Article Figures & Data
Figures
- Figure 1
National ADHD Diagnosis Trends
Notes: This figure presents the percent of children aged 5–17 ever told they had ADHD by a medical professional, as identified within the National Health Interview Survey (NHIS). Gender and race/ethnicity group averages are weighted by NHIS person sample weights. Trends are smoothed using five-year moving averages.
- Figure 2
Initial ADHD Diagnosis Process
Notes: 1, Mayo Clinic (2019); 2, Visser et al. (2015); 3, CDC 2022; 4, Kessler (2022); 5, Chan et al. (2005); 6, Epstein et al. (2014); 7, Gordon et al. (2020).
- Figure 3
Cumulative New Diagnoses by Cohort
Notes: In Panel A, exposed cohort is children continuously enrolled between February 2019 and February 2021. Unexposed cohort is children continuously enrolled between February 2018 and February 2020. In Panel B, exposed cohort is children with at least one INPC encounter between February 2019 and July 2019. Unexposed cohort is children with at least one INPC encounter between February 2018 and July 2018. In both panels, sample includes children without an ADHD diagnosis during the six-month look-back period (February 2019–July 2019 and February 2018–July 2018 for the exposed and unexposed cohorts, respectively).
- Figure 4
Fall 2020 School-Openness Groupings
Notes: Figure displays fall 2020 school-openness groupings derived from SafeGraph mobility data as described in Section IV. In Panel A, low opening states are those with an opening level less than 54.4 percent, medium opening states range from 54.4 percent to 70.4 percent, and high opening states are above 70.4 percent relative to their 2019 levels. In Panel B, low opening counties are those with an opening level less than 76 percent, medium opening counties range from 76 percent to 93 percent, and high opening counties are above 93 percent relative to their 2019 activity levels.
- Figure 5
Event Study Estimates, Nationwide (Optum)
Notes: This figure presents percent changes derived from event study estimates of changes in cumulative new diagnosis rate between the exposed and unexposed cohort. Exposed cohort is children continuously enrolled between February 2019 and February 2021. Unexposed cohort is children continuously enrolled between February 2018 and February 2020. Sample includes children without an ADHD diagnosis during the six-month look-back period (February 2019–July 2019 and February 2018–July 2018 for the exposed and unexposed cohorts, respectively). February 2019/2020 is the reference period for the unexposed/exposed cohorts. Plotted percent changes are the exponentiated event study coefficients minus one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the state by cohort level.
- Figure 6
Event Study Estimates by State School Opening Level, Nationwide (Optum)
Notes: This figure presents percent changes derived from event study estimates of changes in cumulative new diagnosis rate between the exposed and unexposed cohort, interacted with state school opening level. Exposed cohort is children continuously enrolled between February 2019 and February 2021. Unexposed cohort is children continuously enrolled between February 2018 and February 2020. Sample includes children without an ADHD diagnosis during the six-month look-back period (February 2019–July 2019 and February 2018–July 2018 for the exposed and unexposed cohorts, respectively). February 2019/2020 is the reference period for the unexposed/exposed cohorts. Plotted percent changes are the exponentiated event study coefficients for each state school opening group minus one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the state by cohort level.
- Figure 7
Event Study Estimates, Indiana (INPC)
Notes: This figure presents percent changes derived from event study estimates of changes in cumulative new diagnosis rate between the exposed and unexposed cohort. Exposed cohort is children with at least one INPC encounter between February 2019 and July 2019. Exposed cohort is children with at least one INPC encounter between February 2018 and July 2018. Sample includes children without an ADHD diagnosis during the six-month look-back period (February 2019–July 2019 and February 2018–July 2018 for the exposed and unexposed cohorts, respectively). February 2019/2020 is the reference period for the unexposed/exposed cohorts. Plotted percent changes are the exponentiated event study coefficients minus one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the county by cohort level.
- Figure 8
Event Study Estimates by School Opening, Indiana (INPC)
Notes: This figure presents percent changes derived from event study estimates of changes in cumulative new diagnosis rate between the exposed and unexposed cohort, interacted with county school opening level. Exposed cohort is children with at least one INPC encounter between February 2019 and July 2019. Exposed cohort is children with at least one INPC encounter between February 2018 and July 2018. Sample includes children without an ADHD diagnosis during the six-month look-back period (February 2019–July 2019 and February 2018–July 2018 for the exposed and unexposed cohorts, respectively). February 2019/2020 is the reference period for the unexposed/exposed cohorts. Plotted percent changes are the exponentiated event study coefficients minus one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the county by cohort level.
- Figure 9
Counterfactual Total Diagnoses
Notes: This figure plots predicted and counterfactual diagnosis rates. We first calculate predicted and counterfactual (by setting the exposed cohort indicator to zero) cumulative new diagnosis rates for the exposed cohort based on the event study estimates. To translate these into total diagnosis rates we incorporate the number of children that did have an ADHD diagnosis during the look-back period. Total diagnosis rates are equal to (#PreviouslyDiagnosed + NewDiagnosisRate × #NotPreviouslyDiagnosed)/(#PreviouslyDiagnosed + #NotPreviouslyDiagnosed), where the new diagnosis rate is replaced by either the predicted or counterfactual rate for each month. The black dotted line corresponds to the estimated true ADHD prevalence by gender from Marquardt (2021, 2022). The shaded area corresponds to the range of true ADHD prevalence found in the epidemiological and/or psychological literature.
- Figure 10
Flows of New ADHD Diagnoses, Prescriptions, and Behavioral Therapy among ADHD-Naive, Nationwide (Optum)
Notes: Exposed cohort is children continuously enrolled between February 2019 and February 2021. Unexposed cohort is children continuously enrolled between February 2018 and February 2020. Sample includes children without an ADHD diagnosis during the six-month look-back period (February 2019–July 2019 and February 2018–July 2018 for the exposed and unexposed cohorts, respectively). Prescriptions are any ADHD-related prescription, ADHD behavioral therapy includes any behavioral therapy visits with an ADHD diagnosis recorded, and behavioral therapy is any behavioral therapy visit.
Tables
Optum NHIS (Private) INPC NHIS (All) Female 48.65 49.36 48.92 48.57 White 72.14 64.02 67.13 50.67 Black 7.10 6.96 15.91 12.63 Asian 7.72 6.34 3.38 4.54 Hispanic 13.05 16.77 13.58 25.95 Household income ≤$74K 26.64 24.89 51.81 ADHD diagnosis, boys 7.3 7.3 7.3 9.6 ADHD diagnosis, girls 3.1 3.0 3.0 3.8 Notes: All figures are percentages. This table presents demographic composition and ADHD diagnosis rates for the nationwide Optum sample, the INPC sample, and comparisons to random sample of children from the 2019 National Health Interview Survey (NHIS). Each sample include children born between 2009 and 2014, not restricted to ADHD-naive subsamples. For comparison, the second column restricts sample to children covered by private insurance, whereas the fourth column includes all children, and all averages are weighted by the NHIS individual annual weights. For the NHIS samples, ADHD diagnosis rates are calculated as the percent of all children in the sample who report “current” ADHD diagnosis (either initially diagnosed in 2019 or continued diagnosis from the past). For Optum and INPC samples, we report analogous ADHD diagnosis rate as the percent of all children in sample who have an ADHD-related claim/encounter in 2019 (either initial diagnosis or treatment for continued diagnosis).
Boys Boys Girls Girls (1) (2) (3) (4) Panel A: Fixed-Effect Poisson Coefficient Estimates Pandemic −0.0897*** −0.0937*** −0.117*** −0.124*** (0.0191) (0.0213) (0.0249) (0.0268) Pandemic × Asian −0.0762 0.0208 (0.101) (0.104) Pandemic × Black 0.124** 0.148* (0.0548) (0.0807) Pandemic × Hispanic −0.0175 −0.0329 (0.0443) (0.0716) Observations 42,674 42,674 42,351 42,351 Panel B: Overall Percent Changes Pandemic −0.0858*** −0.110*** (0.0175) (0.0222) White −0.0895*** −0.116*** (0.0194) (0.0236) Asian −0.156* −0.0979 (0.0850) (0.0923) Black 0.0311 0.0246 (0.0558) (0.0808) Hispanic −0.105*** −0.145** (0.0353) (0.0585) Observations 42,674 42,674 42,351 42,351 Notes: Standard errors in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01. This table presents difference-in-differences estimates over all in columns 1 and 3 and by race/ethnicity in columns 2 and 4. Panel A presents Poisson regression coefficients. Panel B presents the percent change for each group by exponentiating the appropriate sum of coefficients and subtracting one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the state by cohort level.
- Table 3
Difference-in-Differences Estimates by State School Opening Level, Nationwide (Optum)
Boys Girls (1) (2) Panel A: Fixed-Effect Poisson Coefficient Estimates Pandemic −0.0626** −0.153*** (0.0296) (0.0409) Pandemic × Medium opening −0.0561 0.00614 (0.0423) (0.0556) Pandemic × High opening 0.00180 0.117** (0.0378) (0.0575) Observations 42,674 42,351 Panel B: Overall Percent Changes Low opening −0.0607** −0.142*** (0.0278) (0.0351) Medium opening −0.112*** −0.137*** (0.0275) (0.0335) High opening −0.0590*** −0.0359 (0.0229) (0.0402) Observations 42,674 42,351 Notes: Standard errors in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01. This table presents difference-in-differences estimates by state school opening levels. Panel A presents Poisson regression coefficients. Panel B presents the percent change for each group by exponentiating the appropriate sum of coefficients and subtracting one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the state by cohort level.
- Table 4
Difference-in-Differences Estimates by State School Stability Level, Nationwide (Optum)
Boys Girls (1) (2) Panel A: Fixed-Effect Poisson Coefficient Estimates Pandemic −0.138*** −0.0398 (0.0401) (0.0503) Pandemic × Medium stability 0.0191 −0.0884 (0.0505) (0.0598) Pandemic × High stability 0.0917* −0.103 (0.0475) (0.0631) Observations 42,674 42,351 Panel B: Overall Percent Changes Low stability −0.129*** −0.0390 (0.0349) (0.0483) Medium stability −0.112*** −0.120*** (0.0279) (0.0297) High stability −0.0452* −0.133*** (0.0251) (0.0348) Observations 42,674 42,351 Notes: Standard errors in parentheses. *p < 0.10, **p < 0.05, ***p < 0.01. This table presents difference-in-differences estimates by state school stability levels. Panel A presents Poisson regression coefficients. Panel B presents the percent change for each group by exponentiating the appropriate sum of coefficients and subtracting one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the state by cohort level.
Boys Boys Girls Girls (1) (2) (3) (4) Panel A: Fixed-Effect Poisson Coefficient Estimates Pandemic −0.200*** −0.251*** −0.0732 −0.121* (0.0426) (0.0160) (0.0499) (0.0696) Pandemic × Medium 0.144** 0.213* (0.0695) (0.116) Pandemic × High 0.0439 −0.00150 (0.0873) (0.111) Observations 16,359 16,169 13,509 13,376 Panel B: Overall Percent Changes Pandemic −0.181*** −0.0706 (0.0349) (0.0464) Low opening −0.222*** −0.114* (0.0124) (0.0617) Medium opening −0.101* 0.0957 (0.0609) (0.105) High opening −0.187*** −0.115 (0.0665) (0.0739) Observations 16,359 16,169 13,509 13,376 Notes: Standard errors in parentheses. * p < 0.10, ** p < 0.05, *** p < 0.01. This table presents difference-in-differences estimates by county school opening levels. Panel A presents Poisson regression coefficients. Panel B presents the percent change for each group by exponentiating the appropriate sum of coefficients and subtracting one. The 95 percent confidence intervals are derived using the delta method. Standard errors are clustered at the county by cohort level.
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