Ethnic disparities in special education labeling among children with attention-deficit/hyperactivity disorder.(Report)

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 children's educational and mental health needs.

Keywords: attention-deficit/hyperactivity disorder; mental health services; special education' Medicaid

**********

Children 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 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 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; Vanghn & Linan-Thompson, 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 …