U.S. Department of Health and Human Services 
Office of Inspector General 
 
Many 
Medicaid-Enrolled 
Children Who 
Were Treated for 
ADHD Did Not 
Receive 
Recommended 
Followup Care  
 
OEI-07-17-00170 
August 2019 
Joanne M. Chiedi 
 
Acting Inspector General 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
August 2019 
Office  of Inspector General 
OEI-07-17-00170 
 
 
Many Medicaid-Enrolled Children Who Were 
Why OIG Did This Review 
Treated for ADHD Did Not Receive 
Children with ADHD have higher rates 
of repeating grade levels, dropping 
Recommended Followup Care  
out of school, and receiving hospital 
Attention deficit hyperactivity disorder (ADHD) is a common neurobehavioral  care.  Childhood ADHD is also 
disorder with symptoms of inattention, hyperactivity, and impulsivity.  The  associated with negative outcomes in 
Department of Health and Human Services publishes national quality measures  adulthood such as increased rates of 
that outline timeframes for followup care for children with ADHD.  Additionally,  other mental health problems, criminal 
professional guidelines from American Academy of Pediatrics and American  behavior, and increased risk for 
Academy of Child and Adolescent Psychiatry describe the importance of  suicide.  The annual societal costs of 
followup care and behavioral therapy for these children.  Some children may  ADHD are estimated at up to 
not receive followup care or behavioral therapy for reasons such as limited  $266 billion from loss of productivity, 
access to care or because practitioners may be unaware of the professional  as well as spending in the healthcare, 
recommendations.  This study focuses specifically on the extent to which  justice, and educational systems.     
children do not receive followup services and behavioral therapy.  
An estimated 13 percent of 
What OIG Found  Medicaid-enrolled children are 
Over 500,000 Medicaid-enrolled children who were newly prescribed an ADHD  impacted by ADHD.  Treatment 
medication and over 3,500 children who were hospitalized with a primary  involving behavioral therapy, 
diagnosis of ADHD did not receive followup care within the timeframes  medication, and followup care can 
outlined in the national quality measures.  Additionally, over 54,000 children did  help improve these childrens 
not receive any behavioral therapy as recommended by professional guidelines.    outcomes, long-term prognoses, and 
quality of life.  
What OIG Recommends 
The Office of Inspector General (OIG) recommends that the Centers for  OIG conducted this review in response 
Medicare & Medicaid Services (CMS) work toward improving health outcomes  to a congressional request to evaluate 
by developing strategies to increase the number of children who receive timely  pharmaceutical and behavioral 
followup care for ADHD.  We recommend that CMS accomplish this by working  therapy treatment of 
in three ways:   Medicaid-enrolled children with 
ADHD.   
Collaborate: CMS should collaborate with partners to develop strategies for 
improving rates of followup care for children who receive treatment for ADHD. 
How OIG Did This Review 
Assist: CMS should provide technical assistance to States to implement  We reviewed Medicaid claims data, fiscal 
strategies for improving rates of followup care for children who receive  years 2014 and 2015, from all States and 
treatment for ADHD.  the District of Columbia for 
Medicaid-enrolled children who received 
Analyze: CMS should analyze the effectiveness of strategies for improving rates 
treatment for ADHD.  We examined 
of followup care for children who receive treatment for ADHD. 
whether children received: (1) timely 
CMS concurred with all three recommendations.  followup care with practitioners after 
being newly prescribed an ADHD 
 
medication, (2) timely followup care after 
ADHD hospitalizations, and (3) behavioral 
therapy in addition to ADHD medication.  
We also interviewed professionals to 
understand the impact ADHD has on 
children. 
Full report can be found at oig.hhs.gov/oei/reports/oei-07-17-00170.asp 
   
TABLE OF CONTENTS 
BACKGROUND  1 
Objectives  1 
Methodology  3 
   
FINDINGS  6 
Over 500,000 Medicaid-enrolled children who were newly prescribed an ADHD medication did  6 
not receive followup care within the timeframes outlined in HHSs national quality measures 
Thirty-five percent of Medicaid-enrolled children who were hospitalized for ADHD did not  7 
receive followup care within 30 days 
Nearly half of Medicaid-enrolled children who were newly prescribed an ADHD medication did  8 
not receive behavioral therapy 
   
CONCLUSION AND RECOMMENDATIONS  10 
CMS should collaborate with partners to develop strategies for improving rates of followup  10 
care for children who receive treatment for ADHD 
CMS should provide technical assistance to States to implement strategies for improving rates  10 
of followup care for children who receive treatment for ADHD 
CMS should analyze the effectiveness of strategies for improving rates of followup care for  10 
children who receive treatment for ADHD 
Agency Comments and Office of Inspector General Response  12 
   
APPENDICES   
A: Detailed Methodology   13 
B: Medicaid-Enrolled Children Who Did Not Receive Followup Care After Being Newly  17 
Prescribed an ADHD Medication 
C: Treatment for Medicaid-Enrolled Children With ADHD by Age  21 
D: Medicaid-Enrolled Children Who Did Not Receive Followup Care After Hospitalization for  24 
ADHD 
E: Medicaid-Enrolled Children Who Were Medicated for ADHD and Did Not Receive  28 
Behavioral Therapy  
F: Agency Comments  30 
   
ACKNOWLEDGMENTS  32 
 
ENDNOTES  34 
   
BACKGROUND 
Objectives 
To determine the extent to which Medicaid-enrolled children who were 
treated for attention deficit hyperactivity disorder (ADHD) received: 
1.  timely followup care with practitioners, and 
2.  behavioral therapy in addition to medication. 
Medicaid is a joint State and Federal program that provides health coverage 
to individuals based on eligibility criteria such as income, disability, and 
placement in foster care.  In fiscal year (FY) 2017, nearly 37 million children 
were enrolled in Medicaid.1  An estimated 13 percent of children enrolled in 
Medicaid have been diagnosed with ADHD.2  
ADHD is one of the most common neurobehavioral disorders of childhood 
and can affect all aspects of a childs life, including academic achievement, 
well-being, and social interactions.3  Children with ADHD may experience 
symptoms of inattention, hyperactivity, and impulsivity, and have higher 
rates of repeating grade levels, dropping out of school, and receiving 
hospital care.4, 5  More than half of children with ADHD (60 percent) have at 
least one other mental health disorder.6   
ADHD is associated with negative outcomes in adulthood such as increased 
rates of other mental health problems, criminal behavior, and increased risk 
for suicide.7, 8  The annual societal costs of ADHD are estimated at up to 
$266 billion from loss of productivity, as well as spending in the healthcare, 
justice, and educational systems.9     
Professional Guidance on ADHD Treatment for Children  
Professional organizations such as the American Academy of Pediatrics 
(AAP) and the American Academy of Child and Adolescent Psychiatry 
(AACAP), along with researchers, have published a large body of guidance 
and information on treatment for children diagnosed with ADHD.  
Treatment recommendations include Food and Drug 
Administration-approved ADHD medication and/or evidence-based 
behavioral therapy (i.e., training in specific, evidence-based techniques for 
both the child and parent); generally, the preferred treatment is both 
medication and behavioral therapy.10, 11  Treatment should be individualized 
for each child and include followup care with a practitioner.12  Followup care 
includes monitoring of the child to confirm that ADHD symptoms are well 
controlled, that medication is effective, and that behavioral therapy and 
academic support needs are met.13, 14  Additionally, some children with 
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  1 
OEI-07-17-00170   
ADHD who have complex care needs may be hospitalized and need 
followup care. 15 
The Centers for Medicare & Medicaid Services Use of Quality 
Measures  
The Centers for Medicare & Medicaid Services (CMS) uses the core set of 
childrens healthcare quality measures for Medicaid and the Childrens 
Health Insurance Program (the Child Core Set), a broad set of national 
quality measures published by the Department of Health and Human 
Services (HHS), to promote improved healthcare outcomes.16  The Child 
Core Set measures are not clinical guidelines.  CMS uses these measures to 
collect data about the quality of care provided to these children.  The Child 
Core Set includes two followup care quality measures related to this 
evaluation: 1) when a child is newly prescribed an ADHD medication, and 
2) when a child is hospitalized for mental illness.17, 18  ADHD is one of the 
diagnoses included in the broad range of mental health conditions assessed 
in the followup after hospitalization for mental illness measure.  States 
reporting of these quality measures is voluntary.19, 20  The Child Core Set 
describes timeframes for followup visits with practitioners related to ADHD 
treatment. 
After a child is newly prescribed an ADHD medication:  
  an initial visit within 30 days after the prescription, and 
  two additional visits between 31 and 300 days after the 
prescription. 
After a child is hospitalized for mental illness, including ADHD: 
  a visit within 7 days after hospitalization, or 
  a visit no later than 30 days after hospitalization. 
Other Federal Agency Efforts Related to ADHD 
Other agencies have published work related to ADHD in children, including 
the Centers for Disease Control and Prevention (CDC), National Institute of 
Mental Health (NIMH), Substance Abuse and Mental Health Services 
Administration (SAMHSA), Health Resources and Services Administration 
(HRSA), and the Administration for Children and Families (ACF).  For 
example, CDC has identified treatment of ADHD in young children as a 
public health priority and is developing effective strategies in this area.21  
Additionally, NIMH has collected data on ADHD to establish priorities for 
prevention, treatment, and research.22   
Challenges to Providing ADHD Followup Care   
Professional organizations (e.g., AAP, AACAP), governmental agencies, and 
academic researchers have identified several challenges, which are not 
unique to Medicaid-enrolled children, related to ensuring that all children 
receive followup care for ADHD.  These challenges include the following:  
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  2 
OEI-07-17-00170   
  Workforce shortages persist among many types of behavioral health 
practitioners (e.g., psychiatrists, psychologists, social workers, and 
mental health counselors).23, 24  
  Pediatricians and other practitioners, who may lack specialized 
training in diagnosing and treating behavioral health disorders, are 
often tasked with identifying and managing childrens behavioral 
health needs.25, 26   
  Parents and practitioners might lack awareness of current 
professional recommendations and the benefits of evidence-based 
services.27, 28   
  Evidence-based services may not exist in every community, and 
parents and practitioners may have difficulty identifying and 
accessing ADHD treatment consistent with professional 
recommendations.29   
  Some parents of children with ADHD are also diagnosed with ADHD 
and may experience challenges in consistently providing medication 
and behavioral interventions.30 
Concerns About Medication Monitoring for Children and Related 
OIG Work 
Previous Office of Inspector General (OIG) work identified concerns related 
to monitoring of second-generation antipsychotics (SGAs), a class of 
psychotropic medications that were prescribed to children.31  Specifically, a 
2015 study identified quality-of-care concerns in the medical records for 
67 percent of claims for SGAs prescribed to Medicaid-enrolled children, 
including children diagnosed with ADHD.32  To ensure the quality of the 
care provided to children receiving SGAs, we recommended that CMS work 
with State Medicaid programs to perform utilization reviews, conduct 
periodic reviews of medical records, and consider other methods of 
enhanced oversight.  CMS implemented all of these recommendations. 
A 2018 OIG study found that 34 percent of Medicaid-enrolled children in 
foster care who were prescribed psychotropic medication, including ADHD 
medication, did not receive treatment planning or medication monitoring.33  
We recommended that ACF work to improve States compliance with foster 
care requirements related to treatment planning and medication monitoring 
of psychotropic medications and to assist States in strengthening these 
requirements.  
In addition, OIG received a congressional request raising concerns about 
treatment for Medicaid-enrolled children with ADHD and asking that OIG 
examine these issues.  This evaluation is responsive to that request. 
Methodology  Scope 
This study is limited to an evaluation of Medicaid claims data and interviews 
with ADHD professionals.  We did not conduct medical record review or 
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  3 
OEI-07-17-00170   
assess the quality of the treatment or accuracy of the diagnoses children 
received.   
Data Collection and Analysis 
We collected Medicaid Statistical Information System (MSIS) and Medicaid 
Management Information System (MMIS) fee-for-service claims, managed 
care encounters, and eligibility data for all 50 States and the District of 
Columbia (hereinafter, referred to as States).34, 35  These data included 
FYs 2014 and 2015, the most complete data available at the time of our 
review.  We then analyzed MSIS and MMIS claims data to determine the 
percentages of children continuously enrolled in Medicaid who received 
(1) followup care with practitioners after being newly prescribed an ADHD 
medication, (2) followup care after hospitalizations for ADHD, and  
(3) behavioral therapy in addition to being newly prescribed an ADHD 
medication.   
We developed our analyses to respond to the specifics of the congressional 
request.  We used the technical specifications established by FYs 2014 and 
2015 Child Core Set measures to identify ADHD medications and 
hospitalizations, timeframes for followup care, and which claims are 
considered followup care.  For the rate of followup care after hospitalization 
for mental illness, we analyzed only hospitalizations for ADHD.36  We added 
an analysis related to behavioral therapy for children treated with ADHD 
medication.  Each analysis in the report assesses different aspects of ADHD 
treatment using distinct criteria; therefore, each finding reflects a different 
population of children.  The analyses in this study are not comparable to 
States voluntary reporting on the Child Core Set.  See Appendix A for 
additional details about our methodology.  
We conducted structured interviews with representatives from professional 
organizations who focus on the study and treatment of children with ADHD.  
Our interviews consisted of questions related to the impacts of ADHD on 
the lives of children and their families, clinical implications of inconsistent 
followup care, and circumstances surrounding hospitalization for ADHD. 
Limitations 
The results of our analysis are limited to the data we received.  It is possible 
that some children received services that could not be included in our 
analysis (e.g., incorrect or incomplete diagnosis or procedure coding, 
services not paid for by Medicaid, such as school counseling).37  Therefore, 
this study may have underestimated the provision of services for these 
children.  It is also possible that the population of children treated for ADHD 
could be underestimated if Medicaid claims data were incomplete.  To the 
extent practicable, we conducted extensive quality assurance reviews to 
ensure the usability of Medicaid claims data.  See Appendix A for additional 
details about our methodology for data validation.  
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  4 
OEI-07-17-00170   
We conducted this study in accordance with the Quality Standards for 
Standards 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency.   
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  5 
OEI-07-17-00170   
FINDINGS 
Over 500,000  Over 500,000 Medicaid-enrolled children who were newly prescribed an 
ADHD medication did not receive followup care within the timeframes 
Medicaid-enrolled 
outlined in HHS national quality measures.  Professional guidelines state 
children who were 
that children should have regular followup care to assess medication 
newly prescribed an  effectiveness, identify side effects, and monitor for appropriate medication 
ADHD medication  use when children are newly prescribed an ADHD medication.  Followup 
care is an important part of treatment for ADHD as the disorder can affect 
did not receive 
all aspects of a childs academic and health outcomes (e.g., increased risk of 
followup care within 
dropping out of school, substance abuse, and suicide).  See Appendix B for 
the timeframes  detailed information about the rate of followup care in each State, and 
Appendix C for detailed information about the rate of followup care by age. 
outlined in HHS 
national quality 
Fifty-nine percent of Medicaid-enrolled children who were newly 
measures  prescribed an ADHD medication did not receive followup care 
within 30 days  
During our review period, 873,833 children were newly prescribed an ADHD 
medication, but over half did not receive followup care within 30 days.  
Specifically, 59 percent (516,285 children) did not receive followup care with 
a practitioner within 30 days as outlined in the national quality measures.   
Professional guidelines indicate that followup care is critical for practitioners 
to determine whether medication is effective (i.e., reducing ADHD 
symptoms and improving the childs outcome).  Followup care allows 
practitioners to assess children treated with ADHD medication for side 
effects such as changes in blood pressure and heart rate, sleep problems, 
tics, personality 
changes, 
irritability, and 
impaired 
growth.38, 39  
Practitioners may 
then adjust 
medication as 
necessary.  
Twenty-one percent of Medicaid-enrolled children who were newly 
prescribed an ADHD medication did not receive 2 followup care 
visits within 300 days  
Almost a quarter of the 121,364 children who were subject to the 300-day 
analysis did not receive 2 followup care visits.40  Specifically, 21 percent 
(26,081 children) who were newly prescribed an ADHD medication did not 
receive 2 followup care visits between days 31 and 300, as outlined in the 
national quality measures.  Continued followup care allows practitioners to 
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  6 
OEI-07-17-00170   
evaluate the medication and dose to ensure that the childs needs are met, 
that ADHD symptoms are improved, and that side effects are managed.  
Further, followup care includes close monitoring for appropriate medication 
use. 
For the 300-day analysis, we reviewed those children who were newly 
prescribed an ADHD medication, had a Medicaid claims history long 
enough to analyze their followup care for 300 days, and met other criteria 
(e.g., continuously eligible for Medicaid, had at least 210 days of 
medication).41  
For more 
information 
about the 
different 
populations 
analyzed for 
different 
measures, see 
the Detailed 
Methodology in Appendix A. 
Nine percent of Medicaid-enrolled children who were newly prescribed an 
ADHD medication did not receive any followup care within 300 days.  Of 
the 121,364 children who were newly prescribed an ADHD medication and 
were subject to the 300-day analysis, 9 percent (11,410) did not receive any 
followup care visits within 300 days.42  Although this measure is not included 
as part of the Child Core Set of national quality measures, we have included 
it to demonstrate the number of children who continued to receive ADHD 
medication in the absence of any visits with a practitioner.  Followup visits 
are critical to ensure that a practitioner conducts ongoing assessments of 
medication efficacy and side effects.  Additionally, some of the medications 
prescribed for ADHD are in a drug category with significant potential for 
misuse, abuse and diversion (i.e., giving away, trading, or selling of 
prescription medication); followup allows a practitioner to screen for these 
concerns.43  
Thirty-five percent  More than one-third of children who were hospitalized with ADHD did not 
receive followup care within the timeframes outlined in the national quality 
of Medicaid-
measures.44  Specifically, 35 percent (3,694) of the 10,521 children reviewed 
enrolled children 
for this analysis did not receive followup care after hospitalization within 
who were  30 days.  
Although 
hospitalized for 
the Child 
ADHD did not 
Core Set 
receive followup 
national 
within 30 days  quality 
measure 
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  7 
OEI-07-17-00170   
does not report a separate rate of followup for each mental illness 
diagnosis, we analyzed the rate for ADHD admissions to demonstrate the 
number of children who were hospitalized for this condition and did not 
receive followup visits with a practitioner within 30 days.  Followup care 
after hospitalization is essential to assess the childs response to any 
treatment changes made during the hospital stay and to ensure that 
symptoms are managed with minimal side effects.  See Appendix D for 
detailed information about the rate of followup care in each State. 
Some children with ADHD have complex care needs and other mental 
health conditions and may be hospitalized.45  Timely followup after 
hospitalization can help a child transition back to home and school and 
prevent hospital readmissions.46  See Appendix C for detailed information 
about the rate of followup care by age. 
Additionally, we found that 60 percent (6,560) of Medicaid-enrolled children 
who were hospitalized for ADHD did not receive followup care within 
7 days.  The national quality measure reports two rates of followup care 
after hospitalization for mental illness (including ADHD): within 7 days, and 
within 30 days.  The Child Core Set reporting states that followup care after 
these hospitalizations should ideally include a visit within 7 days.  For this 
review, we analyzed followup care for the 10,918 children who were 
hospitalized with ADHD as the primary reason.  The number of children 
subject to the 7-day analysis is slightly higher than for the 30-day analysis 
because the shorter review period allowed fewer opportunities for lapses in 
Medicaid eligibility and hospital readmissions. 
Nearly half of  Forty-five percent (54,726) of Medicaid-enrolled children who were newly 
prescribed an ADHD medication did not receive behavioral therapy during 
Medicaid-enrolled 
the 120 days prior to, and 300 days following, the new prescription.  For this 
children who were 
analysis, we reviewed the 121,364 children who were subject to the 300-day 
newly prescribed an  analysis.  We used this approach to allow the greatest amount of time for at 
least one behavioral therapy visit before, during, or after being newly 
ADHD medication 
prescribed an ADHD medication.  See Appendix E for detailed information 
did not receive 
about the rate of behavioral therapy in each State.  
behavioral therapy 
Although this rate is not reported in the Child Core Set of national quality 
measures, it does align with professional recommendations for ADHD 
treatment, namely that children receive both ADHD medication and 
evidence-based behavioral therapy.47, 48  Behavioral therapy could include 
parent training and 
group or individual 
sessions conducted 
over time, with 
activities assigned 
for completion 
between sessions.49  
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  8 
OEI-07-17-00170   
Through these activities, parents can learn skills and strategies to help their 
child succeed at school, at home, and in relationships.  Behavioral therapy 
can also help improve childrens behavior, self-control, self-esteem, and 
their ability to understand how the disorder impacts their life.  See Appendix 
C for detailed information about the rate of followup care by age.  
 
   
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  9 
OEI-07-17-00170   
CONCLUSION AND RECOMMENDATIONS 
Many Medicaid-enrolled children who receive treatment for ADHD are not 
receiving followup care within the timeframes outlined in national quality 
measures and professional guidelines.  Specifically, OIG found that over 
500,000 Medicaid-enrolled children who were newly prescribed an ADHD 
medication and over 3,500 children who were hospitalized for ADHD did 
not receive timely followup care as outlined in the national quality 
measures.  Additionally, over 54,000 children did not receive any behavioral 
therapy as recommended by professional guidelines.  Some children may 
not receive followup care or behavioral therapy for reasons such as limited 
access to care or because practitioners may be unaware of the professional 
recommendations.   
CMS is engaged in ongoing efforts related to childrens behavioral health 
needs (e.g., Child Core Set measures).50  Consistent with these efforts, CMS 
should work toward improving health outcomes by developing strategies to 
increase the number of children who receive followup care for ADHD.  We 
recommend that CMS accomplish this by working in three ways:  
Collaborate  Collaborate with partners to develop strategies for improving 
rates of followup care for children treated for ADHD 
CMS should work with professional organizations, States, and Federal 
agencies (e.g., CDC, NIMH, SAMHSA, HRSA, and ACF51, 52) to:  
  identify barriers that may inhibit childrens receipt of followup care, 
and 
  develop strategies that States can adapt for improving followup 
rates and promoting positive long-term outcomes for 
Medicaid-enrolled children.    
Assist   Provide technical assistance to States to implement strategies 
for improving rates of followup care for children treated for 
ADHD 
CMS should help States implement strategies for improving rates of 
followup care for children treated for ADHD.  This technical assistance 
should be accomplished through information-sharing methods such as in-
person educational offerings, distance learning, or webinars.   
Analyze  Analyze the effectiveness of strategies for improving rates of 
followup care for children treated for ADHD 
CMS should establish a plan to analyze the effectiveness of these strategies 
for improving rates of followup care for children treated for ADHD.  CMS 
could accomplish this by doing the following: 
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  10 
OEI-07-17-00170   
  establishing a mechanism to continue engaging professional 
organizations, States, and Federal agencies to measure outcomes of 
these implemented strategies; and 
  analyzing current CMS data to assess whether the rates of ADHD 
followup care improve in States over time.   
CMS should share findings from these analyses so that States may 
evaluate followup rates and adjust strategies as necessary. 
 
Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care  11 
OEI-07-17-00170   
AGENCY COMMENTS AND OIG RESPONSE 
In its response to our draft report, CMS reaffirmed its commitment to 
providing accessible, high-quality healthcare for Medicaid-enrolled children, 
including those being treated for ADHD.  CMS outlined some of its ongoing 
efforts related to childrens behavioral health needs and stated that it is 
committed to collaborating with States to increase the number of children 
who receive followup care for ADHD.  
CMS concurred with each of our three recommendations.  Specifically, in 
response to our recommendation to collaborate with partners, CMS stated 
that it would work with various stakeholders to identify barriers to care and 
best practices for improving rates of followup care for children treated for 
ADHD. 
In response to our recommendation for technical assistance to States, CMS 
stated that it would use information gleaned from working with 
stakeholders, provide technical assistance to States, and share strategies 
that States can implement to improve rates of followup care for children 
treated for ADHD. 
Finally, in response to our recommendation to analyze the effectiveness of 
strategies, CMS stated that it will use publicly reported data to analyze 
whether efforts implemented by States have an impact on the rates of 
followup care for children treated for ADHD. 
The full text of CMSs comments can be found in Appendix F. 
 
 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  12 
OEI-07-17-00170   
APPENDIX A: Detailed Methodology 
Population Selection 
This study evaluates the entire population of children, aged 321 years, who 
were continuously enrolled in Medicaid, and had a claim during FYs 2014 or 
2015 for either of the following: (1) a new prescription for an ADHD 
medication, or (2) an inpatient hospitalization with ADHD as the primary 
diagnosis.  We used criteria from the FYs 2014 and 2015 Child Core Set 
technical specifications to define which medications and which 
hospitalizations to include in the population.   
Medicaid Claims Data Analysis  
We collected MSIS and MMIS claims and eligibility data for all 50 States and 
the District of Columbia for FYs 2014 and 2015.  The data included eligibility 
information and all incurred claims (i.e., all claims that practitioners 
submitted) for children up to 21 years of age, enrolled in Medicaid, who had 
a prescription for an ADHD medication or an inpatient admission with 
ADHD as the principal diagnosis during the review period.   
New ADHD medication prescriptions. The FYs 2014 and 2015 Child Core 
Exhibit 1: Followup 
Set outlines criteria for followup care after initiating and continuing ADHD 
Timeline for a Newly 
medication.  We used these criteria in the Child Core Set technical 
Prescribed ADHD 
specifications to analyze the followup rates for children who were newly 
Medication 
prescribed an ADHD medication during the review period.  A new 
  prescription for an ADHD medication is a pharmacy claim for an ADHD 
medication with no ADHD medication claims during the previous 120 days.  
For the followup rate within 300 days, the population includes only children 
who had at least 210 treatment days (i.e., calendar days covered with 
dispensed prescriptions) within the 300-day period following the new 
prescription.  We reviewed incurred claims data for evidence of at least one 
followup visit with any practitioner within 30 days, and at least two followup 
visits within days 31 through 300 after the new ADHD medication 
prescription (see Exhibit 1).  In the 300-day measure, the criteria allow one of 
the two visits to be a claim for a telephone visit.  Finally, the criteria exclude 
any children who had a hospital stay with a mental illness primary diagnosis 
during the followup measure period because a hospital stay could impede 
their ability to receive outpatient care.   
To respond to the congressional request, we made some revisions to the 
Child Core Set technical specifications.  We limited followup visits to those 
with mental health diagnoses to avoid including visits for unrelated medical 
Source: OIG methodology for 
conditions (e.g., conjunctivitis, ear infections, influenza).  We also limited the 
determining followup rates, 2019. 
population of children reviewed to those who had a mental health diagnosis 
 
on at least one claim within the review period.53  Further, we calculated a 
rate for children who had no followup visits within 300 days of receiving a 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  13 
OEI-07-17-00170   
new ADHD medication, a rate that is not included in the Child Core Set 
technical specifications.   
Differences in number of newly medicated children reviewed.  The 
population for the 30-day analysis was 873,833 children; the population for 
the 300-day analyses was 121,364 children.  There are various reasons for 
the difference in populations.  The full review period for our claims analysis 
was 2 years spanning October 1, 2013, through September 30, 2015.  For the 
30-day analysis, we reviewed new ADHD prescriptions occurring through 
August 31, 2015.  For the 300-day analysis, we were limited to new ADHD 
prescriptions occurring through December 4, 2014, to allow for 300 days of 
followup to occur.  Therefore, the 300-day analysis allowed review of fewer 
children over a shorter span of time.  Additionally, many children were not 
subject to the 300-day claims analysis because they did not receive at least 
210 days of ADHD medication throughout the 300-day analysis period.54  
Further, children reviewed for followup within 30 days were excluded from 
the 300-day analysis if they were not continuously eligible for Medicaid, had 
a hospital admission, or turned 21 years of age.   
Hospitalization for ADHD.  The FYs 2014 and 2015 Child Core Set outlines 
criteria for followup after admission for mental illness, including ADHD.  We 
used these criteria in the Child Core Set technical specifications to analyze 
the followup rates specifically for children who had an inpatient admission 
for ADHD during the review period.  We identified the population of 
children with a claim for an inpatient admission with the principal diagnosis 
of ADHD.  We then analyzed incurred claims data for evidence of followup 
with any practitioner after the hospitalization (i.e., a claim for an outpatient 
visit, an intensive outpatient encounter or a partial hospitalization with a 
mental illness diagnosis that occurred within 7 days after discharge and 
within 30 days after discharge).  We excluded children who had any hospital 
readmission during the rate measure period because hospitalization could 
prevent an outpatient followup visit from occurring.   
To respond to the congressional request, we made some revisions to the 
Child Core Set technical specifications.  We limited followup visits to those 
with mental illness diagnoses to avoid including visits for unrelated medical 
conditions (e.g., conjunctivitis, ear infections, influenza).   
Differences in number of hospitalized children reviewed.  The population 
for the 7-day analysis was 10,918 children; the population for the 30-day 
analysis was 10,521 children.  The differences in populations for the 7-day 
analysis and 30-day analysis result from excluding children if they were not 
continuously eligible for Medicaid, had a hospital readmission, or turned 
21 years of age.   
Behavioral therapy.  There is no Child Core Set measure for behavioral 
therapy.  Therefore, we developed criteria to calculate a behavioral therapy 
rate for the children who were prescribed a new ADHD medication (i.e., the 
121,364 children included in the 300-day analysis). 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  14 
OEI-07-17-00170   
We selected the same population of children from the 300-day analysis to 
assess whether each child received a behavioral therapy visit before or 
during their treatment with ADHD medication.  We used this population to 
allow for the greatest amount of time to identify a behavioral therapy visit 
prior to, during, or following the new medication prescription. These 
children had continuous eligibility for Medicaid, no hospital admissions that 
would impede behavioral therapy, and at least 210 days of medication 
within a 300-day period prior to turning 21 years of age.   
We analyzed incurred claims data for instances of behavioral therapy 
procedure codes that occurred within the period of 120 days before and up 
to 300 days after the new ADHD prescription.  Because there are no specific 
procedure codes for evidence-based ADHD behavioral therapy, we defined 
behavioral therapy as those procedure codes from the technical 
specifications that had definitions related to psychotherapy, counseling, and 
behavioral health.  We then searched for evidence of at least one of these 
visits with any practitioner.  Thus, the percentage of children who received 
an evidence-based ADHD treatment is likely smaller than the figure we 
report for any behavioral therapy. 
Weighted analysis.  For all calculations, the unit of measure was the 
aggregated proportion of ADHD followup care that each child received for 
each study measure (i.e., newly prescribed medication, behavioral therapy, 
and hospitalization).  Children may have had more than one new ADHD 
prescription event or hospitalization event during our review period.  When 
a child had more than one event in a particular measure during the review 
period, we weighted the results of the childs followup visits to create an 
individual child statistic.  The formula below demonstrates this calculation. 
 
sum of events without followup
 for each child
Individual child statistic =  
sum of all events for each child
 
To determine the percentage of children who received followup care, we 
calculated the weighted aggregate rate for each measure and then divided 
the sum of all individual child statistics by the total number of children.  
Data Validation 
We performed extensive data validation checks due to inherent concerns 
with Medicaid data quality, including:    
  null analysis of selected variables compared to MSIS threshold 
tolerances,55 
  month-over-month and year-over-year analysis of claims volume to 
assess completeness, 
  analysis of date variables to determine whether variables were 
logically ordered, and  
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  15 
OEI-07-17-00170   
  contact with State officials to inquire about data anomalies 
(e.g., nonsensical values, State-specific code definitions, and illogical 
claim volume).  
Through this validation process, we concluded that the data were usable for 
the analyses conducted for this study.   
Before publishing this report, we shared each States results with their 
respective State Medicaid officials. 
Interviews With ADHD Professionals  
Interview references in this report are from conversations with practitioners 
from professional organizations (i.e., Society for Developmental and 
Behavioral Pediatrics (SDBP) and the American Professional Society of 
ADHD and Related Disorders (APSARD)).  SDBP seeks to improve the health 
and well-being of children and their families by supporting interdisciplinary 
professionals to advance the field of developmental and behavioral 
pediatrics.  APSARD members include multidisciplinary mental health 
experts working to improve the quality of care for patients with ADHD 
through the advancement and dissemination of research and 
evidence-based practices. 
   
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  16 
OEI-07-17-00170   
APPENDIX B: Medicaid-Enrolled Children Who Did 
Not Receive Followup Care After Being Newly 
Prescribed an ADHD Medication 
Exhibit B-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care 
Within 30 Days After Being Newly Prescribed an ADHD Medication,  
FYs 20142015 
Number of  Percentage of 
Population of 
Medicaid-Enrolled  Medicaid-Enrolled Children 
Medicaid-Enrolled 
Children Who Did Not  Who Did Not Receive a 
Children Who 
State  Receive a Followup Visit  Followup Visit Within 
Were Newly 
Within 30 Days After  30 Days After Being Newly 
Prescribed an 
Being Newly Prescribed  Prescribed an ADHD 
ADHD Medication 
an ADHD Medication   Medication  
Virginia  2,401  2,034  84.7% 
Delaware  4,674  3,815  81.6% 
Massachusetts  10,653  8,634  81.0% 
South Dakota  1,725  1,374  79.6% 
Idaho  5,884  4,405  74.9% 
Wisconsin  10,194  7,618  74.7% 
Oklahoma  16,557  12,131  73.3% 
Rhode Island  488  350  71.7% 
Texas  34,567  24,657  71.3% 
New York  9,804  6,658  67.9% 
Florida  65,971  43,529  66.0% 
North Carolina  42,398  27,563  65.0% 
Alabama  26,957  17,005  63.1% 
South Carolina  29,756  18,686  62.8% 
North Dakota  1,637  1,016  62.1% 
California  47,672  29,443  61.8% 
New Jersey  16,371  10,085  61.6% 
Tennessee  25,109  15,379  61.2% 
Missouri   18,055  11,021  61.0% 
Illinois  26,631  16,002  60.1% 
Colorado  11,167  6,690  59.9% 
Georgia  48,290  28,884  59.8% 
Louisiana  39,094  23,322  59.7% 
continued on next page 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  17 
OEI-07-17-00170   
Exhibit B-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care 
Within 30 Days After Being Newly Prescribed an ADHD Medication,  
FYs 20142015 (continued) 
Number of  Percentage of 
Population of 
Medicaid-Enrolled  Medicaid-Enrolled Children 
Medicaid-Enrolled 
Children Who Did Not  Who Did Not Receive a 
Children Who 
State  Receive a Followup Visit  Followup Visit Within 
Were Newly 
Within 30 Days After  30 Days After Being Newly 
Prescribed an 
Being Newly Prescribed  Prescribed an ADHD 
ADHD Medication 
an ADHD Medication   Medication  
West Virginia  4,547  2,693  59.2% 
   NATIONAL AVERAGE      59.1% 
Hawaii  1,753  1,027  58.6% 
New Hampshire  1,425  815  57.2% 
Oregon  6,908  3,881  56.2% 
Kentucky  23,780  13,244  55.7% 
Michigan  31,121  17,307  55.6% 
Indiana  34,946  19,402  55.5% 
Arizona  17,851  9,841  55.1% 
Mississippi  18,268  9,991  54.7% 
Minnesota  15,880  8,599  54.1% 
Utah  4,573  2,460  53.8% 
Ohio  58,452  31,270  53.5% 
Washington  19,473  10,376  53.3% 
Iowa  10,547  5,547  52.6% 
Maine  4,936  2,584  52.4% 
Alaska  1,694  878  51.8% 
Nebraska  5,918  3,066  51.8% 
New Mexico  7,465  3,853  51.6% 
Nevada  4,299  2,084  48.5% 
Vermont  2,218  1,073  48.4% 
Connecticut  11,442  5,504  48.1% 
Wyoming  1,220  570  46.7% 
Maryland  8,323  3,822  45.9% 
Kansas  10,666  4,826  45.2% 
Arkansas  24,589  10,993  44.7% 
Pennsylvania  40,103  17,898  44.6% 
District of Columbia  2,311  1,027  44.4% 
Montana  3,070  1,353  44.1% 
    NATIONAL TOTAL  873,833  516,285   
Source: OIG analysis of Medicaid data, 2019. 
   
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  18 
OEI-07-17-00170   
Exhibit B-2: Medicaid-Enrolled Children Who Did Not Receive 2 Followup Care 
Visits Within 300 Days After Being Newly Prescribed an ADHD Medication,  
FYs 20142015 
Population of  Number of  Percentage of 
Medicaid-Enrolled  Medicaid-Enrolled  Medicaid-Enrolled 
Children Who  Children Who Did Not  Children Who Did Not 
State  Were Newly  Receive 2 Followup Visits  Receive 2 Followup Visits 
Prescribed an  Within 300 Days After  Within 300 Days After 
ADHD  Being Newly Prescribed  Being Newly Prescribed 
Medication*  an ADHD Medication   an ADHD Medication  
Virginia  73  46  63.0% 
Delaware  413  258  62.5% 
Massachusetts  1,828  1,119  61.2% 
Oklahoma  5,208  2,873  55.2% 
Rhode Island  64  34  53.1% 
South Dakota  315  159  50.5% 
Wisconsin  1,895  940  49.6% 
Idaho  1,026  481  46.9% 
New York  1,256  554  44.1% 
New Hampshire  153  40  26.1% 
Florida  12,098  3,068  25.4% 
Missouri   2,640  669  25.3% 
North Dakota  194  47  24.2% 
California  5,627  1,357  24.1% 
Maryland  1,045  244  23.3% 
New Jersey  1,896  435  22.9% 
Texas  2,607  565  21.7% 
Colorado  1,697  367  21.6% 
     NATIONAL AVERAGE      21.5% 
Indiana  6,129  1,311  21.4% 
Montana  556  119  21.4% 
Utah  653  137  21.0% 
Vermont  471  96  20.4% 
Oregon  447  87  19.5% 
North Carolina  4,581  889  19.4% 
Michigan  4,654  889  19.1% 
South Carolina  3,636  683  18.8% 
Iowa  1,776  330  18.6% 
Hawaii  110  20  18.2% 
Nebraska  1,057  192  18.2% 
Illinois  2,569  451  17.6% 
continued on next page 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  19 
OEI-07-17-00170   
Exhibit B-2: Medicaid-Enrolled Children Who Did Not Receive 2 Followup Care 
Visits Within 300 Days After Being Newly Prescribed an ADHD Medication,  
FYs 20142015 (continued) 
Population of  Number of  Percentage of 
Medicaid-Enrolled  Medicaid-Enrolled  Medicaid-Enrolled 
Children Who  Children Who Did Not  Children Who Did Not 
State  Were Newly  Receive 2 Followup Visits  Receive 2 Followup Visits 
Prescribed an  Within 300 Days After  Within 300 Days After 
ADHD  Being Newly Prescribed  Being Newly Prescribed 
Medication*  an ADHD Medication   an ADHD Medication  
Minnesota  2,185  371  17.0% 
Alaska  259  43  16.6% 
Wyoming  217  36  16.6% 
New Mexico  917  151  16.5% 
Ohio  5,688  912  16.0% 
Alabama  4,024  615  15.3% 
Connecticut  1,626  245  15.1% 
Washington  3,031  454  15.0% 
Nevada  422  61  14.5% 
Tennessee  3,993  570  14.3% 
West Virginia  650  92  14.2% 
Arizona  2,870  401  14.0% 
Kentucky  4,553  620  13.6% 
Arkansas  3,681  496  13.5% 
Pennsylvania  5,991  794  13.3% 
Louisiana  4,744  617  13.0% 
Maine  774  100  12.9% 
Georgia  4,858  584  12.0% 
Mississippi  2,359  272  11.5% 
Kansas  1,709  174  10.2% 
District of Columbia  139  13  9.4% 
    NATIONAL TOTAL  121,364  26,081   
Source: OIG analysis of Medicaid data, 2019. 
*Children were not reviewed for followup within days 31300 if they were not continuously eligible for Medicaid, had a 
readmission, did not receive at least 210 days of medication, or turned 21 years of age. 
   
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  20 
OEI-07-17-00170   
APPENDIX C: Treatment for Medicaid-Enrolled 
Children With ADHD by Age 
Exhibit C-1: Percentage of Medicaid-Enrolled Children Who Did Not 
Receive Followup Care Within 30 Days After Being Newly Prescribed 
an ADHD Medication, FYs 20142015, by Age 
Source: OIG analysis of Medicaid data, 2019. 
 
Exhibit C-2: Percentage of Medicaid-Enrolled Children Who Did Not 
Receive 2 Followup Care Visits Within 300 Days After Being Newly 
Prescribed an ADHD Medication, FYs 20142015, by Age 
Source: OIG analysis of Medicaid data, 2019. 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  21 
OEI-07-17-00170   
Exhibit C-3: Percentage of Medicaid-Enrolled Children Who Did Not 
Receive Any Followup Care Within 300 Days After Being Newly 
Prescribed an ADHD Medication, FYs 20142015, by Age 
 
Source: OIG analysis of Medicaid data, 2019. 
Exhibit C-4: Percentage of Medicaid-Enrolled Children Who Did Not 
Receive Followup Care Within 30 Days After Hospitalization for 
ADHD, FYs 20142015, by Age 
 
Source: OIG analysis of Medicaid data, 2019. 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  22 
OEI-07-17-00170   
Exhibit C-5: Percentage of Medicaid-Enrolled Children Who Did Not 
Receive Followup Care Within 7 Days After Hospitalization for ADHD, 
FYs 20142015, by Age 
Source: OIG analysis of Medicaid data, 2019. 
Exhibit C-6: Percentage of Medicaid-Enrolled Children Who Were 
Medicated for ADHD and Did Not Receive Behavioral Therapy, 
FYs 20142015, by Age 
 
Source: OIG analysis of Medicaid data, 2019. 
   
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  23 
OEI-07-17-00170   
APPENDIX D: Medicaid-Enrolled Children Who 
Did Not Receive Followup Care After 
Hospitalization for ADHD
 
Exhibit D-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care 
Within 30 Days After Hospitalization for ADHD, FYs 20142015 
Number of 
Percentage of 
Population of  Medicaid-Enrolled 
Medicaid-Enrolled Children 
Medicaid-Enrolled  Children Who Were 
Who Were Hospitalized for 
State  Children Who Were  Hospitalized for ADHD 
ADHD Who Did Not Receive 
Hospitalized for  Who Did Not Receive a 
a Followup Visit Within 30 
ADHD*  Followup Visit Within 30 
Days 
Days 
Delaware**  --  --  100.0% 
Rhode Island**  --  --  100.0% 
Virginia  23  19  82.6% 
Idaho  25  20  80.0% 
Massachusetts  14  11  78.6% 
South Dakota  140  103  73.6% 
New York  1,101  747  67.8% 
Colorado**  --  --  63.6% 
Montana  19  12  63.2% 
North Carolina  316  189  59.8% 
Oklahoma  21  12  57.1% 
Florida  1,095  531  48.5% 
North Dakota**  --  --  47.1% 
New Mexico  64  28  43.8% 
New Hampshire**  --  --  40.0% 
New Jersey  410  164  40.0% 
Kentucky  176  66  37.5% 
     NATIONAL AVERAGE      35.1% 
Arizona  72  25  34.7% 
Maine  139  48  34.5% 
Alabama  529  178  33.6% 
Wyoming**  --  --  33.3% 
Mississippi  611  199  32.6% 
Alaska  233  76  32.6% 
Georgia  53  16  30.2% 
South Carolina  159  47  29.6% 
continued on next page 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  24 
OEI-07-17-00170   
Exhibit D-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care 
Within 30 Days After Hospitalization for ADHD, FYs 20142015 (continued) 
Number of 
Percentage of 
Population of  Medicaid-Enrolled 
Medicaid-Enrolled Children 
Medicaid-Enrolled  Children Who Were 
Who Were Hospitalized for 
State  Children Who Were  Hospitalized for ADHD 
ADHD Who Did Not Receive 
Hospitalized for  Who Did Not Receive a 
a Followup Visit Within 30 
ADHD*  Followup Visit Within 30 
Days 
Days 
Tennessee  136  40  29.4% 
Connecticut  98  28  28.6% 
West Virginia  363  101  27.8% 
Maryland  641  176  27.5% 
Louisiana  48  13  26.5% 
Arkansas  178  46  25.7% 
Hawaii**  --  --  25.0% 
Indiana  204  50  24.4% 
Wisconsin  207  50  24.0% 
Texas  280  66  23.6% 
California  96  22  22.9% 
Nebraska  133  30  22.6% 
Nevada  126  28  22.0% 
Missouri  493  108  21.9% 
Minnesota  221  47  21.3% 
District of Columbia  122  26  21.1% 
Illinois  149  31  20.7% 
Ohio**  --  --  20.0% 
Pennsylvania  1,227  238  19.4% 
Michigan  67  12  17.6% 
Kansas  80  12  14.8% 
Iowa  345  48  13.9% 
Washington**  --  --  7.7% 
Oregon**  --  0  0.0% 
Utah**  --  0  0.0% 
Vermont**  --  0  0.0% 
   NATIONAL TOTAL  10,521  3,694   
Source: OIG analysis of Medicaid data, 2019. 
*Children were not reviewed for followup 30 days after hospitalization for ADHD if they were not continuously eligible 
for Medicaid, had a readmission, or turned 21 years of age. 
**To protect privacy, values of 1 to 10 are not reported.  Additionally, values that allow a value of 1 to 10 to be derived 
are also not reported. 
   
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  25 
OEI-07-17-00170   
Exhibit D-2: Medicaid-Enrolled Children Who Did Not Receive Followup Care 
Within 7 Days After Hospitalization for ADHD, FYs 20142015 
Number of 
Percentage of 
Population of  Medicaid-Enrolled 
Medicaid-Enrolled Children 
Medicaid-Enrolled  Children Who Were 
Who Were Hospitalized for 
State  Children Who Were  Hospitalized for ADHD 
ADHD Who Did Not Receive 
Hospitalized for  Who Did Not Receive a 
a Followup Visit Within 7 
ADHD  Followup Visit Within 7 
Days 
Days 
Delaware**  --  --  100.0% 
Rhode Island**  --  --  100.0% 
South Dakota  145  129  88.4% 
Virginia  23  20  87.0% 
Oklahoma  22  19  86.4% 
Montana  20  17  85.0% 
North Carolina  330  274  83.0% 
New York  1,149  944  82.2% 
Colorado**  --  --  81.8% 
New Mexico  69  56  81.2% 
Idaho  25  20  80.0% 
Massachusetts  14  11  78.6% 
Wyoming  14  11  78.6% 
Florida  1,151  827  71.9% 
New Jersey  436  294  67.4% 
Mississippi  630  423  67.1% 
West Virginia  377  252  66.8% 
Hawaii**  --  --  66.7% 
Alabama  542  348  64.2% 
Kentucky  182  115  63.2% 
North Dakota  19  12  63.2% 
New Hampshire**  --  --  60.0% 
     NATIONAL AVERAGE      60.0% 
Texas  289  173  59.9% 
Maine  141  84  59.6% 
Arkansas  186  110  58.8% 
Alaska  242  141  58.3% 
Illinois  158  90  57.0% 
Ohio**  --  --  56.3% 
South Carolina  164  90  54.9% 
Maryland  659  359  54.5% 
Tennessee  140  76  54.3% 
continued on next page 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  26 
OEI-07-17-00170   
Exhibit D-2: Medicaid-Enrolled Children Who Did Not Receive Followup Care 
Within 7 Days After Hospitalization for ADHD, FYs 20142015 (continued) 
Number of 
Percentage of 
Population of  Medicaid-Enrolled 
Medicaid-Enrolled Children 
Medicaid-Enrolled  Children Who Were 
Who Were Hospitalized for 
State  Children Who Were  Hospitalized for ADHD 
ADHD Who Did Not Receive 
Hospitalized for  Who Did Not Receive a 
a Followup Visit Within 7 
ADHD  Followup Visit Within 7 
Days 
Days 
Connecticut  103  54  51.9% 
Nevada  131  64  48.5% 
Indiana  213  103  48.4% 
Georgia  56  27  48.2% 
Arizona  79  38  48.1% 
Wisconsin  222  107  48.0% 
Missouri   520  244  46.9% 
Minnesota  223  103  46.2% 
Nebraska  135  61  45.2% 
Pennsylvania  1,252  544  43.5% 
Kansas  87  38  43.2% 
Louisiana  49  21  42.0% 
District of Columbia  123  52  41.9% 
Michigan  69  26  37.7% 
California  98  36  36.4% 
Oregon**  --  --  30.8% 
Washington**  --  --  30.8% 
Iowa  351  107  30.5% 
Utah**  --  0  0% 
Vermont**  --  0  0% 
   NATIONAL TOTAL  10,918  6,560   
Source: OIG analysis of Medicaid data, 2019. 
**To protect privacy, values of 1 to 10 are not reported.  Additionally, values that allow a value of 1 to 10 to be derived 
are also not reported.   
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  27 
OEI-07-17-00170   
APPENDIX E: Medicaid-Enrolled Children Who 
Were Medicated for ADHD and Did Not Receive 
Behavioral Therapy 
Exhibit E-1: Medicaid-Enrolled Children Who Were Medicated for ADHD and 
Did Not Receive Behavioral Therapy, FYs 20142015 
Number of  Percentage of 
Population of 
Medicaid-Enrolled  Medicaid-Enrolled 
Medicaid-Enrolled 
Children Who Were  Children Who Were 
State  Children Who Were 
Medicated for ADHD  Medicated for ADHD Who 
Medicated for 
Who Did Not Receive  Did Not Receive 
ADHD* 
Behavioral Therapy  Behavioral Therapy  
Massachusetts  1,828  1,642  89.8% 
Idaho  1,026  804  78.4% 
Virginia  73  53  72.6% 
South Dakota  315  216  68.6% 
Florida  12,098  7,755  64.1% 
South Carolina  3,636  2,149  59.1% 
North Carolina  4,581  2,658  58.0% 
New York  1,256  709  56.4% 
Wisconsin  1,895  1,053  55.6% 
Louisiana  4,744  2,583  54.4% 
North Dakota  194  102  52.6% 
Texas  2,607  1,306  50.1% 
Washington  3,031  1,463  48.3% 
Missouri   2,640  1,264  47.9% 
New Jersey  1,896  905  47.7% 
Alabama  4,024  1,833  45.6% 
Delaware  413  187  45.3% 
     NATIONAL AVERAGE      45.1% 
Tennessee  3,993  1,789  44.8% 
Utah  653  292  44.7% 
Oklahoma  5,208  2,324  44.6% 
Colorado  1,697  752  44.3% 
Indiana  6,129  2,673  43.6% 
Illinois  2,569  1,117  43.5% 
continued on next page 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  28 
OEI-07-17-00170   
Exhibit E-1: Medicaid-Enrolled Children Who Were Medicated for ADHD and 
Did Not Receive Behavioral Therapy, FYs 20142015 (continued) 
Number of  Percentage of 
Population of 
Medicaid-Enrolled  Medicaid-Enrolled 
Medicaid-Enrolled 
Children Who Were  Children Who Were 
State  Children Who Were 
Medicated for ADHD  Medicated for ADHD Who 
Medicated for 
Who Did Not Receive  Did Not Receive 
ADHD* 
Behavioral Therapy  Behavioral Therapy  
Michigan  4,654  1,962  42.1% 
Georgia  4,858  2,039  42.0% 
Kentucky  4,553  1,897  41.7% 
California  5,627  2,329  41.4% 
Oregon  447  183  40.8% 
Rhode Island  64  26  40.6% 
New Hampshire  153  62  40.5% 
West Virginia  650  261  40.2% 
Alaska  259  100  38.6% 
Ohio  5,688  2,173  38.2% 
Maine  774  287  37.1% 
Nevada  422  149  35.3% 
Mississippi  2,359  815  34.5% 
Hawaii  110  36  32.7% 
Connecticut  1,626  529  32.5% 
Wyoming  217  69  31.8% 
Arkansas  3,681  1,136  30.9% 
Minnesota  2,185  674  30.8% 
Iowa  1,776  530  29.8% 
Montana  556  158  28.4% 
Vermont  471  131  27.8% 
Nebraska  1,057  293  27.7% 
New Mexico  917  254  27.7% 
Pennsylvania  5,991  1,626  27.1% 
Kansas  1,709  438  25.6% 
Maryland  1,045  251  24.0% 
District of Columbia  139  32  23.0% 
Arizona  2,870  657  22.9% 
   NATIONAL TOTAL  121,364  54,726   
Source: OIG analysis of Medicaid data, 2019. 
*Children were not reviewed for behavioral therapy if they were not continuously eligible for Medicaid, had a 
readmission, did not receive at least 210 days of medication, or turned 21 years of age. 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  29 
OEI-07-17-00170   
APPENDIX F: Agency Comments 
   
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  30 
OEI-07-17-00170   
 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  31 
OEI-07-17-00170   
ACKNOWLEDGMENTS 
Jamila Murga served as the team leader for this study, and Abbi Warmker 
served as lead analyst.  Others in the Office of Evaluation and Inspections 
who conducted the study include Katharine Fry, Anna Pechenina, Dana 
Squires, and Andrea Staples.  Office of Evaluation and Inspections central 
office staff who provided support include Clarence Arnold, Eddie Baker, Jr., 
and Kevin Manley.  Other Office of Inspector General staff who provided 
support include Erin Fratangelo, Scott Frederixon, Gus George, Logan 
Kingma, Art Livingston, Ann Lowe, Conswelia McCourt, Jim Rodgers, Jessica 
Swanstrom, and Michael Willey. 
This report was prepared under the direction of Brian T. Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City regional 
office, and Jennifer E. King, Deputy Regional Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.   
 
Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care  32 
OEI-07-17-00170   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, as amended, is to protect the integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and 
welfare of beneficiaries served by those programs.  This statutory mission is 
carried out through a nation-wide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency 
throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.   
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and 
civil monetary penalty cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements.  OCIG renders 
advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the healthcare industry concerning 
the anti-kickback statute and other OIG enforcement authorities.  
 
33 
   
 
ENDNOTES 
1 CMS, FY 2017 Childrens Enrollment Report.  Accessed at https://www.medicaid.gov/chip/downloads/fy-2017-childrens-
enrollment-report.pdf on December 26, 2018. 
2 Danielson, et al., Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and 
Adolescents, 2016.  Journal of Clinical Child and Adolescent Psychology, pp. 114. 
3 American Academy of Pediatrics (AAP), ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of 
Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, Pediatrics, Vol. 128, No. 5, November 2011.  Accessed at 
http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 17, 2016. 
4 Visser, et al., Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among 
Insured Children Aged 25 YearsUnited States, 20082014, Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016.  
Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 
5 Untreated adolescents with ADHD have higher rates of risky sexual behaviors, suicidal thoughts in college, incarcerations, 
automobile accidents, and medical burdens.  Brahmbhatt, et al., Diagnosis and Treatment of ADHD during Adolescence in the 
Primary Care Setting: Review and Future Directions, Journal of Adolescent Health, Vol. 59, No. 2, August 2016.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576000/ on May 14, 2019. 
6 Centers for Disease Control and Prevention (CDC) Attention-Deficit/Hyperactivity Disorder and Psychiatric Comorbidity: 
Functional Outcomes in a School-Based Sample of Children.  Accessed at https://www.cdc.gov/ncbddd/adhd/features/adhd-
keyfindings-psychiatric-comorbidity-school-children.html  on May 6, 2019. 
7 Visser, et al., Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among 
Insured Children Aged 25 YearsUnited States, 20082014, Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016.  
Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 
8 Fletcher, et al., Long-term Consequences of Childhood ADHD on Criminal Activities, Journal of Mental Health Policy Economics, 
Vol 12, No. 3, September 2009, pp. 119138.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398051/pdf/nihms386784.pdf on April 15, 2019. 
9 Doshi, et al., Economic Impact of Childhood and Adult Attention-Deficit/Hyperactivity Disorder in the United States, Journal of 
the American Academy of Child and Adolescent Psychiatry, Vol. 51, No. 10, pp. 9901002, October 2012. 
10 AAP, ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder 
in Children and Adolescents, Pediatrics, Vol. 128, No. 5, November 2011.  Accessed at 
http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 17, 2016. 
11 Centers for Disease Control and Prevention (CDC), Behavior therapy for young children with ADHD.  Accessed at 
https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html on November 16, 2018.  
12 AACAP, Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity 
Disorder, Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 46, No. 7, July 2007.  Accessed at 
https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/jaacap_adhd_2007.pdf on January 10, 2018. 
13 Ibid. 
14 AAP, ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder 
in Children and Adolescents, Pediatrics, Vol. 128, No. 5, November 2011.  Accessed at 
http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 7, 2016. 
15 Although ADHD is not typically the primary reason for inpatient admissions, the disorder is often listed as one of the health 
conditions treated during childrens hospital stays.  For hospitalizations with any mental health diagnosis in children ages 
3-20 years, ADHD was one of the most commonly listed health conditions treated during the hospitalization.  Specifically, ADHD 
was one of the diagnoses in 19 percent of hospitalizations in general hospitals (i.e., those that serve adults and children) and 
23 percent of hospitalizations in childrens hospitals (i.e., those that serve children only).  This finding suggests that ADHD may 
contribute to factors (e.g., accidents, medical nonadherence) that lead to hospitalization.  Bardach, et al., Common and Costly 
Hospitalizations for Pediatric Mental Health Disorders, Pediatrics, Vol. 133, No. 4, April 2014.  Accessed at 
http://pediatrics.aappublications.org/content/early/2014/03/11/peds.2013-3165 on December 16, 2016. 
16 The Child Core Set was developed as a requirement of Section 401 of the Childrens Health Insurance Program Reauthorization 
Act of 2009 (CHIPRA), P.L. No. 111-3 (Feb. 4, 2009).  Accessed at https://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW-
111publ3.pdf on November 22, 2016. 
17 The first measure includes the percentage of children who were newly prescribed an ADHD medication who had at least two 
followup visits within a 10-month period.  Two rates are reported: (1) the percentage of children who had one followup visit with a 
 
34 
   
 
practitioner within 30 days; (2) the percentage of children who had at least two followup visits within 300 days.  The second 
measure includes the percentage of discharges for children 6 years of age and older who were hospitalized for treatment of 
selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with 
a mental health practitioner.  The Child Core Set measure reports the followup after hospitalization rate for all mental illness 
diagnoses in aggregate.  ADHD is one of the diagnoses included in the hospitalization measure.  The followup timeframes 
outlined in this measure were not developed specifically for ADHD hospitalizations, but rather for any hospitalization for the broad 
range of mental illnesses.  Two rates are reported: (1) the percentage of children who received followup within 7 days of discharge; 
(2) the percentage of children who received followup within 30 days of discharge.  CMS, 2015 Annual Report on the Quality of 
Care for Children in Medicaid and CHIP, Chart Pack (August 2016), pp. 49-55.  Accessed at 
https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-chart-pack.pdf on November 29, 2016.  
18 The Child Core Set measure establishes an ADHD medication list which includes all drugs indicated for ADHD; it is possible 
children were prescribed these medications for other indications.  We used the list exactly as defined in the Child Core Set 
measure to identify the population of children who were newly prescribed an ADHD medication.  
19 There are several limitations to voluntary data reporting.  States may not always adhere to technical specifications when 
reporting, or include different populations in the measures (i.e., Medicaid versus CHIP).  Additionally, not all States submit data 
because reporting is voluntary.  The Department of Health and Human Services (HHS), 2015 Annual Report on the Quality of Care 
for Children in Medicaid and CHIP.  Accessed at https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-sec-
rept.pdf on November 11, 2016. 
20 Recent legislation will require States mandatory reporting beginning fiscal year 2024.  P.L. 115-123  50102.  Accessed at 
https://www.congress.gov/bill/115th-congress/house-bill/1892/text on December 18, 2018. 
21 CDC has identified treatment of ADHD in young children as a public health priority that has the potential for large-scale, positive 
impact in a relatively short amount of time.  Therefore, the agency has applied their Winnable Battles approach to this 
high-priority area, using known effective strategies to address it.  CDC uses the Winnable Battles approach for certain public health 
challenges to identify priority strategies, define clear targets, and work closely with public health partners, to make significant 
progress in reducing the health burden from diseases and conditions.  The Winnable Battles approach enabled the treatment of 
ADHD program in CDCs National Center on Birth Defects and Developmental Disabilities to garner agency-wide leadership 
support and collaboration to refine and advance its work on this initiative to promote impact.  Accessed at 
https://www.cdc.gov/winnablebattles/report/docs/winnable-battles-final-report.pdf on March 11, 2019. 
22 NIMH has collected data on the prevalence and distribution of ADHD to establish resource allocation priorities for prevention, 
treatment and research.  Merikangas, et al. Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National 
Comorbidity Study-Adolescent Supplement (NCS-A), Journal of American Academy of Child Adolescent Psychiatry. Vol 49, No 10, 
October 2010.  Accessed at https://www.ncbi.nlm.nih.gov/pubmed/20855043 on January 24, 2019. 
23 HHS Health Resources and Services Administration, National Projections of Supply and Demand for Selected Behavioral Health 
Practitioners: 2013-2025.  Accessed at https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-
analysis/research/projections/behavioral-health2013-2025.pdf on September 19, 2018.  
24 In 2012, there were approximately 8,300 practicing child and adolescent psychiatrists in the country.  Children in rural areas and 
areas of low socioeconomic status had significantly reduced access.  The national child and adolescent psychiatrist to per youth 
was 12.9 to 100,000.  AACAP, Child and Adolescent Psychiatry Workforce Crisis: Solutions To Improve Early Intervention and Access to 
Care.  Accessed at 
https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_brochure_2013.pdf on 
January 23, 2018.  
25 Reimbursement for practitioners who provide recommended ADHD care may not be proportionate to their services since this 
condition requires more time than other conditions they typically address.  For example, recommended ADHD care requires that 
practitioners spend more time with patients and families, developing contacts with school personnel, and providing continuous, 
coordinated care than for other conditions. AAP, ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of 
Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, Pediatrics, Vol. 128, No. 5, November 2011.  Accessed at 
http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 7, 2016. 
26 An AAP survey assessed pediatricians perception of availability of mental health services in the community, the extent of their 
mental health education and their interest in future education in this area.  When asked to name barriers to treatment or referral 
of mental health problems for children, pediatricians listed the following: lack of training in mental health treatment (70 percent), 
lack of competence in ability to diagnose mental health problems (65 percent), lack of confidence in ability to treat mental health 
problems with medication (64 percent), lack of time to treat mental health problems (80 percent), long waiting periods for referred 
mental health providers (79 percent), inadequate reimbursement for treatment (54 percent), unfamiliarity with procedure codes 
that reimburse for treatment (49 percent).  AAP, Periodic Survey #59 Identification, Management, and Referral for Patient Mental 
Health Problems and Maternal Depression.  Accessed at https://www.aap.org/en-us/professional-
35 
 
   
 
resources/Research/Pages/PS59_Executive_Summary_IdentificationManagementandReferralforPatientMentalHealthProblems.aspx 
on March 11, 2019. 
27 Visser, et al., Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among 
Insured Children Aged 25 YearsUnited States, 20082014, Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016.  
Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 
28 Research has identified inconsistencies in pediatricians ADHD care practices when compared to professional guidelines.  
Specifically, a 2014 study that conducted chart review of a random sample of 1,594 medical records across 188 pediatricians at 50 
different practices found approximately 90 percent of pediatricians did not use parent and teacher rating scales to monitor 
treatment response and side effects despite AAP consensus recommendations to do so.  Additionally, the study found that only 
half of children evaluated for ADHD received an evidence-based assessment and diagnosis.  Epstein, et al., Variability in ADHD 
Care in Community-Based Pediatrics, Pediatrics. Vol. 134, No. 6, September 2014.  Accessed at 
www.pediatrics.org/cgi/doi/10.1542/peds.2014-1500 on January 8, 2018. 
29 Visser, et al., Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among 
Insured Children Aged 25 YearsUnited States, 20082014, Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016.  
Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 
30 AAP, ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder 
in Children and Adolescents, Pediatrics, Vol. 128, No. 5, November 2011.  Accessed at 
http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654  on November 7, 2016. 
31 OIG, Second-Generation Antipsychotic Drug Use Among Medicaid-Enrolled Children: Quality-of-Care Concerns, OEI-07-12-00320, 
March 2015.  Accessed at https://oig.hhs.gov/oei/reports/oei-07-12-00320.asp on March 26, 2019. 
32 The sample was selected using Medicaid-paid claims for SGAs including aripiprazole, clozapine, lurasidone, iloperidone, 
asenapine, olanzapine, paliperidone, quetiapine fumarate, risperidone, and ziprasidone.  None of these were considered an ADHD 
medication in the current study. 
33 OIG, Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication, 
OEI-07-15-00380, September 2018.  Accessed at https://oig.hhs.gov/oei/reports/oei-07-15-00380.asp on March 11, 2019. 
34 MSIS is the system in which CMS collects all Medicaid claims and related data from all States. 
35 MMIS are the State-specific systems to collect and process Medicaid claims.  MMIS data systems are not validated by CMS.  See 
the Detailed Methodology for more information on our process for validating these data. 
36 We analyzed children hospitalized with a primary diagnosis of ADHD.  These children may have had additional diagnoses that 
contributed to their need for hospitalization. 
37 Additionally, Medicaid reimbursement policy differs among States.  It is possible that guidelines on criteria for admission and for 
hospital services may have varied.  These variations may have impacted the claims that were used to identify the population and 
determine followup rates. 
38 Visser, et al., Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among 
Insured Children Aged 25 YearsUnited States, 2008-2014, Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016.  
Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 
39 AACAP, Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention Deficit/Hyperactivity 
Disorder, Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 46, No. 7, July 2007.  Accessed at 
https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/jaacap_adhd_2007.pdf on January 10, 2018. 
40 Children were not reviewed for followup within days 31300 if they were not continuously eligible for Medicaid, had a 
readmission, did not receive at least 210 days of medication, or turned 21 years of age.  Therefore, the population of the 300-day 
analysis differs from the population of the 30-day analysis. 
41 Research shows that Medicaid-enrolled children often discontinue ADHD medication treatment over time.  Charach and 
Fernandez, Enhancing ADHD Medication Adherence: Challenges and Opportunities. Current Psychiatry Reports. 2013; 15(7): 371.  
Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718998/ on March 1, 2019. 
42 Children were not reviewed for followup within 300 days if they were not continuously eligible for Medicaid, had a readmission, 
did not receive at least 210 days of medication, or turned 21 years of age.  Therefore, the population of this analysis differs from 
the population of the 30-day analysis. 
43 Harstad, et al., ADHD: Attention-Deficit/Hyperactivity Disorder and Substance Abuse, Pediatrics, Vol. 134, No. 1, July 2014.  
Accessed at http://pediatrics.aappublications.org/content/pediatrics/134/1/e293.full.pdf on March 11, 2019. 
44 Children were not reviewed for followup within 30 days if they were not continuously eligible for Medicaid, had a readmission, 
or turned 21 years of age.  Therefore, the population of the 30-day analysis differs from the population of the 7-day analysis. 
45 Bardach, et al., Common and Costly Hospitalizations for Pediatric Mental Health Disorders, Pediatrics, Vol. 133, No. 4, 
April 2014.  Accessed at http://pediatrics.aappublications.org/content/early/2014/03/11/peds.2013-3165 on December 16, 2016.  
46 HHS, 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP.  Accessed at 
36 
https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-sec-rept.pdf on November 29, 2016. 
    
 
47 AAP, ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder 
in Children and Adolescents, Pediatrics, Vol. 128, No. 5, November 2011.  Accessed at 
http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 7, 2016. 
48 Centers for Disease Control and Prevention (CDC), Behavior therapy for young children with ADHD.  Accessed at 
https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html on November 16, 2018.  
49 CDC, Behavior therapy for young children with ADHD.  Accessed at https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html  
on November 16, 2018. 
50 CMS has collaborated with multiple divisions within HHS, including ACF, FDA, and SAMHSA, on behavioral health issues.  For 
example, these agencies work together to strengthen oversight and monitoring of psychotropic medications for Medicaid-enrolled 
children.  Accessed at https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf on April 24, 2016. 
51 ACF is responsible for the oversight of child welfare programs, including foster care.   
52 Researchers examined Medicaid outpatient and prescription drug claims from 2011 from multiple states and found that more 
than 1 in 4 children between the ages of 2 and 17 years who were in foster care had received an ADHD diagnosis.  Additionally, 
children with ADHD who were in foster care were also more likely to have another mental health disorder simultaneously (e.g., 
oppositional defiant disorder, depression, or anxiety).  These findings show a substantial need for medical and behavioral services 
within this group.  Abstract presentation of "The Diagnosis and Treatment of ADHD among Children in Foster Care Using Medicaid 
Claims Data, by Melissa Danielson, CDC statistician, at the American Academy of Pediatrics Experience conference, 
October 26, 2015.  Accessed at https://aap.confex.com/aap/2015/webprogram/Paper30570.html on March 11, 2019. 
53 Some ADHD medications can also be used to treat medical conditions (e.g., hypertension and narcolepsy).  To exclude those 
children who were prescribed ADHD medications for a medical condition, we excluded from our analysis children who did not 
have at least one claim with a mental illness diagnosis and children under 3 years of age. 
54 This decrease is consistent with research that shows Medicaid-enrolled children often discontinue ADHD medication treatment 
over time.  Some reasons for discontinuation can include side effects, ineffective medication or dosage, and lack of social supports. 
Charach and Fernandez, Enhancing ADHD Medication Adherence: Challenges and Opportunities, Current Psychiatry Reports, 
2013; 15(7): 371.  Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718998/ on March 1, 2019. 
55 MSIS threshold error tolerances allow between 0.1 and 5.0 percent missing, unknown, or invalid codes for the variables used in 
this analysis.  CMS, MSIS File Specifications and Data Dictionary, 2012.  Accessed at https://www.cms.gov/Research-Statistics-Data-
and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MSIS-Data-Dictionary-2012.pdf on 
February 5, 2018. 
37