Trends in Mental Health Diagnoses Among Publicly Insured Children

Janet R Cummings; Xin Hu; Jordan Marchak; Cristian Ramos; Ilana Graetz; Xu Ji

doi:10.1001/jama.2025.4605

. 2025 Apr 24;333(22):1988–1997. doi: 10.1001/jama.2025.4605

Trends in Mental Health Diagnoses Among Publicly Insured Children

Janet R Cummings ^1,^✉, Xin Hu ^1,², Jordan Marchak ^3,⁴, Cristian Ramos ¹, Ilana Graetz ^1,², Xu Ji ^1,^3,⁴

¹Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia

²Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia

³Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia

⁴Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia

Accepted for Publication: March 15, 2025.

Published Online: April 24, 2025. doi:10.1001/jama.2025.4605

^✉

Corresponding Author: Janet R. Cummings, PhD, Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Ste 650, Atlanta, GA 30322 (jrcummi@emory.edu).

Author Contributions: Dr Hu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cummings, Hu, Marchak, Graetz, Ji.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cummings, Ramos.

Critical review of the manuscript for important intellectual content: Cummings, Hu, Marchak, Graetz, Ji.

Statistical analysis: Hu.

Obtained funding: Cummings, Ji.

Administrative, technical, or material support: Hu, Ramos, Ji.

Supervision: Cummings, Graetz.

Other - validation and visualization: Ji.

Other - clinical support: Marchak.

Conflict of Interest Disclosures: Dr Cummings reported receiving personal fees from ChangeLab Solutions outside the submitted work. Dr Hu reported receiving grants from PhRMA Foundation, St Jude Children's Research Hospital, Pfizer, and Johnson & Johnson outside the submitted work. Dr Marchak reported receiving grants from Pfizer outside the submitted work. Dr Graetz reported receiving grants from Pfizer and PRIME Education outside the submitted work. Dr Ji reported receiving grants from Leukemia & Lymphoma Society and Rally Foundation for Childhood Cancer Research; and being an American Cancer Society visiting scientist outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the Synergy Award program at Emory University.

Role of the Funder/Sponsor: Emory University had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

^✉

Corresponding author.

PMCID: PMC12022859 PMID: 40272810

Key Points

Question

How did the percentage of publicly insured children diagnosed with mental health or neurodevelopmental disorders change between 2010 and 2019?

Findings

Using claims data from 22 states, this observational study found that the percentage of publicly insured children diagnosed with any mental health or neurodevelopmental disorder increased from 10.7% in 2010 to 16.5% in 2019. Statistically significant increases were observed in 9 of 13 specific diagnostic categories.

Meaning

The percentage of publicly insured children who received any mental health or neurodevelopmental disorder diagnosis statistically significantly increased between 2010 and 2019, as did the percentage who received a diagnosis in many specific categories.

Abstract

Importance

Children living in poverty are at increased risk of mental health and neurodevelopmental disorders. Little is known about the trends in diagnoses of these disorders among children enrolled in public insurance programs, such as Medicaid, which insure more than 1 in 3 US children.

Objective

To provide comprehensive, multistate estimates of changes in the percentage of publicly insured children with mental health and/or neurodevelopmental disorder diagnoses.

Design, Setting, and Participants

This serial, cross-sectional study used administrative claims data from 22 states to test trends from 2010 to 2019 in the percentage of publicly insured children aged 3 to 17 years with mental health or neurodevelopmental disorder diagnoses. Regression models included a dummy variable for each year, controlled for child demographics, county-level metropolitan status, median household income, and US Census region. Adjusted risk differences were estimated, with standard errors clustered at the state level.

Exposure

Calendar year.

Main Outcomes

Any mental health or neurodevelopmental disorder diagnosis in the calendar year, and any diagnosis in 1 of 13 specific diagnostic categories.

Results

A total of 129 306 637 child-year observations (29 925 633 unique publicly insured children) were included. The percentage of publicly insured children with any diagnosed mental health or neurodevelopmental disorder increased from 10.7% in 2010 to 16.5% in 2019; this change remained significant after adjustment for covariates (adjusted risk difference [aRD], 6.7 percentage points [95% CI, 5.0-8.4]). Statistically significant increases were also observed in 9 of the 13 diagnostic categories examined. The largest absolute increases were observed for attention-deficit/hyperactivity disorder (aRD, 2.3 percentage points [95% CI, 1.4-3.3]), trauma- and stressor-related disorders (aRD, 1.7 percentage points [95% CI, 0.9-2.5]), anxiety disorders (aRD, 1.6 percentage points [95% CI, 1.2-2.1]), autism spectrum disorders (aRD, 1.1 percentage points [95% CI, 0.9-1.4]), depressive disorders (aRD, 0.9 percentage points [95% CI, 0.6-1.3]), and other neurodevelopmental disorders (aRD, 2.6 percentage points [95% CI, 1.8-3.5]).

Conclusions and Relevance

The percentage of publicly insured children receiving any mental health or neurodevelopmental disorder diagnosis significantly increased between 2010 and 2019, with increases observed for most diagnostic categories examined. These findings highlight the need for access to appropriate services in safety net systems and other settings that serve this population.

This cross-sectional, multistate study examines trends in the percentage of publicly insured children who received a mental health or neurodevelopmental disorder diagnosis between 2010 and 2019.

Introduction

Concern about child mental health has increased in recent years.^1,2 A US national survey of parents in 2016 found that 25% of children had been diagnosed with a mental health, behavioral health, or developmental disorder at some point in their life by a health care professional.³ Since the 2020 onset of the COVID-19 pandemic, concerns about child mental health have increased.^4,5 Data have shown increases in anxiety and depression^3,6,7,8 as well as in diagnosed learning disabilities and developmental delays.³ Furthermore, research has reported increasing percentages of mental health–related emergency department visits⁹ and higher numbers and percentages of mental health–related hospitalizations among children.¹⁰ In 2021, 3 health professional organizations that serve children, including the American Academy of Pediatrics, declared an emergency in child mental health,¹¹ and the surgeon general released a report on child mental health that highlighted these worrisome trends.¹²

In the US, 16% of children live in poverty,¹³ which is associated with increased risk of mental health disorders and poor mental health outcomes.^14,15 Public insurance programs, such as Medicaid and the Children’s Health Insurance Program (CHIP), covered 38.8% of US children in 2023,¹⁶ including those from families with low incomes, with disabilities, or living in the foster care system.¹⁷ To date, there is limited data examining trends in mental health diagnoses among publicly insured children. The only known multistate study that examined trends in mental health diagnoses among Medicaid-enrolled youth used data from 2001 to 2010 and focused on a single diagnosis.¹⁸ To the authors’ knowledge, no prior study has broadly examined trends in mental health and neurodevelopmental diagnoses among publicly insured children using data from multiple states.

To address this gap in the literature, the current study used the most comprehensive data source available—multistate administrative claims data from 2010 to 2019—to examine trends in mental health and neurodevelopmental diagnoses among publicly insured children overall as well as for 13 diagnostic categories.

Methods

Data

Medicaid and CHIP data came from a 100% sample of the 2010 to 2015 Medicaid Statistical Information System (MSIS) Analytic eXtract (MAX) and the 2014 to 2019 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) from the Centers for Medicare & Medicaid Services (CMS). The data were accessed through the Virtual Research Data Center’s Chronic Conditions Warehouse. Of note, the transition from the older MSIS to T-MSIS was implemented across states on a rolling basis from 2014 through 2016.¹⁹ Data were also merged from the 2020 and 2022 Area Health Resources Files²⁰ and the 2013 Rural-Urban Continuum Codes,²¹ using the beneficiary zip code and county code in the MAX and TAF data.

Analytic Sample

The primary unit of analysis for the study was the child-year observation. Using this unit, some children appeared in the data in more than 1 year. To derive the analytic sample, the data were used to first identify 302 760 591 child-year observations from 64 714 691 unique Medicaid and/or CHIP child beneficiaries aged 3 to 17 years during 1 or more of the study years (2010-2019). Next, observations were excluded for children with records in multiple states in a given year, and those living in 1 of 28 states that had high data quality concerns on the TAF Other Services Files or on the race and ethnicity data in the TAF Demographic and Eligibility Files.²² Thus, the analytic sample was derived from 160 108 834 child-year observations in 22 states (Alaska, California, Delaware, Georgia, Idaho, Illinois, Indiana, Maine, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Texas, Vermont, Virginia, Washington, Wisconsin) with higher-quality data on our study variables. From this sample, observations were excluded if the child had fewer than 6 months of public insurance enrollment in the calendar year (~9%); this threshold facilitated the capture of sufficient encounters in which children sought mental health services and received a diagnosis. Next, observations were excluded with missing information on race and ethnicity (~7%), county-level identifiers (~2%), county-level median household income (~3%), and sex (<0.001%). These exclusions resulted in a sample of 129 306 637 child-year observations from 2010 to 2019, representing 29 925 633 unique children (eFigure 1 in Supplement 1). This study was approved by the Emory University Institutional Review Board, which waived the requirement to obtain informed consent.

For sensitivity analyses, an expanded sample was derived from 42 states that did not have high data quality concerns on the Other Service Files (regardless of data quality on race and ethnicity data in the TAF Demographic and Eligibility Files; n = 188 240 302 child-year observations).²²

Measures

Outcomes included dichotomous indicators for having any mental health or neurodevelopmental disorder diagnosis in a given year, 1 of the 13 specific diagnostic categories described below, and a diagnosis of 2 or more of the 13 specific diagnostic categories. Diagnosis of a mental health or neurodevelopmental disorder was defined as 2 or more inpatient and/or outpatient health care claims on distinct dates with the International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for a specific category (eTable 1 in Supplement 1). The 13 categories of specific conditions included (1) attention-deficit/hyperactivity disorder (ADHD); (2) autism spectrum disorders; (3) anxiety disorders; (4) bipolar disorder; (5) depressive disorders; (6) disruptive, impulse control, and conduct disorders; (7) eating disorders; (8) obsessive-compulsive and related disorders; (9) personality disorders; (10) schizophrenia and other psychotic disorders; (11) trauma- and stressor-related disorders; (12) other neurodevelopmental disorders; and (13) other mental health disorders.

Demographic and contextual-level variables were created to enable analyses of trends within subgroups and control for potential changes in the composition of the population over time. At the child-year level, we created categorical measures for age, sex, and racial and ethnic groups (non-Hispanic American Indian or Alaska Native [American Indian or Alaska Native], non-Hispanic Asian [Asian], non-Hispanic Black [Black], Hispanic, non-Hispanic multiracial [multiracial], non-Hispanic Pacific Islander [Pacific Islander], and non-Hispanic White [White]). Information on race and ethnicity is generally self-reported by beneficiaries (or those filling out paperwork on behalf of beneficiaries), although there is state variation in how this information is collected.²³ At the contextual level, we created measures of county metropolitan status, county-level median household income, and US Census region (Northeast, South, Midwest, and West). The 3 categories for county-level metropolitan status (metropolitan, nonmetropolitan urban, and rural) were derived using the Rural-Urban Continuum Codes.

Analyses

Trends were plotted for the annual percentage of children with any mental health or neurodevelopmental disorder diagnosis, and the annual percentage of children with diagnoses in 2 or more categories. Trends were also plotted for each of the 13 mental health and neurodevelopmental disorders. Additionally, trends in the annual percentage of children with any mental health and/or neurodevelopmental disorder diagnosis were stratified and examined within age group, sex, race and ethnicity, and county metropolitan status.

Next, for each outcome, logistic regression models were estimated with year dummies (using 2010 as the reference year) to test for significant changes in the annual percentage of children with a mental health or neurodevelopmental disorder diagnosis. This modeling approach allowed for the flexibility to account for nonlinear changes in the outcomes over time and to estimate the predicted percentage point changes between the baseline and each year (ie, the adjusted risk difference [aRD]), using the SAS software margins macros (SAS Institute) following the logistic regression.²⁴ While the models leverage all years of data, we estimated and presented aRDs for 3 different time points (2013, 2016, and 2019) relative to the baseline (2010). These time points were selected based on important changes during the study period, including the transition from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to DSM-5,²⁵ from ICD-9 to ICD-10,²⁶ and from MAX to TAF files in the Medicaid system.²⁷ Regression models controlled for demographic characteristics (ie, age group, sex, race and ethnicity), county metropolitan status, county-level median household income, and US Census region, and standard errors were clustered at the state level. In supplemental analyses presented in the eAppendix in Supplement 1, trends were tested within each of the demographic subgroups and by county metropolitan status in regression models.

Results

Among 129 306 637 child-year observations in the total sample, 41.8% were aged 6 to 11 years, 36.5% were aged 12 to 17 years, and 50.9% were male (Table 1). Among the observations, 1.6% were American Indian or Alaska Native, 3.1% were Asian, 20.2% were Black, 38.4% were Hispanic, 0.8% were Pacific Islander, and 35.3% were White.

Table 1. Characteristics of Child-Year Observations, Publicly Insured Children Aged 3 to 17 Years^a.

Characteristic	No. (%)
Characteristic	Any mental health or neurodevelopmental disorder diagnosis^b	Total sample
Total observations of child-years	17 054 686 (100)	129 306 637 (100)
Total observations of unique children	7 007 905 (100)	29 925 633 (100)
Age group, y
3-5	2 344 894 (13.37)	27 984 720 (21.64)
6-11	7 650 442 (44.86)	54 087 853 (41.83)
12-17	7 059 350 (41.39)	47 234 064 (36.53)
Sex
Male	10 373 337 (60.82)	65 785 052 (50.88)
Female	6 681 349 (39.18)	63 521 585 (49.12)
Race and ethnicity^c
American Indian or Alaska Native	336 361 (1.97)	2 114 979 (1.64)
Asian	211 138 (1.24)	3 995 809 (3.09)
Black	3 460 175 (20.29)	26 159 418 (20.23)
Hispanic	4 531 126 (26.57)	49 630 425 (38.38)
Multiracial	132 779 (0.78)	738 785 (0.57)
Pacific Islander	53 437 (0.31)	1 070 905 (0.83)
White	8 329 670 (48.84)	45 596 316 (35.26)
County-level metropolitan status
Metropolitan	13 746 534 (80.60)	110 107 859 (85.15)
Nonmetropolitan urban	3 049 751 (17.88)	17 564 156 (13.58)
Rural	258 401 (1.52)	1 634 622 (1.26)
County-level median household income, mean (SD), $	55 252.84 (14 845.45)	56 226.33 (15 116.71)
US Census region
South	6 254 928 (36.68)	46 354 932 (35.85)
Midwest	4 941 934 (28.98)	29 458 181 (22.78)
West	4 375 049 (25.65)	45 325 194 (35.05)
Northeast	1 482 775 (8.69)	8 168 330 (6.32)

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^{^a}

Analysis conducted using administrative claims data from 22 states; unit of analysis was the child-year observation. Across all years of data (2010-2019), the total analytic sample was N = 129 306 637 child-year observations, which represented 29 925 633 unique children.

^{^b}

Cohort characteristics for specific mental health conditions are presented in eTable 3 in Supplement 1.

^{^c}

Information on race and ethnicity is generally self-reported by beneficiaries (or those filling out paperwork on behalf of beneficiaries), although there is state variation in how this information is collected.²³

Among 17 054 686 child-year observations in the sample with any mental health or neurodevelopmental disorder diagnosis, 41.4% were aged 12 to 17 years and 60.8% were male. Regarding racial and ethnic composition, 2.0% were American Indian or Alaska Native, 1.2% were Asian, 20.3% were Black, 26.6% were Hispanic, 0.3% were Pacific Islander, and 48.8% were White.

Trends in Diagnoses

The unadjusted percentage of publicly insured children with any mental health or neurodevelopmental disorder increased from 10.7% in 2010 to 14.2% in 2016 and 16.5% in 2019 (Figure 1, Table 2). After controlling for covariates (Table 3), the aRDs indicated a 4.0–percentage point increase (95% CI, 2.1-6.0) in the percentage with any diagnosis between 2010 and 2016 and a 6.7–percentage point increase (95% CI, 5.0-8.4) between 2010 and 2019. Similarly, the percentage of children with at least 2 diagnoses increased from 3.0% in 2010 to 4.2% in 2016 and 5.5% in 2019 (Figure 1, Table 2). After controlling for covariates (Table 3), the aRD indicated a 1.5–percentage point increase (95% CI, 0.5-2.4) in the percentage with at least 2 diagnoses between 2010 and 2016 and a 2.9–percentage point increase (95% CI, 1.9-3.9) between 2010 and 2019.

Figure 1. — Sample size for each year: 2010, n = 11 648 016; 2011, n = 12 059 241; 2012, n = 12 924 452; 2013, n = 12 943 459; 2014, n = 11 915 896; 2015, n = 12 210 114; 2016, n = 13 810 625; 2017, n = 13 576 249; 2018, n = 14 248 567; 2019, n = 13 970 018. Y-axes change among panels based on relative prevalence of diseases shown.

^aIncludes neurodevelopmental disorders not classified above, such as expressive language disorder, specific reading disorder, and borderline intellectual functioning; for the full list of *ICD* codes used for this category, see eTable 1 in Supplement 1.

^bIncludes mental health disorders not classified above, such as unspecified childhood emotional disorder, unspecified nonpsychotic mental disorder, and other childhood disorders of social functioning; for the full list of *ICD* codes used for this category, see eTable 1 in Supplement 1.

ADHD indicates attention-deficit/hyperactivity disorder; *ICD*, *International Classification of Diseases*.

Table 2. Percentage of Publicly Insured Children Aged 3 to 17 Years Diagnosed With Mental Health or Neurodevelopmental Disorders^a.

Disorder	No. with disorder at baseline (2010)	Percentage with disorder, unadjusted % (95% CI)
Disorder	No. with disorder at baseline (2010)	2010	2013	2016	2019
Any mental health and/or neurodevelopmental disorder	1 242 546	10.667 (10.650-10.685)	12.230 (12.212-12.248)	14.177 (14.159-14.195)	16.487 (16.468-16.507)
Attention-deficit/hyperactivity disorder	449 754	3.861 (3.850-3.872)	4.585 (4.574-4.597)	5.128 (5.117-5.140)	5.296 (5.284-5.308)
Trauma- and stressor-related disorders	248 742	2.135 (2.127-2.144)	2.432 (2.423-2.440)	2.724 (2.716-2.733)	3.691 (3.681-3.701)
Disruptive, impulse control, and conduct disorders	228 198	1.959 (1.951-1.967)	2.064 (2.056-2.072)	1.808 (1.801-1.815)	1.859 (1.851-1.866)
Depressive disorders	150 674	1.294 (1.287-1.300)	1.449 (1.442-1.455)	1.702 (1.695-1.709)	2.343 (2.335-2.351)
Anxiety disorders	79 754	0.685 (0.680-0.689)	1.063 (1.058-1.069)	1.590 (1.583-1.596)	2.354 (2.346-2.362)
Schizophrenia and other psychoses	76 499	0.657 (0.652-0.661)	0.834 (0.829-0.839)	0.094 (0.092-0.095)	0.097 (0.095-0.098)
Bipolar disorder	50 141	0.430 (0.427-0.434)	0.317 (0.314-0.321)	0.286 (0.283-0.288)	0.245 (0.242-0.248)
Autism spectrum disorders	33 161	0.285 (0.282-0.288)	0.508 (0.504-0.512)	0.986 (0.980-0.991)	1.527 (1.520-1.533)
Obsessive-compulsive and related disorders	3867	0.033 (0.032-0.034)	0.041 (0.040-0.042)	0.058 (0.057-0.060)	0.066 (0.064-0.067)
Eating disorders	2656	0.023 (0.022-0.024)	0.038 (0.037-0.039)	0.050 (0.049-0.051)	0.064 (0.063-0.065)
Personality disorders	2434	0.021 (0.020-0.022)	0.029 (0.028-0.030)	0.046 (0.045-0.048)	0.032 (0.031-0.033)
Other neurodevelopmental disorders	357 231	3.067 (3.057-3.077)	3.590 (3.580-3.600)	4.699 (4.688-4.710)	5.512 (5.500-5.524)
Other mental health disorders	50 951	0.437 (0.434-0.441)	0.474 (0.470-0.478)	0.992 (0.987-0.998)	1.209 (1.203-1.214)
≥2 Diagnoses	344 749	2.960 (2.950-2.969)	3.634 (3.624-3.644)	4.231 (4.221-4.242)	5.471 (5.459-5.483)

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^{^a}

Table 3. Changes in the Percentage of Publicly Insured Children Aged 3 to 17 Years Diagnosed With Mental Health or Neurodevelopmental Disorders After Adjustment for Covariates^a.

Disorder	Percentage point changes with diagnosis over time [adjusted risk difference] from regressions, % (95% CI)^b
Disorder	2013 (vs 2010)	2016 (vs 2010)	2019 (vs 2010)
Any mental health and/or neurodevelopmental disorder	1.723 (−0.567 to 4.013)	4.042 (2.056 to 6.028)	6.704 (4.965 to 8.443)
Attention-deficit/hyperactivity disorder	0.857 (0.006 to 1.708)	1.718 (0.771 to 2.664)	2.344 (1.430 to 3.259)
Trauma- and stressor-related disorders	0.317 (−0.195 to 0.829)	0.673 (0.001 to 1.345)	1.697 (0.905 to 2.488)
Disruptive, impulse control, and conduct disorders	0.188 (−0.367 to 0.743)	0.103 (−0.502 to 0.707)	0.358 (−0.266 to 0.981)
Depressive disorders	0.136 (−0.105 to 0.378)	0.372 (0.010 to 0.734)	0.948 (0.632 to 1.263)
Anxiety disorders	0.369 (0.192 to 0.546)	0.892 (0.575 to 1.208)	1.612 (1.159 to 2.065)
Schizophrenia and other psychoses	0.180 (−0.003 to 0.363)	−0.557 (−0.674 to −0.441)	−0.555 (−0.667 to −0.443)
Bipolar disorder	−0.101 (−0.178 to −0.024)	−0.122 (−0.221 to −0.024)	−0.158 (−0.246 to −0.069)
Autism spectrum disorders	0.221 (0.020 to 0.421)	0.681 (0.491 to 0.871)	1.127 (0.886 to 1.368)
Obsessive-compulsive disorder	0.008 (−0.003 to 0.018)	0.025 (0.012 to 0.038)	0.030 (0.015 to 0.045)
Eating disorders	0.015 (0.009 to 0.021)	0.026 (0.016 to 0.036)	0.036 (0.023 to 0.050)
Personality disorders	0.008 (−0.001 to 0.017)	0.029 (0.0004 to 0.057)	0.016 (−0.016 to 0.048)
Other neurodevelopmental disorders	0.586 (−0.197 to 1.368)	1.810 (0.971 to 2.649)	2.643 (1.760 to 3.527)
Other mental health disorders	0.044 (−0.080 to 0.168)	0.587 (0.440 to 0.734)	0.844 (0.653 to 1.035)
≥2 Diagnoses	0.719 (−0.177 to 1.615)	1.454 (0.469 to 2.439)	2.856 (1.854 to 3.859)

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^{^a}

^{^b}

Adjusted risk difference represents the percentage point change in the percentage of children with a given diagnosis, estimated using the SAS Margins macro following logit regression models. Regression models included year dummy variables and controlled for age group, sex, racial and ethnic group, county-level metropolitan status, county-level median household income, and US Census region. Standard errors were clustered at the state level.

In unadjusted analyses, there were significant increases in the percentage of children with a diagnosis in 10 of the 13 diagnostic categories examined (Table 2, Figure 1). The largest absolute increases occurred among the most commonly diagnosed disorders, with the exception of autism spectrum disorders. In 2010, 5 of the most common diagnostic categories in the sample were ADHD (3.9%); trauma- and stressor-related disorders (2.1%); disruptive, impulse control, and conduct disorders (2.0%); depressive disorders (1.3%); and anxiety disorders (0.7%). Moreover, 0.3% were diagnosed with an autism spectrum disorder and 3.1% were diagnosed with at least 1 other neurodevelopmental disorder in 2010 (Table 2).

In adjusted analyses, there were statistically significant increases in 9 of the 13 diagnostic categories examined. The largest absolute increases between 2010 and 2019 (Table 3) were observed for ADHD (aRD, 2.3 percentage points [95% CI, 1.4-3.3]), trauma- and stressor-related disorders (aRD, 1.7 percentage points [95% CI, 0.9-2.5]), anxiety disorders (aRD, 1.6 percentage points [95% CI, 1.2-2.1]), autism spectrum disorders (aRD, 1.1 percentage points [95% CI, 0.9-1.4]), depressive disorders (aRD, 0.9 percentage points [95% CI, 0.6-1.3]), and other neurodevelopmental disorders (aRD, 2.6 percentage points [95% CI, 1.8-3.5]).

Analyses by Demographic Groups

Statistically significant increases in the percentage of children diagnosed with any mental health or neurodevelopmental disorder were observed in each demographic subgroup (Figure 2) (eTable 4 in Supplement 1). The percentage with any diagnosis was higher among males (13.0%) than females (8.3%) in 2010 (eTable 4 in Supplement 1). In addition, aRDs from regression analyses showed that the increase in the percentage of children with a diagnosis between 2010 and 2019 was 7.4 percentage points (95% CI, 5.6-9.2) among males and 5.7 percentage points (95% CI, 4.5-7.0) among females (eTable 5 in Supplement 1).

Figure 2. — Analysis conducted among N = 129 306 637 child-year observations in 22 states.

Regarding race and ethnicity, the percentage of children with any mental health or neurodevelopmental disorder diagnosis in 2010 was largest among multiracial children (15.2%), followed by White children (14.4%), American Indian or Alaska Native children (13.5%), Black children (11.3%), Hispanic children (7.0%), Pacific Islander children (3.9%), and Asian children (3.3%) (eTable 4 in Supplement 1). Furthermore, between 2010 and 2019, regression results indicated that the absolute greatest increase in the likelihood of receiving any mental health or neurodevelopmental disorder diagnosis was observed among White children (aRD, 8.9 percentage points [95% CI, 6.1-11.8]), followed by Hispanic children (aRD, 6.3 percentage points [95% CI, 5.5-7.1]), and Black children (aRD, 4.8 percentage points [95% CI, 2.8-6.9]) (eTable 5 in Supplement 1).

Sensitivity Analyses

Examination of descriptive trends in an expanded sample from 42 states showed consistent trends with the primary analysis (eFigures 2 and 3 in Supplement 1).

Discussion

This study found that the percentage of publicly insured children aged 3 to 17 years with any mental health or neurodevelopmental disorder diagnosis increased from 10.7% in 2010 to 16.5% in 2019, a change of 6.7 percentage points after adjustment for covariates. Increases were also identified in 9 of the 13 diagnostic categories, with the largest model-adjusted absolute increases observed in regression models for ADHD (2.3 percentage points), trauma- and stressor-related disorders (1.7 percentage points), anxiety disorders (1.6 percentage points), autism spectrum disorders (1.1 percentage points), depressive disorders (0.9 percentage points), and other neurodevelopmental disorders (2.6 percentage points). The baseline rate of having any diagnosis was higher among White children than American Indian or Alaska Native, Asian, Black, Hispanic, and Pacific Islander children, and White children also had the highest absolute increase in the likelihood of having a diagnosis in the study period.

This is the first known multistate study of trends in the percentage of publicly insured children with any mental health or neurodevelopmental disorder diagnosis as well as multiple diagnostic categories. The overall increase and the increases observed for several diagnostic categories (eg, anxiety, depression, eating disorders, and ADHD) are consistent with those seen in commercially insured children from 2012 to 2018.²⁸ Findings for specific diagnoses, such as depression and anxiety, also align with those observed in a national survey of adolescents,²⁹ a national survey of caregivers about their child’s health,³⁰ and national facility-level data on the distribution of diagnoses among children in state-funded mental health facilities.³¹

The increases observed in this study may be due to increased prevalence of the conditions, increased detection of the conditions, or both. For example, national survey data report that the underlying prevalence of major depressive disorder increased from 8.0% to 15.7% among adolescents between 2010 and 2019.^32,33 For disorders such as trauma- and stressor-related disorders and autism, the relative increase in diagnoses may partially reflect an increased awareness and likelihood that children are screened for these conditions.^34,35 Moreover, for disorders such as autism, the increase in diagnoses may be partially explained by changes in Medicaid reimbursement policies and covered services for these conditions,^36,37 which may have also influenced the detection of these disorders.

Conversely, decreases were observed in the percentage of publicly insured children diagnosed with bipolar disorder and/or schizophrenia. These trends may be linked, in part, to changes in the diagnostic criteria in the DSM-5 in 2013²⁵ and/or the 2015 transition from the ICD-9 to ICD-10 coding system.³⁸ For example, the decrease in bipolar disorder diagnoses may have been partially related to the introduction of disruptive mood dysregulation disorder (DMDD; F34.81) into the DSM-5^39,40 to address concerns about overdiagnosis of bipolar disorder in children.^41,42,43 Additionally, the observed increase in the category of “other mental health disorders” after 2014 may reflect the addition of DMDD and the 2015 transition from the ICD-9 to ICD-10 coding system, which reclassified some of the original bipolar and schizophrenia codes into unspecified mood disorders.

Although the overall increasing trend in mental health and/or neurodevelopmental disorder diagnosis was observed among every demographic group, it was notable that White children had the second highest rate of diagnosis in 2010 (behind multiracial children), and the largest absolute increase in the likelihood of having a diagnosis during the study period. The lower diagnosis rates observed among other racially and ethnically minoritized groups in the study data align with prior research highlighting disparities in access⁴⁴ and may reflect barriers to care, such as greater stigma associated with seeking diagnosis and treatment⁴⁵ and/or greater fear or mistrust of the mental health system⁴⁶ compared with White families. At the systems level, prior research has documented less geographic availability of mental health services in communities with a higher percentage of racially and ethnically minoritized residents.^47,48

The significant increase in the diagnosis of mental health and neurodevelopmental disorders has important implications for the health care delivery systems that serve publicly insured children. The increases in the number and percentage of publicly insured children who received 1 or more of these diagnoses may signify increasing need for appropriate services. Higher need combined with documented gaps in access to outpatient and inpatient care,^48,49 shortages of mental health professionals,⁵⁰ and declining psychiatrist participation in Medicaid⁵¹ may contribute to the adverse outcomes observed in recent studies, including increasing percentages of mental health–related emergency department visits,⁹ duration of boarding in emergency departments,⁵² and increasing mental health–related hospitalizations.¹⁰

Limitations

This study has limitations. First, administrative claims data may include data entry errors.⁵³ Second, this study was not able to validate diagnoses in a subset of participants via chart review or other means. The reliance on health care professional diagnoses may introduce inaccuracies due to misdiagnosis, overdiagnosis, or underdiagnosis of these disorders; moreover, coding practices may be influenced by reimbursement requirements.^54,55,56 Third, data quality can vary across states and years, including the reporting of diagnoses, procedures, and race and ethnicity. To address this limitation, our primary analysis used data from a subset of states with higher data quality on these measures. Fourth, the basis of Medicaid eligibility is an important variable to consider when examining trends in diagnoses, yet challenges with missing data during the transition from MAX to TAF precluded its inclusion in these analyses. Fifth, trends were examined through 2019, and it will be important to monitor these trends following the onset of the COVID-19 pandemic. Despite these limitations, this study provides the most comprehensive examination of trends in mental health and neurodevelopmental diagnoses among publicly insured children to date, using multistate administrative claims data.

Conclusions

The percentage of publicly insured children who received any mental health or neurodevelopmental disorder diagnosis significantly increased between 2010 and 2019, with increases observed for most diagnoses and all demographic groups. These findings highlight the need for appropriate services in safety net systems and other settings that serve this population.

Supplement 1.

eTable 1. List of ICD codes used to classify mental health and neurodevelopmental disorders

eTable 2. Characteristics of child-year observations, publicly insured children aged 3 to 13 years

eTable 3. Sample characteristics for each mental health and/or neurodevelopmental disorders diagnostic category (2010-2019)

eTable 4. Unadjusted percentage of publicly insured children with any mental health and/or neurodevelopmental disorder by demographic characteristics (2010, 2013, 2016, & 2019)

eTable 5. Results from stratified logistic regressions estimating changes in the percentage of publicly insured children diagnosed with any mental health and/or neurodevelopmental disorders, by demographic subgroups

eFigure 1. Sample derivation flowchart

eFigure 2. Trends in the percentage of publicly insured children with mental health and/or neurodevelopmental disorders from 42 states

eFigure 3. Trends in the percentage of publicly insured children with any mental health and/or neurodevelopmental disorder from 42 states, by demographic characteristics

eMethods. Additional Details on Statistical Methods

jama-e254605-s001.pdf^{(429.4KB, pdf)}

Supplement 2.

Data Sharing Statement

jama-e254605-s002.pdf^{(130.5KB, pdf)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 1. List of ICD codes used to classify mental health and neurodevelopmental disorders

eTable 2. Characteristics of child-year observations, publicly insured children aged 3 to 13 years

eTable 3. Sample characteristics for each mental health and/or neurodevelopmental disorders diagnostic category (2010-2019)

eTable 4. Unadjusted percentage of publicly insured children with any mental health and/or neurodevelopmental disorder by demographic characteristics (2010, 2013, 2016, & 2019)

eFigure 1. Sample derivation flowchart

eFigure 2. Trends in the percentage of publicly insured children with mental health and/or neurodevelopmental disorders from 42 states

eFigure 3. Trends in the percentage of publicly insured children with any mental health and/or neurodevelopmental disorder from 42 states, by demographic characteristics

eMethods. Additional Details on Statistical Methods

jama-e254605-s001.pdf^{(429.4KB, pdf)}

Supplement 2.

Data Sharing Statement

jama-e254605-s002.pdf^{(130.5KB, pdf)}

[joi250020r1] 1.Centers for Disease Control and Prevention . YRBS data summary & trends report: 2023. August 6, 2024. Accessed March 20, 2025. https://www.cdc.gov/yrbs/dstr/index.html

[joi250020r2] 2.Abrams Z. Kids’ mental health is in crisis: here’s what psychologists are doing to help. American Psychological Association . January 1, 2023. Accessed March 20, 2025. https://www.apa.org/monitor/2023/01/trends-improving-youth-mental-health

[joi250020r3] 3.Leeb RT, Danielson ML, Claussen AH, et al. Trends in mental, behavioral, and developmental disorders among children and adolescents in the US, 2016-2021. Prev Chronic Dis. 2024;21:E96. doi: 10.5888/pcd21.240142 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi250020r4] 4.Theberath M, Bauer D, Chen W, et al. Effects of COVID-19 pandemic on mental health of children and adolescents: a systematic review of survey studies. SAGE Open Med. 2022;10:20503121221086712. doi: 10.1177/20503121221086712 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi250020r5] 5.Abramson A. Children’s mental health is in crisis. American Psychological Association . January 1, 2022. Accessed March 20, 2025. https://www.apa.org/monitor/2022/01/special-childrens-mental-health

[joi250020r6] 6.Bitsko RH, Claussen AH, Lichstein J, et al. Mental health surveillance among children—United States, 2013-2019. MMWR Suppl. 2022;71(2):1-42. doi: 10.15585/mmwr.su7102a1 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi250020r7] 7.Parodi KB, Holt MK, Green JG, Porche MV, Koenig B, Xuan Z. Time trends and disparities in anxiety among adolescents, 2012-2018. Soc Psychiatry Psychiatr Epidemiol. 2022;57(1):127-137. doi: 10.1007/s00127-021-02122-9 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi250020r8] 8.Daly M. Prevalence of depression among adolescents in the U.S. from 2009 to 2019: analysis of trends by sex, race/ethnicity, and income. J Adolesc Health. 2022;70(3):496-499. doi: 10.1016/j.jadohealth.2021.08.026 [DOI] [PubMed] [Google Scholar]

[joi250020r9] 9.Bommersbach TJ, McKean AJ, Olfson M, Rhee TG. National trends in mental health–related emergency department visits among youth, 2011-2020. JAMA. 2023;329(17):1469-1477. doi: 10.1001/jama.2023.4809 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi250020r10] 10.Arakelyan M, Freyleue S, Avula D, McLaren JL, O’Malley AJ, Leyenaar JK. Pediatric mental health hospitalizations at acute care hospitals in the US, 2009-2019. JAMA. 2023;329(12):1000-1011. doi: 10.1001/jama.2023.1992 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi250020r11] 11.American Academy of Pediatrics . AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. Updated October 19, 2021. Accessed March 20, 2025. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/

[joi250020r12] 12.US Department of Health and Human Services . Protecting youth mental health: the US Surgeon General’s advisory. 2021. Accessed March 20, 2025. https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf [PubMed]

[joi250020r13] 13.Benson C. US poverty rate varies by age groups. United States Census Bureau . December 4, 2023. Accessed March 20, 2025. https://www.census.gov/library/stories/2023/12/poverty-rate-varies-by-age-groups.html

[joi250020r14] 14.McLeod JD, Shanahan MJ. Poverty, parenting, and children’s mental health. Am Sociol Rev. 1993;58(3):351. doi: 10.2307/2095905 [DOI] [Google Scholar]

[joi250020r15] 15.Mcleod JD, Shanahan MJ. Trajectories of poverty and children’s mental health. J Health Soc Behav. 1996;37(3):207-220. doi: 10.2307/2137292 [DOI] [PubMed] [Google Scholar]

[joi250020r16] 16.KFF . Health insurance coverage of children 0-18. 2024. Accessed March 20, 2025. https://www.kff.org/other/state-indicator/children-0-18/

[joi250020r17] 17.Cornachione E, Rudowitz R, Artiga S. Children’s health coverage: the role of Medicaid and CHIP and issues for the future. KFF . June 27, 2016. Accessed October 4, 2024. https://www.kff.org/report-section/childrens-health-coverage-the-role-of-medicaid-and-chip-and-issues-for-the-future-issue-brief/

[joi250020r18] 18.Hoagwood KE, Kelleher K, Zima BT, Perrin JM, Bilder S, Crystal S. Ten-year trends in treatment services for children with attention deficit hyperactivity disorder enrolled in Medicaid. Health Aff (Millwood). 2016;35(7):1266-1270. doi: 10.1377/hlthaff.2015.1423 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi250020r19] 19.Park C. Update on Transformed Medicaid Statistical Information System (T-MSIS). Medicaid and CHIP Payment and Access Commission . October 31, 2019. Accessed March 20, 2025. https://www.macpac.gov/wp-content/uploads/2019/11/Update-on-Transformed-Medicaid-Statistical-Information-System-T-MSIS.pdf

[joi250020r20] 20.Health Resources and Services Administration, US Department of Health and Human Services . Area health resources files. Updated November 8, 2024. Accessed March 20, 2025. https://data.hrsa.gov/topics/health-workforce/ahrf

[joi250020r21] 21.US Department of Agriculture, Economic Research Service . Rural-Urban Continuum Codes. Updated January 7, 2025. Accessed March 20, 2025. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes

[joi250020r22] 22.Centers for Medicare & Medicaid Services . DQ Atlas. Accessed March 20, 2025. https://www.medicaid.gov/dq-atlas/welcome

[joi250020r23] 23.Saunders H, Chidambaram P. Medicaid administrative data: challenges with race, ethnicity, and other demographic variables. KFF . April 28, 2022. Accessed March 20, 2025. https://www.kff.org/medicaid/issue-brief/medicaid-administrative-data-challenges-with-race-ethnicity-and-other-demographic-variables/

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PERMALINK

Trends in Mental Health Diagnoses Among Publicly Insured Children

Janet R Cummings, PhD

Xin Hu, PhD

Jordan Marchak, PhD

Cristian Ramos, MPH

Ilana Graetz, PhD

Xu Ji, PhD

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposure

Main Outcomes

Results

Conclusions and Relevance

Introduction

Methods

Data

Analytic Sample

Measures

Analyses

Results

Table 1. Characteristics of Child-Year Observations, Publicly Insured Children Aged 3 to 17 Yearsa.

Trends in Diagnoses

Figure 1. Trends in the Percentage of Publicly Insured Children Who Received a Mental Health or Neurodevelopmental Disorder Diagnosis, 2010-2019.

Table 2. Percentage of Publicly Insured Children Aged 3 to 17 Years Diagnosed With Mental Health or Neurodevelopmental Disordersa.

Table 3. Changes in the Percentage of Publicly Insured Children Aged 3 to 17 Years Diagnosed With Mental Health or Neurodevelopmental Disorders After Adjustment for Covariatesa.

Analyses by Demographic Groups

Figure 2. Trends in the Percentage of Publicly Insured Children Who Received Any Mental Health or Neurodevelopmental Disorder Diagnosis From 2010 to 2019, by Demographic Characteristics.

Sensitivity Analyses

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Table 1. Characteristics of Child-Year Observations, Publicly Insured Children Aged 3 to 17 Years^a.

Table 2. Percentage of Publicly Insured Children Aged 3 to 17 Years Diagnosed With Mental Health or Neurodevelopmental Disorders^a.

Table 3. Changes in the Percentage of Publicly Insured Children Aged 3 to 17 Years Diagnosed With Mental Health or Neurodevelopmental Disorders After Adjustment for Covariates^a.