Journal of Emotional and Behavioral Disorders

http://ebx.sagepub.com Ethnic Disparities in Special Education Labeling Among Children With Attention-Deficit/Hyperactivity Disorder
David S. Mandell, Jasmine K. Davis, Katherine Bevans and James P. Guevara Journal of Emotional and Behavioral Disorders 2008; 16; 42 DOI: 10.1177/1063426607310848 The online version of this article can be found at: http://ebx.sagepub.com/cgi/content/abstract/16/1/42

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Ethnic Disparities in Special Education Labeling Among Children With AttentionDeficit/Hyperactivity Disorder
David S. Mandell
University of Pennsylvania

Journal of Emotional and Behavioral Disorders Volume 16 Number 1 March 2008 42-51 2008 Hammill Institute on Disabilities 10.1177/1063426607310848 http://jebd.sagepub.com hosted at http://online.sagepub.com

Jasmine K. Davis
Hampton University

Katherine Bevans James P. Guevara

The Childrens Hospital of Philadelphia
The authors examined disparities in special education labeling among children diagnosed with attention-deficit/hyperactivity disorder (ADHD) by merging calendar year 2002 special education records and Medicaid mental health claims for 4,852 children who had been diagnosed with ADHD in Philadelphia, Pennsylvania. Thirty-eight percent were receiving special education services. In adjusted analyses, Black children were less likely than White children to receive these services (odds ratio [O.R.] = 0.78); among the children in special education, Black children were more likely to have the emotional disturbance (ED) label (O.R. = 1.40). There was a significant interaction between ethnicity and receipt of behavioral health and rehabilitation services (BHRS): White children with BHRS were more likely to be in special education than were White children without BHRS or Black children. Among the children in special education, White children with BHRS and Black children were more likely than White children without BHRS to be labeled ED. The results indicate ethnic disparities in special education labeling among children with similar clinical profiles and that mental health and education services are substituted for each other differently based on ethnicity. Possible reasons include undertreatment of ADHD, differential interpretation of associated behaviors, and differences in parents ability to advocate for childrens educational and mental health needs. Keywords: attention-deficit/hyperactivity disorder; mental health services; special education; Medicaid

hildren with attention-deficit/hyperactivity disorder (ADHD) often experience academic difficulties (Biederman et al., 2004; Mayes, Calhoun, & Crowell, 2000; Murphy, Barkley, & Bush, 2002; Redden & Forness, 2003; Spira & Fischel, 2005), in recognition of which the U.S. Department of Education (2000) specified that these children can qualify for special education services through the category of other health impairment (OHI). They also can qualify through the categories of learning disability (LD) and emotional disturbance (ED), depending on need (Reid, Maag, Vasa, & Wright, 1994; Schnoes, Reid, Wagner, & Marder, 2006). As much as 50% of the children who are receiving special education services meet the diagnostic criteria for ADHD (Bussing, Zima, Perwien, Belin, & Widawski, 1998), including 66% of children in the OHI category (Forness & Kavale, 2002; Schnoes et al., 2006; Wagner & Blackorby, 2002), 25% to 65% of children in the ED
42

category (Duncan, Forness, & Hartsough, 1995; Garland et al., 2001; Schnoes et al., 2006), and 16% to 31% of children in the LD category (Bussing, Zima, Belin, & Forness, 1998; Schnoes et al., 2006; Wagner & Blackorby, 2002). Conversely, studies conducted in the United States and Canada have indicated that between 50% and 66% of children with ADHD are served through special education, mostly through the LD category (Reid et al., 1994; Szatmari, Offord, & Boyle, 1989). Little is known regarding the factors associated with whether and where children with ADHD receive special education services and how they are labeled. Need may drive the label that children receive. For example, children who have difficulty attending may be labeled as
Authors Note: For questions regarding this article, please address correspondence to David S. Mandell, Center for Mental Health Policy and Services Research, University of Pennsylvania School of Medicine, 3535 Market St., 3rd Floor, Philadelphia, PA 19104.

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Mandell et al. / Special Education Among Children With ADHD 43

OHI, children with a skill-specific disability may be labeled as LD, and children who exhibit disruptive behaviors may be labeled as ED. Most children in special education, however, have impairments that could qualify them for multiple labels (Blackorby et al., 2005; Mattison, Hooper, & Glassberg, 2002; Sabornie, Cullinan, Osborne, & Brock, 2005). Although data on special education outcomes are limited (Donovan & Cross, 2002), children with ADHD who are labeled as ED may fare worse than children in other special education categories. The stigma associated with special education may be greatest for the ED category (Hosp & Reschly, 2003). Children with ED experience worse academic outcomes than other children in special education (Anderson, Kutash, & Duchnowski, 2001; Greenbaum et al., 1996; Landrum, Tankersley, & Kauffman, 2003) and are less likely than children with LD or OHI to be in inclusive settings (Landrum, Katsiyannis, & Archwamety, 2004), despite the fact that these settings are associated with better outcomes (Fisher & Meyer, 2002; Vaughn & Linan-Thompson, 2003). Children who have been labeled as ED or LD share many clinical characteristics and educational needs, which suggests that other factors may be associated with who receives which label (Blackorby et al., 2005; Bussing, Zima, Belin, & Forness, 1998; Mattison et al., 2002; Sabornie et al., 2005). The label given to a child in turn may play an important role in his or her educational outcomes. For example, more evidence has been provided for the effectiveness of educational practices for children with LD than for children with ED (Cook & Schirmer, 2003; Landrum et al., 2003; Vaughn & LinanThompson, 2003). In addition, although best practices are generally underutilized in special education (Cook & Schirmer, 2003), this is especially true for children labeled as ED (Wagner & Davis, 2006), with teachers who specialize in ED reporting that they feel less prepared to work with their students than do other special education teachers (Wagner et al., 2006). The stigma and negative outcomes associated with some special education categories lend urgency to the study of associated disparities. Black students are more likely than White students to be identified as having special education needs, and especially to be given the labels of ED and mental retardation (MR). They are less likely to be labeled as LD (Coutinho & Oswald, 2005; Coutinho, Oswald, Best, & Forness, 2002; De Valenzuela, Copeland, Qi, & Park, 2006; Hosp & Reschly, 2003; Skiba, Poloni-Staudinger, Gallini, Simmons, & Feggins-Azziz, 2006; Skiba, Poloni-Staudinger, Simmons, Feggins-Azziz, & Chung, 2005). Associated hypotheses have implicated genetics, culture, poverty, geography, and professional bias (Artilles,

2003; Donovan & Cross, 2002), although studies have been hampered by limited information regarding students behavioral and cognitive profiles. When these data are available, they are often provided by the same professionals who are making service recommendations, which can introduce bias. Children are usually referred for special education services by their teachers (Donovan & Cross, 2002). In turn, the assessment team that determines need and label tends to confirm teachers recommendations, even when contradictory evidence is present (Hosp & Reschly, 2003).

Study Purpose
The goal of this study was to examine disparities in special education labeling among children diagnosed with ADHD. We attempted to address several of the limitations mentioned previously. First, we selected children who had been diagnosed with a particular disorder, ADHD, that could qualify them for several different special education labels. Choosing this group limits heterogeneity in clinical presentation and educational needs compared with population-based studies of disproportionality in special education labeling. Second, we required that the children had to have received the ADHD label through the behavioral health system rather than the education system. Although it is likely that these systems do not operate completely independently, this requirement reduced some of the bias associated with studies of special education labeling in which educational professionals both assess children and make decisions about appropriate labels. Based on the literature cited previously, we hypothesized that when controlling for clinical and service characteristics, we would find that Black children would be more likely than White children to be given the ED label.

Method
Data Sources and Sample
We used Medicaid mental health claims for calendar year 2002 for the city of Philadelphia, Pennsylvania, to identify children ages 6 to 18 years who had been diagnosed with ADHD (Code 314; World Health Organization, 1977) and merged these data with special education records. Name, birth date, and gender were used to create a unique identifier. To accomplish this matching, we first created a data set of all of the children who had at least one Medicaidreimbursed claim associated with a diagnosis of ADHD

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44 Journal of Emotional and Behavioral Disorders

for calendar year 2002 (n = 6,489). We then created an 11character string variable identifier for the children in this data set and the children in the special education data set (n = 12,027). This identifier was composed of four elements: the first three letters of the last name, the first letter of the first name, the birth date (mm/dd/yy), and a letter identifying gender (M or F). We used this variable to match children across the two data sets. A second matching, in which one of the identifier elements was allowed to vary, was then conducted. This strategy identified 141 children in one data set who were identical on three out of the four elements. These children were compared across data sets; 86 of them had the same information except for minor variations in the spelling of their names. These children were considered a match; the remaining 55 children were considered not to be a match. We then limited the data set to the 4,852 children ages 6 to 18 years who had received at least five Medicaidreimbursed claims for ADHD in Philadelphia during 2002 and for whom an indicator of their special education category label was available. The criterion of five ADHDrelated claims was used to increase the probability that ADHD was the primary diagnosis and was not due to evaluation or coding error (Lurie, Popkin, Dysken, Moscovice, & Finch, 1992; Walkup, Boyer, & Kellermann, 2000). Of the 6,489 children who had received at least one diagnosis of ADHD, 750 had only one ADHD-related claim. Of those with two or more ADHD-related claims, there was a linear reduction in the sample size as the required number of ADHD-related claims increased. At five claims, however, there was a significant increase in the proportion of children for whom ADHD was the most frequently occurring diagnosis (79% for children with five ADHD-related claims vs. 62% for children with two to four ADHD-related claims). In addition, whereas 55% of children with four claims had five or more claims, 64% of children with five claims had six or more. In comparison, 66% of children with six claims had seven or more.

only two students in this sample fell into that category and were therefore categorized as Other. Clinical characteristics, consisting of other psychiatric diagnoses received and behavioral health services received (described below), were used as proxies for severity and clinical complexity. Psychiatric diagnoses were obtained from the Medicaid claims and included Codes 290 through 319 from the ninth revision of the International Classification of Diseases (ICD-9). Diagnoses were coded as disruptive disorder (312 and 313), adjustment disorder (309), affective disorder (296 and 311), schizophreniform disorder (295), and pervasive developmental disorder (299). These codes accounted for 98% of all diagnoses. Use of behavioral health services was categorized as follows: Psychotropic medication use included claims for anticholinergics, anticonvulsants or mood stabilizers, antidepressants, antipsychotics, benzodiazapenes, sedatives, or stimulants. We also separately examined use of the three most common classes of drugs: stimulants, antipsychotics, and mood stabilizers. Behavioral health and rehabilitation services (BHRS) included Medicaid claims for which the service and provider types indicated EPSDT, which is the billing code used in Philadelphia to reimburse for BHRS. These services consist primarily of intensive one-on-one interventions provided by a behavioral health worker in the school, community, and home settings rather than traditional office-based settings. Case management included the assignment of a case manager whose purpose was to coordinate care within and across systems. It was coded if there was at least one claim for which the associated service type was case management. Inpatient psychiatric hospitalization included claims for which there was payment for an overnight stay and the provider type was a private psychiatric hospital, public psychiatric hospital, or extended acute psychiatric care facility, or the type of service was coded as psychiatric care in a general hospital. Partial psychiatric hospitalization, also known as day treatment, included claims where the service type was for partial hospitalization.

Variables
Receipt of special education services was coded by the Philadelphia School District as one of the following 12 categories: autism, hearing and visual impairment, emotionally disturbed, hearing impairment, multiple disabilities, mental retardation, other health impairment, orthopedic impairment, specific learning disability, speechlanguage impairment, traumatic brain injury, or visual impairment. These categories were further grouped into the following four categories: learning disability (LD), emotional disturbance (ED), mental retardation (MR), and Other. Although studies have indicated that ADHD is prevalent among children in the OHI category,

Demographics, including age, gender, and ethnicity, were abstracted from the Medicaid eligibility and special education databases. In the Medicaid database, ethnicity was coded into the mutually exclusive categories of American Indian, Asian, Black, Latino, White, and Other.

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Mandell et al. / Special Education Among Children With ADHD 45

Table 1 Characteristics of Children Ages 6 to 18 Years Receiving at Least Five Medicaid-Reimbursed Claims for ADHD in Philadelphia: Calendar Year 2002
Characteristic Demographics Age: yrs (SD) Male Special education placement, any Special education label Learning disability Emotional disturbance Mental retardation Other exceptionality Other diagnoses received Any Disruptive disorder Adjustment disorder Affective disorder Schizophreniform disorder Pervasive developmental disorder Use of behavioral health care Case management Behavioral health rehabilitation Inpatient stay Partial hospitalization Office-based therapy Use of psychotropic medication Any medication Stimulant Antipsychotic Mood stabilizer Number of medications 1 2 3 4 Total 10.7 (2.6) 78% 37% 50% 29% 10% 12% 34% 24% 9% 10% 2% 1% 32% 52% 10% 14% 88% 74% 63% 16% 8% 40% 21% 9% 4% Blacka 10.6 (2.6) 78% 36% 47% 33% 9% 11% 36% 27% 10% 8% 3% 1% 37% 63% 11% 17% 84% 69% 59% 13% 7% 40% 18% 7% 4% Latinob 10.9 (2.7) 75% 39% 64% 21% 10% 5% 26% 14% 6% 11% 1% 1% 20% 27% 6% 5% 96% 82% 71% 21% 8% 41% 26% 11% 4% Whitec 10.8 (2.8) 79% 41% 46% 27% 10% 17% 32% 19% 8% 14% 2% 3% 28% 42% 11% 10% 89% 82% 69% 21% 14% 38% 24% 13% 7% Otherd 10.5 (2.7) 79% 35% 60% 20% 9% 11% 27% 17% 7% 12% 2% 1% 18% 28% 8% 8% 97% 83% 73% 21% 8% 39% 30% 10% 4% < 0.001 < 0.001 0.012 < 0.001 0.053 0.004 < 0.001 < 0.001 0.007 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 p 0.105 0.406 0.018 < 0.001

Note: N = 4,852. ADHD = attention-deficit/hyperactivity disorder. a. n = 3,031. b. n = 383. c. n = 820. d. n = 618.

Because of the very small numbers of American Indian and Asian children, they were categorized as Other. Syntheses of health disparities research have provided compelling evidence for race and ethnicity as social, rather than biological, constructs (Institute of Medicine, 2002). Cooper, Beach, Johnson, and Inui (2006) referred to observable constructs such as race, ethnicity, and social class as the tip of the iceberg (p. S21) in understanding health disparities and recommended the use of the term ethnicity, rather than race, in describing their relationship to disparities, a recommendation that we followed for this article.

for age and chi-square tests for other variables were used to estimate differences in the variables of interest by ethnicity. We then used binary logistic regression to estimate the odds of any special education label and the odds of being labeled ED among children in special education.

Results
Table 1 provides a description of the study sample as a function of ethnicity. White children were most likely to receive special education services, whereas children in the Other category were least likely to receive them. Among the children in special education, Latinos and children of other ethnicities were more likely than Black and White children to be labeled as LD. In addition, Black children were most likely to be labeled as ED, and

Analyses
We conducted descriptive analyses using means or frequencies as appropriate. Analyses of variance (ANOVAs)

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46 Journal of Emotional and Behavioral Disorders

Table 2 Logistic Regression Predicting Special Education Placement Among Children Ages 6 to 18 Years With at Least Five ADHD-Related Medicaid-Reimbursed Claims in Philadelphia: Calendar Year 2002
Any Special Education Placement Characteristic Demographics Age (yrs) Gender (male) Black Latino Other Diagnosis Disruptive disorder Adjustment disorder Affective disorder Schizophreniform disorder Pervasive developmental disorder Use of other behavioral health care Case management Behavioral health rehabilitation services Inpatient stay Partial hospitalization Use of psychotropic medication Stimulant Antipsychotic Mood stabilizer Odds Ratio 1.10 1.14 0.78 0.98 0.86 0.87 0.70 0.86 0.75 2.52 1.60 1.36 0.99 0.89 1.28 1.28 1.14 95% CI 0.951.28 1.111.17 0.660.93 0.761.26 0.681.07 0.751.02 0.560.88 0.691.08 0.501.13 1.504.22 1.381.86 1.171.58 0.781.25 0.741.07 1.121.45 1.081.53 0.901.43 ED Placement for Children in Special Education Odds Ratio 1.06 1.81 1.40 0.86 0.89 1.16 0.92 1.13 4.52 0.59 1.66 2.10 0.91 1.13 1.21 1.86 1.55 95% CI 1.011.12 1.342.43 1.041.89 0.521.43 0.581.38 0.891.51 0.611.38 0.761.68 2.139.59 0.281.24 1.302.12 1.592.75 0.621.35 0.811.58 0.951.53 1.402.46 1.092.22

Note: ADHD = attention-deficit/hyperactivity disorder; ED = emotional disturbance. Bold indicates statistical significance at p < .05.

White children were most likely to be labeled with other exceptionalities. About one third of the sample had been diagnosed through the mental health system as having a psychiatric disorder in addition to ADHD. Black children were most likely and Latino children least likely to have received diagnoses in addition to ADHD. Black children were also most likely and Latino children also least likely to receive a diagnosis of disruptive disorder or adjustment disorder. Latino children were most likely and Black children least likely to receive a diagnosis of affective disorder. White children were most likely to receive a diagnosis of pervasive developmental delay (PDD). Black children were most likely to use case management, BHRS, and partial hospitalization services; Latino children were least likely to use BHRS and partial hospitalization services; and children in the Other ethnicity category were least likely to use case management services. Inpatient services were used by 11% of Black and White children, 6% of Latino children, and 8% of children in the Other category. Black children were least likely to use each type of medication or any medication. The proportion taking medications was similar across

the other groups, although White children were most likely to take mood stabilizers. Table 2 presents the results of the logistic regression analyses, without interaction terms, for predicting special education placement. Boys were more likely than girls (odds ratio [O.R.] = 1.14) and Black children were less likely than children of other ethnicities (O.R. = 0.78) to receive special education services. Children who had a diagnosis of adjustment disorder were the least likely (O.R. = 0.70) and children with PDD were the most likely (O.R. = 2.52) to receive these services. Use of case management (O.R. = 1.60), BHRS (O.R. = 1.36), stimulants (O.R. = 1.28), and antipsychotics (O.R. = 1.28) all increased the probability of receiving special education services. Among children in special education, older children (O.R. = 1.06), boys (O.R. = 1.81), and Black children (O.R. = 1.40) were more likely than younger children, girls, or other ethnicities, respectively, to be labeled with an ED. Children who had been given a diagnosis of schizophrenia (O.R. = 4.52), used case management (O.R. = 1.66) or BHRS (O.R. = 2.10), or for whom antipsychotics (O.R. = 1.86) or mood stabilizers (O.R. = 1.55) had been prescribed were more likely to be labeled ED.

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Mandell et al. / Special Education Among Children With ADHD 47

Figure 1 Special Education Placement Among Children With Attention-Deficit/Hyperactivity Disorder

adjusted analyses, Black children without BHRS (O.R. = 2.90), Black children with BHRS (O.R. = 4.10), and White children with BHRS (O.R. = 4.28) were all at increased risk for an ED label, compared to White children without BHRS.

Discussion
This study found ethnic disparities in special education services and labeling in a large sample of children who had been diagnosed with ADHD. Black children were less likely than White children to receive special education services. Among children in special education, Black children were more likely to have the ED label. The use of BHRS, which constitute an intensive service delivered in schools and homes, predicted special education service use and labeling differently for Black and White children. These findings differ from those of previous studies that reported that Black children were overrepresented in special education, but they are similar in that Black children were overrepresented in the ED category (Coutinho & Oswald, 2005; Coutinho et al., 2002; De Valenzuela et al., 2006; Hosp & Reschly, 2003; Serwatka, Deering, & Grant, 1994; Skiba et al., 2006; Skiba et al., 2005). The differences in this study from previous studies are most likely due to our focus on a group of children whose diagnosis suggested a high risk for special education needs rather than on the general population of school-age children. The fact that Black children were less likely to receive special education services is in line with findings that Black children diagnosed with ADHD are less likely than similarly diagnosed White children to have a diagnosed LD (Pastor & Reuben, 2005), and it suggests under-recognition of their learning needs. Among the children in special education, Black children were more likely to have the ED label than were their White counterparts, which suggests that the education system is more likely to identify disruptive behavior as the primary contributor to academic underachievement for Black children than for White children. Although tested as a post hoc analysis, the interaction between ethnicity and BHRS may offer some insight into service and labeling disparities. Compared with Black children with or without BHRS, White children with BHRS were at increased risk for receiving any special education services. Perhaps the threshold for receiving BHRS is lower for Black children than for White children, so that White children receiving BHRS are more severely affected, therefore necessitating the use of

Note: Numbers represent adjusted odds ratios; numbers in bold typeface are significantly different from the reference group at p < .05. BHRS = behavioral health and rehabilitation services.

Because of the significant differences that we observed in service use by ethnicity and the differences in special education labeling, we included the interaction terms for ethnicity and BHRS, case management, and stimulant use in the logistic regression model. These interaction terms were used to test whether mental health and education services might be differentially substituted for each other among children of different ethnicities. Figure 1 displays the interaction between being Black or White and receiving BHRS in predicting special education services and receiving the ED label. The interactions between ethnicity and other types of service use were not statistically significant, nor were the interactions between children of other ethnicities and BHRS. In addition, introduction of the interaction terms did not appreciably change the point estimates or statistical significance of other coefficients. Among all of the children in the sample, 32% of White children and 30% of Black children who did not receive BHRS had received some special education services. In contrast, 50% of White children and 38% of Black children who received BHRS had received some special education services. In adjusted analyses, only White children with BHRS differed from White children without BHRS in their odds of receiving special education services (O.R. = 1.70). Among children in special education, 11% of White children and 26% of Black children who did not receive BHRS had the ED label. Among children who received BHRS, 37% of White children and 40% of Black children had this label. In

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48 Journal of Emotional and Behavioral Disorders

special education services. Black children were about 1.5 times more likely than were White children to receive BHRS, which provides some evidence for this hypothesis. Another explanation is that among children with ADHD, Black children are more likely to receive either special education or BHRS services, whereas White children are more likely to receive both services. Because the federal contribution is greater for Medicaidreimbursed services than for special education services, local jurisdictions have an incentive to shift costs from education to Medicaid. Because ADHD can affect children in multiple domains (e.g., school, family, peer groups), however, a combination of school, medical, and family-centered services facilitates best treatment practices (Barkley, 1998). White parents also may be more effective than Black parents in advocating for care for their children in multiple systems (Bussing, Schoenberg, & Perwien, 1998; Bussing, Zima, Perwien, et al., 1998). Another interpretation is that among children in special education who were not receiving BHRS services, the higher proportion of Black children with the ED label resulted from a bias in the special education classification process. Studies have shown that teachers tend to rate the behavior of Black children as more disruptive than that of White children, even when independent observations suggested no difference (Elhoweris, Mutua, Alsheikh, & Holloway, 2005; Epstein et al., 2005; Hosp & Hosp, 2001; Skiba, Michael, Nardo, & Peterson, 2002). This perception may lead to an ED label, regardless of the educational needs of the child. Among children in special education who were not receiving BHRS services, the increased risk for an ED label among Black children suggests that the education system is more likely to identify disruptive behavior as their primary barrier to educational attainment, even when service use and associated diagnoses in the mental health system do not suggest a greater risk associated with these behaviors. An increase in disruptive behaviors could result from undertreatment, which is suggested by (a) the lower proportion of Black children in this study who were taking stimulants, the most effective treatment for ADHD (Biederman & Faraone, 2005), and (b) the increased proportion of Black children who were receiving behavioral interventions of unknown effectiveness (Weisz & Jensen, 1999). Other findings deserve mention as well. Even after adjusting for service and clinical characteristics, we found that boys were more likely than girls to receive any special education services and, among children in special education, were almost twice as likely to have the ED label. This finding should be interpreted with caution, given the limited data on clinical presentation, but it

suggests that learning problems may be more underidentified in girls than in boys and that when those problems are identified, boys behaviors are more likely to be seen as disruptive.

Limitations
Several study limitations should be noted. First, an ADHD diagnosis in Medicaid claims has not been validated. In a related study, Lewczyk, Garland, Hurlburt, Gearity, and Hough (2003) found low concordance between clinicians and researchers in regards to child psychiatric diagnoses, although concordance was highest for ADHD and there was no difference by child ethnicity. We attempted to reduce this limitation by selecting a cohort with multiple ADHD claims. Second, we had no information regarding the special educational service use or need of each child, separate from his or her label, or measures of psychiatric symptoms or functioning. Unobserved need may have driven the use of special education services and labeling, confounding the observed associations. Third, we also had no information regarding ADHD treatment received in primary care. Although ADHD is often treated in primary care (Stevens, Harman, & Kelleher, 2004), Philadelphia manages the behavioral health care of Medicaid-enrolled children, while physical health care is managed by private insurance companies, which limits the incentive to treat ADHD in a physical health setting. Fourth, these data are cross-sectional, and causal inference is limited. We do not believe this is an issue for the main analyses because we used behavioral health claims as a marker of clinical presentation rather than as a predictor of special education label per se. The testing of interactions, however, presents a shift in focus to the issue of service substitution. Our related findings require further longitudinal study. Finally, the generalizability of our results is limited by our focus on a single geographic location and on a Medicaidenrolled sample. It is likely that geographic differences exist in how mental health and educational referrals are made (Serwatka et al., 1994). Similarly, the interaction of behavioral health care and special education services may be different for poor children. For example, the Medicaidenrolled children in Philadelphias behavioral health carveout may have more direct access to behavioral health services than other children, because (a) this system requires no gatekeeping from primary care and (b) Medicaid behavioral health benefits are traditionally more generous than those received through private insurance (Semansky, Koyanagi, & Vandivort-Warren, 2003). Another important possible limitation is that ethnic differences that lead to different behavioral health care patterns and special

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Mandell et al. / Special Education Among Children With ADHD 49

education labels may be different for poor children than for other children. For example, being poor may exacerbate differences in help-seeking behavior or in teachers interpretations of behaviors. Conversely, being enrolled in Medicaid may ameliorate traditional disparities in health care utilization. It is important to note, however, that 50% of school children in Philadelphia are enrolled in Medicaid, a similar percentage to those of other major urban areas.

are prescribed psychotropic medications that may affect their ability to learn. Future studies should take into account that services delivered in one system may greatly affect need and associated service delivery in the other.

References
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Implications
Despite these limitations, some implications should be considered. A number of investigators have raised concerns that Black children with ADHD are less likely than their non-Black peers to receive appropriate clinical and educational services (Bussing, Zima, & Belin, 2003; Olfson, Gameroff, Marcus, & Jensen, 2003). The results of this study suggest that inappropriate care may be present in the mental health and education systems, which raises the question as to whether more appropriate care in one system would reduce the need for specialized care in the other. The observed disparities in mental health care may be driven by ethnic differences in parental beliefs about the causal mechanisms of ADHD and concerns about side effects (Bussing, Schoenberg, & Perwien, 1998; Yeh, Hough, McCabe, Lau, & Garland, 2004) and suggest the need for research on more effective parental education and strategies for eliciting and interpreting the treatment concerns of Black parents and their children. Medication use also may be driven by practitioner beliefs. For example, Kendall and Hatton (2002) suggested that clinicians may endorse a biomedical model of symptoms for White children with ADHD but believe Black childrens behavior to be more related to environment. The higher proportion of disruptive disorder diagnosis and greater use of behavioral interventions among Black children offer some evidence for this hypothesis and suggest the need for research on methods to prevent statistical discrimination in the diagnostic and treatment process. Statistical discrimination refers to situations in which clinicians have different expectations by ethnicity about the effectiveness of medication use, its acceptability to caregivers, and adherence (Balsa & McGuire, 2001; Institute of Medicine, 2002). Disparity in special education labeling of children with similar diagnostic profiles may be improved through the use of a more standardized, culturally sensitive, and independent special education evaluation process. Labeling and service decisions might be enhanced by increased collaboration between the mental health and education systems. The need for increased collaboration is also evident in the apparent clinical complexity of children in special education, 10% of whom experience inpatient episodes that remove them from their communities and more of whom

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David S. Mandell, ScD, is an assistant professor at the University of Pennsylvania School of Medicine in the Departments of Psychiatry and Pediatrics. His current interests include child psychiatric epidemiology and related health and educational service needs. Jasmine K. Davis is an undergraduate at Hampton University. Her interests include health and health care disparities. Katherine Bevans, PhD, is a research assistant professor at The Childrens Hospital of Philadelphia. Her research interests include the schools role in health promotion. James P. Guevara, MD, MPH, is an assistant professor at The Childrens Hospital of Philadelphia. His research interests include collaborative care for children with attention deficit disorder. Address: David S. Mandell, Center for Mental Health Policy and Services Research, University of Pennsylvania School of Medicine, 3535 Market St., 3rd Floor, Philadelphia, PA 19104.

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