State Variation in Increased ADHD Prevalence: Links to NCLB School Accountability and State Medication Laws

The study's objective was to investigate whether attention-deficit hyperactivity disorder (ADHD) diagnoses from 2003 to 2011 were associated with either public school consequential accountability reforms initiated by the No Child Left Behind (NCLB) Act, particularly for low-income children, or with state psychotropic medication laws that prohibit public schools from recommending or requiring medication use.

Logistic regression difference-in-differences models were estimated with repeated U.S. and state-representative cross-sections of responses to the 2003, 2007, and 2011 National Survey of Children's Health. Each wave included approximately 35,000 public school children between ages six and 13.

From 2003 to 2007, the change in adjusted diagnostic prevalence was 2.8 percentage points higher for children ages six to 13 in households with incomes ≤185% of the federal poverty level residing in states first exposed to consequential accountability through NCLB (from 8.5% to 13.2%), compared with demographically similar children residing in other states (from 10.2% to 12.1%). From 2003 to 2011, the change in adjusted diagnostic prevalence was 2.2 percentage points lower for children ages six to 13 residing in states with a psychotropic medication law (from 8.1% to 7.8%), compared with children residing in other states (from 8.1% to 10.1%).

NCLB-initiated consequential accountability reforms were associated with more ADHD diagnoses among low-income children, consistent with increased academic pressures from NCLB for this subgroup. In contrast, psychotropic medication laws were associated with fewer ADHD diagnoses, because they may indirectly reduce diagnoses via restrictions on recommending or requiring medication use. Future research should investigate whether children most affected by these policies are receiving appropriate diagnoses.