study revealed that children living in house­ had extremely decreased access to mental health services compared to
holds with higher income levels were less likely to have behavioral children with insurance. A different study found that a higher number of
disorders and depression compared to children living below the federal children with public insurance used mental health services compared to
poverty level, although this was not significant after adjustment. How­ privately insured and uninsured children (Kataoka et al., 2002). They
ever, prior research has noted that children from poor families were less also found that children in foster care have a much higher rate of
likely to be diagnosed or treated (Hodgkinson et al., 2017). Further­ obtaining the necessary services, which is attributed to access to services
more, examining the insurance status, uninsured and privately insured that are reimbursed by Medicaid as well as having a foster family and

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G. Okwori Children and Youth Services Review 136 (2022) 106441

Table 3
Unadjusted and Adjusted Odds Ratios and 95% Wald Confidence Intervals for Current Mental Health Outcomes by Sociodemographic Among Respondents to the 2018
NSCH.
Characteristic Current ADHD Current Behavior Disorder Current Anxiety Current Depression

OR (95% CI) aOR (95% CI)† OR (95% CI) aOR (95% CI)† OR (95% CI) aOR (95% CI)† OR (95% CI) aOR (95% CI)†

Individual Level
Sex
Female Referent Referent Referent Referent Referent Referent Referent Referent
Male 2.19 2.26 1.82 1.87 0.77 0.76 0.72 0.70
(1.84–2.61)*** (1.89–2.71)*** (1.48–2.23) *** (1.51–2.30) *** (0.66–0.90) * (0.65–0.90) ** (0.56–0.92) * (0.54–0.91) **
Race/Ethnicity
White, Non– Referent Referent Referent Referent Referent Referent Referent Referent
Hispanic
Black, Non– 0.97 0.76 1.44 0.90 0.51 0.36 0.99 0.55
Hispanic (0.75–1.25) (0.56–1.03) (1.11–1.87) * (0.67–1.20) (0.38–0.69) *** (0.26–0.50) *** (0.67–1.47) (0.34–0.91) ^
Hispanic 0.62 0.56 0.83 0.68 0.55 0.50 0.60 0.45
(0.46–0.82) ** (0.41–0.76) ** (0.62–1.09) (0.50–0.92) * (0.42–0.72) *** (0.38–0.66) *** (0.41–0.87) * (0.31–0.65) ***
Other, Non- 0.60 0.56 0.82 0.69 0.52 0.45 0.74 0.59
Hispanic (0.48–0.76) *** (0.44–0.71) *** (0.63–1.05) (0.52–0.90) * (0.40–0.68) *** (0.34–0.60) *** (0.47–1.16) (0.36–0.99) ^
Age
12–17 years Referent Referent Referent Referent Referent Referent Referent Referent
6–11 years 0.89 0.88 1.62 1.63 0.65 0.64 0.28 0.27
(0.75–1.05) (0.74–1.04) (1.34–1.96) *** (1.33–1.99) *** (0.54–0.77) *** (0.54–0.76) *** (0.21–0.39) *** (0.20–0.38) ***
3–5 years 0.11 0.11 0.71 0.73 0.16 0.16 0.03 0.03
(0.08–0.17) *** (0.08–0.16) *** (0.54–0.95) ^ (0.54–0.98) ^ (0.12–0.23) *** (0.11–0.23) *** (0.01–0.11) *** (0.01–0.11) ***
Insurance Status
Public only Referent Referent Referent Referent Referent Referent Referent Referent
Private only 0.72 0.70 0.40 0.47 0.88 0.72 0.52 0.52
(0.60–0.87) ** (0.53–0.93) ^ (0.33–0.49) *** (0.37–0.61) *** (0.74–1.05) (0.57–0.92) * (0.40–0.67) *** (0.39–0.69) ***
Public and private 1.64 1.54 1.45(1.05–2.0) 1.40 1.75 1.62 1.79 1.80
(1.20–2.24) * (1.11–2.12) * ^ (1.01–1.95) ^ (1.24–2.47) * (1.13–2.30) * (1.11–2.89) ^ (1.09–2.98) ^
Uninsured 0.62 0.58 0.61 0.65 0.95 0.84 0.55 0.47
(0.42–0.91) ^ (0.40–0.86) * (0.40–0.90) ^ (0.43–0.99) ^ (0.62–1.46) (0.54–1.31) (0.31–0.98) ^ (0.26–0.83) *
Family Level
Family Structure
Two Parents Referent Referent Referent Referent Referent Referent Referent Referent
Married
Two Parents 1.24 1.11 1.75 1.33 1.12 1.10 1.65 1.33
Unmarried (0.86–1.78) (0.76–1.63) (1.21–2.53) * (0.90–1.96) (0.79–1.58) (0.76–1.59) (1.02–2.67) ^ (0.81–2.18)
Single Parent 1.40 1.17 2.19 1.60 1.38 1.21 2.17 1.38
(1.16–1.69) ** (0.94–1.46) (1.77–2.71) *** (1.27–2.02) *** (1.15–1.66) ** (0.97–1.51) ** (1.64–2.87) *** (1.01–1.90) ^
Non-Parent/ Other 1.73 4.03 2.67 4.84 1.19 2.21 1.98 1.06
Relative (1.34–2.23) *** (2.41–6.75)*** (2.04–3.49) *** (2.67–8.75)*** (0.89–1.59) (0.50–9.81)* (1.36–2.88)** (0.09–12.97)
Household
Educational Level
Some college or Referent Referent Referent Referent Referent Referent Referent Referent
more
<High school/ 1.10 1.00 1.13 0.74 0.79 0.66 1.31 0.92
High school (0.90–1.35) (0.77–1.29) (0.92–1.39) (0.58–0.94) ^ (0.64–0.97) ^ (0.52–0.83) ** (0.99–1.74) (0.64–1.31)
Income/Poverty
Level
<100% FPL; Referent Referent Referent Referent Referent Referent Referent Referent
100–199% FPL; 0.93 1.04 0.83 1.02 0.90 0.97 0.81 1.02
(0.70–1.22) (0.79–1.39) (0.64–1.08) (0.77–1.33) (0.68–1.19) (0.73–1.29) (0.56–1.17) (0.70–1.48)
200–399% FPL; 0.86 1.16 0.67 1.15 1.00 1.10 0.53 0.87
(0.68–1.10) (0.86–1.54) (0.51–0.88) * (0.84–1.56) (0.76–1.31) (0.81–1.52) (0.38–0.76) ** (0.62–1.23)
≥400% FPL 0.86 1.20 0.48 1.00 0.94 1.08 0.62 1.18
(0.68–1.07) (0.90–1.60) (0.38–0.62) *** (0.74–1.36) (0.73–1.21) (0.80–1.45) (0.44–0.88) * (0.80–1.74)
Caregiver Mental
Health
Fair/poor Referent Referent Referent Referent Referent Referent Referent Referent
Excellent, very 0.28 0.31 0.19 0.26 0.19 0.22 0.14 0.23
good/good (0.20–0.40) *** (0.21–0.45) *** (0.13–0.26) *** (0.17–0.39) *** (0.12–0.33) *** (0.15–0.33) *** (0.09–0.21) *** (0.14–0.36) ***
Community/
Societal
Opportunities for
play/activity
Yes Referent Referent Referent Referent Referent Referent Referent Referent
No 1.07 0.98 1.05 0.92 1.07 0.95 1.00 0.85
(0.90–1.28) (0.81–1.18) (0.86–1.29) (0.73–1.15) (0.88–1.31) (0.78–1.16) (0.76–1.31) (0.65–1.12)
Safe Neighborhood
Agree Referent Referent Referent Referent Referent Referent Referent Referent
Disagree 1.19 0.99 1.37 0.90 1.43 1.25 1.95 1.28
(0.89–1.59) (0.71–1.37) (0.98–1.94) (0.60–1.37) ^ (1.05–1.95) ^ (0.90–1.76) (1.27–3.00) * (0.82–2.00)
Medical Home
Yes Referent Referent Referent Referent Referent Referent Referent Referent
No 1.27 1.18 1.60 1.34 1.52 1.54 1.72 1.45
(1.08–1.50) * (0.99–1.42) (1.32–1.93) *** (1.08–1.66) * (1.30–1.78) *** (1.32–1.81)*** (1.33–2.23) *** (1.10–1.91) *

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G. Okwori Children and Youth Services Review 136 (2022) 106441

†Adjusted for all variables ^p ≤ 0.05 *p ≤ 0.01 **p ≤ 0.001 ***p ≤ 0.0001.

caseworker that ensure use of mental health services. Detecting these Funding
types of differences and trends by type of insurance over time could be
used to examine differences in the frequency of diagnoses for sub­ No funding was received for conducting this study.
populations as well as to recognize any changes within the underlying
population of children diagnosed with these mental health disorders. CRediT authorship contribution statement
The lack of insurance also contributes to disparities in the utilization
of health services by Black and Hispanic individuals. In 2018, the Glory Okwori: Conceptualization, Data curation, Formal analysis,
number of uninsured Hispanics and Blacks were 19% and 11.5% Investigation, Methodology, Project administration, Visualization,
respectively to 7.5% of Whites (Kaiser Family Foundation, 2020). Writing – review & editing.
Decreasing the number of uninsured individuals could possibly elimi­
nate some of the cost barriers associated with mental health care.
Declaration of Competing Interest
Increasing the number of mental health facilities that offer sliding fees or
accept public insurance could improve the affordability of mental health
The authors declare that they have no known competing financial
services. Since insurance most times provide less coverage for mental
interests or personal relationships that could have appeared to influence
health services, improving coverage could enhance affordability.
the work reported in this paper.
Regarding family structure, children living in single-parent homes or
living with other relatives were more likely to have mental health dis­
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