National Health Statistics Reports

Number 139  February 19, 2020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Prevalence of Children Aged 3–17 Years With 

Developmental Disabilities, by Urbanicity: 

United States, 2015–2018

by Benjamin Zablotsky, Ph.D., and Lindsey I. Black, M.P.H.

Abstract

Objective—This report examines the prevalence of developmental disabilities 

among children in both rural and urban areas as well as service utilization among 

children with developmental issues in both areas.

Methods—Data from the 2015–2018 National Health Interview Survey (NHIS) 

were used to examine the prevalence of 10 parent- or guardian-reported developmental 

disability diagnoses (attention-deficit/hyperactivity disorder [ADHD], autism 

spectrum disorder, blindness, cerebral palsy, moderate to profound hearing loss, 

learning disability, intellectual disability, seizures, stuttering or stammering, and other 

developmental delays) and service utilization for their child. Prevalence estimates are 

presented by urbanicity of residence (urban or rural). Bivariate logistic regressions 

were used to test for differences by urbanicity.

Results—Children living in rural areas were more likely to be diagnosed with a 

developmental disability than children living in urban areas (19.8% compared with 

17.4%). Specifically, children living in rural areas were more likely than those in 

urban areas to be diagnosed with ADHD (11.4% compared with 9.2%) and cerebral 

palsy (0.5% compared with 0.2%). However, among children with a developmental 

disability, children living in rural areas were significantly less likely to have seen a 

mental health professional, therapist, or had a well-child checkup visit in the past year, 

compared with children living in urban areas. Children with a developmental disability 

living in rural areas were also significantly less likely to receive Special Educational 

or Early Intervention Services compared with those living in urban areas.

Conclusion—Findings from this study highlight differences in the prevalence of 

developmental disabilities and use of services related to developmental disabilities by 

rural and urban residence.

Keywords: attention-deficit/hyperactivity disorder • autism spectrum disorder • urban 

• rural • National Health Interview Survey

Introduction

Developmental disabilities are a 

group of conditions, typically lifelong, 

resulting from impairments in physical, 

learning, language, or behavioral 

areas. In recent years, the number of 

children with a developmental disability 

has increased (1). Children with 

developmental disabilities require more 

health care and educational services than 

their typically developing peers (2,3) 

and use of specialty and mental health 

services are often needed (4). They also 

are more likely to have an unmet health 

need, with less access to a medical 

home, community services, and adequate 

health insurance (5). In a similar way, 

it is known that children living in rural 

areas have greater unmet medical needs 

when compared with children living 

in urban areas (6). For this reason, it is 

possible that children with developmental 

disabilities in rural areas may be some 

of the most vulnerable when it comes to 

receiving a variety of health care services. 

The primary objective of this report is to 

use timely, nationally representative data 

to describe geographic health disparities 

for selected developmental disability 

conditions and use of related services in 

the United States.

NCHS reports can be downloaded from: https://www.cdc.gov/nchs/products/index.htm.
Page 2 National Health Statistics Reports  Number 139  February 19, 2020

Methods

Data source

Data from the 2015–2018 National 

Health Interview Survey (NHIS) 

were used for this analysis. NHIS is a 

nationally representative survey of the 

civilian noninstitutionalized population. 

Within each household, families are 

identified, and selected demographic and 

broad health measures are collected for 

each family member. In addition, a parent 

or guardian answers more detailed health 

questions on a randomly selected child. 

Sample children aged 3–17 years were 

included in this analysis (n = 33,775). 

The final response rate for the sample 

child questionnaire ranged from 59.2%–

63.4%, between 2015–2018 (7). 

Measures

Developmental disabilities examined 

in this report were attention-deficit/

hyperactivity disorder (ADHD), autism 

spectrum disorder, blindness, cerebral 

palsy, moderate to profound hearing loss, 

learning disability, intellectual disability, 

seizures in the past 12 months, stuttering 

or stammering in the past 12 months, or 

any other developmental delay. Children 

whose parents answered that their child 

had one or more of these conditions were 

classified as having any “developmental 

disability.”

Urbanicity of residence (available 

on a restricted NHIS dataset) was 

categorized as urban or rural—urban was 

defined as areas consisting of urbanized 

areas of 50,000 or more people and urban 

clusters of 2,500–49,999 persons; rural 

was defined as all other areas (8).

One of the goals of this analysis 

was to examine health care and 

educational service use among children 

with developmental disabilities by 

urbanicity. Utilization of the following 

five health and educational services were 

explored: whether the child saw 1) a 

mental health professional (psychiatrist, 

psychologist, psychiatric nurse, or 

clinical social worker) in the past 12 

months, 2) a specialist (medical doctor 

who specializes in a particular medical 

disease or problem) in the past 12 

months, 3) a therapist (physical therapist, 

speech therapist, respiratory therapist, 

audiologist, or occupational therapist) in 

the past 12 months, 4) had a well-child 

checkup in the past 12 months, and 5) 

currently receives Special Education 

or Early Intervention Services (EIS). 

A count of specialty care services was 

created from whether the child saw a 

mental health professional, specialist, or 

therapist in the past 12 months. 

Statistical analysis 

Weighted percentages of children 

aged 3–17 years who had each of the 

selected developmental disabilities 

and any developmental disability 

were calculated for the overall time 

period 2015–2018 and stratified by 

urbanicity of residence. In addition, 

weighted percentages of health care and 

educational service use among children 

aged 3–17 years with any developmental 

disability were calculated and stratified 

by urbanicity of residence. Differences 

between percentages of developmental 

disabilities by urbanicity and health 

care and educational service utilization 

were tested using bivariate logistic 

regressions. All analyses incorporated 

clustering, stratification, and weights to 

reflect the complex sampling design and 

allow for the calculation of nationally 

representative estimates using SUDAAN 

version 11.0. All estimates reported 

meet NCHS standards of reliability as 

specified in, “National Center for Health 

Statistics Data Presentation Standards for 

Proportions” (9). 

Results

Prevalence 

During 2015–2018, the prevalence 

of any developmental disability among 

children aged 3–17 years was 17.8% 

(95% confidence interval ([CI]): 

17.3–18.4). During this time period, 

children living in rural areas (19.8% 

[95% CI: 18.5–21.2]) were more likely 

to be diagnosed with a developmental 

disability than children living in urban 

areas (17.4% [95% CI: 16.8–18.0], 

p < 0.01) (Figure 1). 

Of the selected developmental 

disabilities examined, children living 

in rural areas (compared to urban) were 

more likely to be diagnosed with ADHD 

(11.4% [95% CI: 10.4–12.4] compared 

with 9.2% [95% CI: 8.8–9.7], p < 0.001) 

and cerebral palsy (0.5% [95% CI: 

0.3–0.9] compared with 0.2% [95% CI: 

0.2–0.3], p < 0.05) (Table).

Health care and educational 

service utilization 

Among children aged 3–17 years 

with developmental disabilities, those 

living in rural areas were less likely to 

Figure 1. Prevalence of children aged 3–17 years ever diagnosed with a developmental 

disability, by urbanicity: United States, 2015–2018

1Significantly different from children in urban areas (p < 0.05).

NOTE: Access data table for Figure 1 at: https://www.cdc.gov/nchs/data/nhsr/nhsr139_tables-508.pdf#1. 

SOURCE: NCHS, National Health Interview Survey, 2015–2018.

 

 

 

 

 

 
National Health Statistics Reports  Number 139  February 19, 2020 Page 3

months when compared with children 

living in urban areas (Figure 2). Children 

in rural areas were also less likely to be 

currently receiving Special Education 

or EIS (37.7% [95% CI: 34.1–41.4] 

compared with 44.2% [95% CI: 

42.2–46.1], p < 0.05).

A further examination of specialty 

care revealed that nearly one-half of 

have seen a mental health professional 

(24.6% [95% CI: 21.5–27.8] compared 

with 33.1% [95% CI: 31.3–34.9], 

p < 0.05); therapist (22.4% [95% CI: 

19.2–25.8] compared with 26.7% [95% 

CI: 25.0–28.4], p < 0.05); or have had 

a well-child checkup (83.4% [95% CI: 

80.6–86.0] compared with 87.4% [95% 

CI: 86.1–88.6], p < 0.05) in the past 12 

Figure 2. Health care and educational service utilization among children aged 3–17 years with any developmental disability, by urbanicity: 

United States, 2015–2018

children with developmental disabilities 

living in rural areas (49.4% [95% CI: 

45.7–53.0]) did not use any of the three 

specialty providers (mental health 

professional, specialist, or therapist) in 

the past 12 months. This was significantly 

more than children with developmental 

disabilities living in urban areas (41.8% 

[95% CI: 40.0–43.7], p < 0.05) (Figure 3).

1Significantly different from children in urban areas (p < 0.05).

NOTES: Mental health professionals include psychiatrists, psychologists, psychiatric nurses, or clinical social workers and is based on a visit in the past 12 months. Specialists include 

medical doctors who specialize in a particular medical disease or problem and is based on a visit in the past 12 months. Therapists include physical therapists, speech therapists, respiratory 

therapists, audiologists, or occupational therapists and is based on a visit in the past 12 months. EIS is Early Intervention Services. Access data table for Figure 2 at: https://www.cdc.gov/

nchs/data/nhsr/nhsr139_tables-508.pdf#2. 

SOURCE: NCHS, National Health Interview Survey, 2015–2018.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table. Prevalence of any developmental disability and selected developmental disabilities in children aged 3–17 years, by urbanicity: 

United States, 2015–2018

Condition n (unweighted)

Total Urban Rural

Estimate (95% CI) SE Estimate (95% CI) SE Estimate (95% CI) SE

Any developmental disability . . . . . . . . . . . . . . . . . . . . . . . 6,067 17.8 (17.3–18.4) 0.28 17.4 (16.8–18.0) 0.30 †19.8 (18.5–21.2) 0.66

ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,360 9.6 (9.2–10.0) 0.21 9.2 (8.8–9.7) 0.22 †11.4 (10.4–12.4) 0.51

Autism spectrum disorder. . . . . . . . . . . . . . . . . . . . . . . . . . 856 2.5 (2.2–2.7) 0.12 2.5 (2.2–2.7) 0.14 2.5 (2.0–3.1) 0.26

Blind or unable to see at all . . . . . . . . . . . . . . . . . . . . . . . . 50 0.2 (0.1–0.2) 0.03 0.2 (0.1–0.2) 0.03 0.1 (0.0–0.3) 0.05

Cerebral palsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 0.3 (0.2–0.4) 0.04 0.2 (0.2–0.3) 0.04 †0.5 (0.3–0.9) 0.14

Moderate to profound hearing loss . . . . . . . . . . . . . . . . . . . 204 0.6 (0.5–0.7) 0.06 0.6 (0.5–0.8) 0.06 0.6 (0.4–0.8) 0.11

Learning disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,665 7.7 (7.3–8.1) 0.21 7.6 (7.2–8.1) 0.23 8.1 (7.3–9.1) 0.46

Intellectual disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 1.2 (1.1–1.4) 0.08 1.2 (1.0–1.4) 0.09 1.2 (0.9–1.6) 0.18

Seizures, past 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . 265 0.8 (0.7–0.9) 0.06 0.8 (0.6–0.9) 0.07 0.9 (0.6–1.3) 0.17

Stuttered or stammered, past 12 months. . . . . . . . . . . . . . 655 2.1 (1.9–2.3) 0.10 2.1 (1.9–2.4) 0.12 1.9 (1.5–2.4) 0.22

Other developmental delay. . . . . . . . . . . . . . . . . . . . . . . . . 1,361 4.1 (3.8–4.3) 0.14 4.0 (3.7–4.3) 0.15 4.5 (3.9–5.2) 0.33

† Significantly different from children in urban areas (p < 0.05). 

NOTES: CI is confidence interval. SE is standard error. ADHD is attention-deficit/hyperactivity disorder.

SOURCE: NCHS, National Health Interview Survey, 2015–2018.
Page 4 National Health Statistics Reports  Number 139  February 19, 2020

Discussion

Findings from this study highlight 

differences in the prevalence of 

developmental disabilities among 

children aged 3–17 years by rural and 

urban residence, as well as the use of 

health care and educational services in 

the past 12 months among the population 

of children with developmental 

disabilities. Overall, developmental 

disabilities were more prevalent in 

children living in rural areas than 

urban areas. This difference appears 

to be largely attributable to the higher 

prevalence of ADHD seen among 

children living in rural areas, although 

children living in rural areas were also 

more likely to be diagnosed with cerebral 

palsy. 

Differences were also seen in the 

receipt of some, but not all services, 

among children who were diagnosed 

with a developmental disability by 

urbanicity. More specifically, children 

with a developmental disability living in 

rural areas were less likely to have seen a 

mental health professional or therapist in 

the past year. They were also less likely 

to receive Special Education or EIS or 

have received a well-child checkup in the 

past year.

Receipt of a well-child checkup 

represents one element of the medical 

home (10) and may provide a setting 

for clinicians to address health issues 

and provide necessary referrals to 

specialists. Given the high co-occurrence 

of mental health disorders among 

children with developmental disabilities 

(11), the need for referrals to mental 

health professionals and specialty care 

therapists may be increased (12), and a 

lack thereof may contribute to the unmet 

medical needs previously reported in 

this population (13). Additional research 

exploring questions of unmet need 

and the accessibility of services and 

interventions (14,15) may help to better 

understand the disparities seen between 

children with developmental disabilities 

living in urban and rural areas.

Previous research has found that 

children living in rural areas are more 

likely to experience family adversity, 

potentially in the form of poor parental 

mental health and financial difficulties 

(16). This, in combination with a lack of 

individual and community level resources 

for treatment, may lead to higher rates 

of persistent behavioral problems (17). 

Consistent with this, these analyses found 

a higher prevalence of developmental 

disabilities, particularly ADHD, among 

rural children. Furthermore, children 

living in rural areas often lack physical 

and social resources (6), fueled by 

accessibility problems, such as reliable 

transportation, that may play a key role 

in care coordination and accessing health 

care services (18,19).

Limitations

Diagnoses for all conditions were 

parent-reported and were not validated 

either through clinical evaluation or 

educational records. Parental report is 

susceptible to recall biases, particularly 

among parents of older children. Despite 

this, NHIS has several notable strengths 

in both its large sample size and high 

response rate for a national survey.

Conclusions

There was a higher prevalence of 

children with developmental disabilities 

in rural areas compared with urban 

areas. Furthermore, among children with 

developmental disabilities, those living 

in rural areas were less likely to use a 

range of health care and educational 

services compared with their urban 

peers. Additional research may elucidate 

mechanisms that may contribute to 

alterations in developmental differences 

and use of services by urban or rural 

status, including lack of resources to pay 

for health care and educational services 

and access to trained specialty providers 

that may vary by geographic location.

References

1. Zablotsky B, Black LI, Maenner MJ, 

Schieve LA, Danielson ML, Bitsko 

RH, et al. Prevalence and trends of 

developmental disabilities among 

children in the United States: 2009–2017. 

Pediatrics 144(4):1–11. 2019.

2. Arim RG, Miller AR, Guèvremont 

A, Lach LM, Brehaut JC, Kohen DE. 

Children with neurodevelopmental 

disorders and disabilities: A population‐

based study of healthcare service 

utilization using administrative data. Dev 

Med Child Neurol 59(12):1284–90. 2017.

3. Boulet SL, Boyle CA, Schieve LA. Health 

care use and health and functional impact 

of developmental disabilities among 

U.S. children, 1997–2005. Arch Pediatr 

Adolesc Med 163(1):19–26. 2009.

Figure 3. Percent distribution for number of specialty health care services utilized in the 

past 12 months among children aged 3–17 years with any developmental disability, by 

urbanicity: United States, 2015–2018

1Significantly different from children in urban areas (p < 0.05).

NOTES: Number of specialty health care services was calculated based on seeing a mental health professional, 

specialist, or therapist in the past 12 months. Access data table for Figure 3 at: https://www.cdc.gov/nchs/data/nhsr/

nhsr139_tables-508.pdf#3. 

SOURCE: NCHS, National Health Interview Survey, 2015–2018.

 
National Health Statistics Reports

 Number 139 February 19, 2020 Page 5

4. Bitsko RH, Holbrook JR, Robinson LR, 

Kaminski JW, Ghandour R, Smith C, et 

al. Health care, family, and community 

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65(9):221–6. 2016.

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care for children with developmental 

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6. Meit M, Knudson A, Gilbert T, Yu AT, 

Tanenbaum E, Ormson E, et al. The 2014 

update of the rural-urban chartbook. 

Bethesda, MD: Rural Health Reform 

Policy Research Center. 2014. Available 

from: http://worh.org/sites/default/

files/2014-rural-urban-chartbook.pdf.

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(NHIS) public use data release: Survey 

description. 2019. Available from: 

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NHIS/2018/srvydesc.pdf.

8. United States Census Bureau. 2010 

Census urban and rural classification and 

urban area criteria. Available from: 

https://www.census.gov/programssurveys/geography/guidance/geo-areas/

urban-rural/2010-urban-rural.html.

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V, Carroll M, Gonzalez JF Jr, et al. 

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presentation standards for proportions. 

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10. American Academy of Pediatrics. The 

medical home: Medical home initiatives 

for children with special needs advisory 

committee. Pediatrics 110(1):184–6. 2002.

11. Munir KM. The co-occurrence of mental 

disorders in children and adolescents 

with intellectual disability/intellectual 

developmental disorder. Curr Opin 

Psychiatry 29(2):95–102. 2016.

12. Fox RA, Keller KM, Grede PL, Bartosz 

AM. A mental health clinic for toddlers 

with developmental delays and behavior 

problems. Res Dev Disabil 28(2):119–29. 

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13. Brown NM, Green JC, Desai MM, 

Weitzman CC, Rosenthal MS. Need and 

unmet need for care coordination among 

children with mental health conditions. 

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14. Vohra R, Madhavan S, Sambamoorthi U, 

St Peter C. Access to services, quality of 

care, and family impact for children with 

autism, other developmental disabilities, 

and other mental health conditions. 

Autism 18(7):815–26. 2014.

15. Lindly OJ, Chavez AE, Zuckerman KE. 

Unmet health services needs among U.S. 

children with developmental disabilities: 

Associations with family impact and 

child functioning. J Dev Behav Pediatr 

37(9):712–23. 2016.

16. Robinson LR, Holbrook JR, Bitsko RH, 

Hartwig SA, Kaminski JW, Ghandour 

RM, et al. Differences in health 

care, family, and community factors 

associated with mental, behavioral, and 

developmental disorders among children 

aged 2–8 years in rural and urban areas—

United States, 2011–2012. MMWR Morb 

Mortal Wkly Rep 66(8):1–11. 2017.

17. Aber JL, Jones SM, Cohen J. The impact 

of poverty on the mental health and 

development of very young children. New 

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18. Smalley KB, Yancey CT, Warren JC, 

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Page 6 National Health Statistics Reports  Number 139  February 19, 2020

Technical Notes

Definition of terms

Attention deficit/hyperactivity 

disorder (ADHD)—Based on a positive 

response to the survey question, “Has a 

doctor or health professional ever told 

you that [sample child] had Attention 

Deficit Hyperactivity Disorder (ADHD) 

or Attention Deficit Disorder (ADD)?”

Autism spectrum disorder—Based 

on a positive response to the survey 

question, “Has a doctor or health 

professional ever told you that [sample 

child] had autism, Asperger’s disorder, 

pervasive developmental disorder, or 

autism spectrum disorder?”

Blind/unable to see at all—Based 

on a positive response to the survey 

question, “Is [sample child] blind or 

unable to see at all?”

Cerebral palsy—Based on a positive 

response to the survey question, “Has a 

doctor or health professional ever told 

you that [sample child] had cerebral 

palsy?”

Developmental disability—A 

composite measure based on the 

responses to a series of survey questions 

that asked whether the parent had 

ever been told by a doctor or health 

professional that the child had attentiondeficit/hyperactivity disorder, autism 

spectrum disorder, blindness, cerebral 

palsy, moderate to profound hearing loss, 

learning disability, intellectual disability, 

seizures, stuttering or stammering, or 

other developmental delay.

Intellectual disability—Based on a 

positive response to the survey question, 

“Has a doctor or health professional 

ever told you that [sample child] had 

an intellectual disability, also known as 

mental retardation?”

Learning disability—Based on a 

positive response to the survey question, 

“Has a representative from a school or 

a health professional ever told you that 

[sample child] had a learning disability?”

Moderate to profound hearing loss—

Respondents were asked to describe the 

child’s hearing without the use of hearing 

aids or other listening devices. Based on 

the survey question, “Which statement 

best describes [sample child]’s hearing: 

Excellent, good, a little trouble hearing, 

moderate trouble, a lot of trouble, or 

is [sample child] deaf?” Responses of 

“moderate trouble,” “a lot of trouble,” and 

“deaf” were considered to have moderate 

to profound hearing loss.

Seizures—Based on a positive 

response to the survey question, “During 

the past 12 months, has [sample child] 

had seizures?”

Stuttering or stammering—Based on 

a positive response to the survey question, 

“During the past 12 months, has [sample 

child] had stuttering or stammering?”

Other developmental delay—Based 

on a positive response to the survey 

question, “Has a doctor or health 

professional ever told you that [sample 

child] had any other developmental 

delay?”

Receipt of Special Education or 

Early Intervention Services—Based 

on a positive response for the sample 

child to the survey question, ‘‘Do any of 

these family members, [list of children’s 

names], receive Special Educational or 

Early Intervention Services?’’

Receipt of specialty care—A 

composite measure based on a positive 

response to either use of a mental health 

professional, specialist, or therapist.

Urbanicity of residence—Based 

on the location of residence. Urban was 

defined as areas consisting of urbanized 

areas of 50,000 or more people and urban 

clusters of 2,500–49,999 persons; rural 

was defined as all other areas; see 

https://www.census.gov/programssurveys/geography/guidance/geo-areas/

urban-rural/2010-urban-rural.html.

Use of mental health professional—

Based on a positive response for the 

sample child to the survey question, 

“During the past 12 months, have you 

seen or talked to any of the following 

health care providers about [sample 

child]’s health? A mental health 

professional such as a psychiatrist, 

psychologist, psychiatric nurse, or

clinical social worker.”

Use of specialist—Based on a 

positive response for the sample child to 

the survey question, “During the past 12 

months, have you seen or talked to any 

of the following health care providers 

about [sample child]’s health? A medical 

doctor who specializes in a particular 

medical disease or problem (other than 

obstetrician/gynecologist, psychiatrist, or 

ophthalmologist).”

Use of therapist—Based on a 

positive response for the sample child to 

the survey question, “During the past 12 

months, have you seen or talked to any 

of the following health care providers 

about [sample child]’s health? A physical 

therapist, speech therapist, respiratory 

therapist, audiologist, or occupational 

therapist?”

Well-child checkup—Based on a 

positive response for the sample child 

to the survey question, “During the past 

12 months, did [sample child] receive a 

well-child checkup—that is, a general 

checkup when he/she was not sick or 

injured?”
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Suggested citation

Zablotsky B, Black LI. Prevalence of children 

aged 3–17 years with developmental 

disabilities, by urbanicity: United States, 

2015–2018. National Health Statistics Reports; 

no 139. Hyattsville, MD: National Center for 

Health Statistics. 2020.

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health Statistics

Jennifer H. Madans, Ph.D., Acting Director

Amy M. Branum, Ph.D., Acting Associate

Director for Science

Division of Health Interview Statistics

Stephen J. Blumberg, Ph.D., Director

Anjel Vahratian, Ph.D., M.P.H., Associate

Director for Science