Research

JAMA Psychiatry | Original Investigation

Incidence Rates and Cumulative Incidences of the Full Spectrum

of Diagnosed Mental Disorders in Childhood and Adolescence
Søren Dalsgaard, MD, PhD; Erla Thorsteinsson, MSc; Betina B. Trabjerg, MSc; Jörg Schullehner, PhD;
Oleguer Plana-Ripoll, PhD; Isabell Brikell, PhD; Theresa Wimberley, PhD; Malene Thygesen, MA;
Kathrine Bang Madsen, PhD; Allan Timmerman, PhD; Diana Schendel, PhD; John J. McGrath, PhD;
Preben Bo Mortensen, DrMedSc; Carsten B. Pedersen, DrMedSc

Supplemental content
IMPORTANCE Knowledge about the epidemiology of mental disorders in children and
adolescents is essential for research and planning of health services. Surveys can provide
prevalence rates, whereas population-based registers are instrumental to obtain precise
estimates of incidence rates and risks.
OBJECTIVE To estimate age- and sex-specific incidence rates and risks of being diagnosed
with any mental disorder during childhood and adolescence.

DESIGN This cohort study included all individuals born in Denmark from January 1, 1995,
through December 31, 2016 (1.3 million), and followed up from birth until December 31, 2016,
or the date of death, emigration, disappearance, or diagnosis of 1 of the mental disorders
examined (14.4 million person-years of follow-up). Data were analyzed from September 14,
2018, through June 11, 2019.

EXPOSURES Age and sex.

MAIN OUTCOMES AND MEASURES Incidence rates and cumulative incidences of all mental
disorders according to the ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic
Criteria for Research, diagnosed before 18 years of age during the study period.

RESULTS A total of 99 926 individuals (15.01%; 95% CI, 14.98%-15.17%), including 41 350 girls
(14.63%; 95% CI, 14.48%-14.77%) and 58 576 boys (15.51%; 95% CI, 15.18%-15.84%), were
diagnosed with a mental disorder before 18 years of age. Anxiety disorder was the most
common diagnosis in girls (7.85%; 95% CI, 7.74%-7.97%); attention-deficit/hyperactivity
disorder (ADHD) was the most common in boys (5.90%; 95% CI, 5.76%-6.03%). Girls had
a higher risk than boys of schizophrenia (0.76% [95% CI, 0.72%-0.80%] vs 0.48% [95% CI,
0.39%-0.59%]), obsessive-compulsive disorder (0.96% [95% CI, 0.92%-1.00%] vs 0.63%
[95% CI, 0.56%-0.72%]), and mood disorders (2.54% [95% CI, 2.47%-2.61%] vs 1.10% [95%
CI, 0.84%-1.21%]). Incidence peaked earlier in boys than girls in ADHD (8 vs 17 years of age),
intellectual disability (5 vs 14 years of age), and other developmental disorders (5 vs 16 years
of age). The overall risk of being diagnosed with a mental disorder before 6 years of age was
2.13% (95% CI, 2.11%-2.16%) and was higher in boys (2.78% [95% CI, 2.44%-3.15%]) than in
girls (1.45% [95% CI, 1.42%-1.49%]).

CONCLUSIONS AND RELEVANCE This nationwide population-based cohort study provides a

first comprehensive assessment of the incidence and risks of mental disorders in childhood
and adolescence. By 18 years of age, 15.01% of children and adolescents in this study were
diagnosed with a mental disorder. The incidence of several neurodevelopmental disorders
peaked in late adolescence in girls, suggesting possible delayed detection. The distinct
signatures of the different mental disorders with respect to sex and age may have important
implications for service planning and etiological research.
Author Affiliations: Author
affiliations are listed at the end of this
article.
Corresponding Author: Søren
Dalsgaard, MD, PhD, National Centre
for Register-Based Research,
Department of Economics and
Business Economics, Aarhus
University, Fuglesangs Allé 26,
JAMA Psychiatry. 2020;77(2):155-164. doi:10.1001/jamapsychiatry.2019.3523 Bldg R, 8210 Aarhus V, Denmark
Published online November 20, 2019. ([email protected]).

(Reprinted) 155
© 2019 American Medical Association. All rights reserved.
 Research Original Investigation Incidence Rates of Diagnosed Mental Disorders in Childhood and Adolescence

S
ince 1990, studies on the global burden of disease have
continuously ranked mental disorders as some of the Key Points
most impairing conditions worldwide.1,2 The Global Bur-
Question What are the age- and sex-specific incidence rates and
den of Disease studies recently reported that in children and cumulative incidences of the full spectrum of diagnosed mental
adolescents, mental disorders account for the most years lived disorders during childhood and adolescence?
with disability.3 The World Health Organization emphasized
Findings In this nationwide cohort study of 1.3 million individuals
in their Mental Health Action Plan 2013-2020 the strong need
in Denmark, the risk (cumulative incidence) of being diagnosed
for age- and sex-specific data on child mental health.4 The with a mental disorder before 18 years of age was 14.63% in girls
United States and Australia have good survey data, but only and 15.51% in boys. Distinct age- and sex-specific patterns of
7% of all countries worldwide have such data,5 and in 2013, occurrence were found across mental disorders in children and
none of 29 member states in the European Union could pro- adolescents.
vide data on incidence of mental disorders in children or Meaning These findings suggest that precise estimates of rates
adolescents.6 and risks of all mental disorders during childhood and adolescence
Knowledge of the age-specific risks of mental disorders are essential for future planning of services and care and for
forms the backbone for public health decisions, prioritiza- etiological research.
tion of resources, evidence-based medicine, and research on
risk factors and outcomes. Occurrence of a condition in a popu-
lation is measured as prevalence (cases at a specific point) or required for register-based studies. This study followed the
incidence (new cases per unit of time). The cumulative inci- Strengthening the Reporting of Observational Studies in
dence estimates the risk of developing the condition before a Epidemiology (STROBE) reporting guideline.
specified age, taking into consideration individual follow-up
time.7 Estimates of the prevalence of mental health disorders Assessment of Mental Illness
in childhood are often based on information from adoles- The Danish Psychiatric Central Research Register and the Dan-
cents or parents and are thus prone to recall, information, and ish National Patient Register provided data on diagnosed men-
survival biases. tal disorders for all individuals within the study population.31
In adults, health registry data have made important con- These registers include nationwide data on all hospital con-
tributions to our understanding of the incidence of the full tacts (inpatient, outpatient, and emergency ward visits) from
spectrum of mental disorders8 and their risk factors and 1995 onward. In Denmark, hospital treatment is free of charge,
outcomes.9-13 In children and adolescents, similar methods all visits are registered, and diagnoses of mental disorders
have been informative about the frequency of a few certain are made according the ICD-10 Classification of Mental and
mental disorders14-16 and their comorbidities,17 risk factors,18-20 Behavioral Disorders: Diagnostic Criteria for Research (ICD-10-
and outcomes.21-24 These findings have been supplemented DCR), since 1994.32 The ICD-10-DCR codes of the categories
by prevalence estimates from surveys, most often at a single of disorders are shown in Table 1, and observation time, strati-
point25-27 and sometimes with repeated assessments.28,29 fied by sex, is presented in eTable 1 in the Supplement. Indi-
Hence, surveys estimating prevalence rates and registry stud- viduals with more than 1 disorder were included in the
ies estimating incidence rates of diagnoses complement each numerator for each specific disorder. Age at diagnosis was de-
other and each have their own limitations. fined as the first day of the first contact, given the diagnosis
Nevertheless, evidence on the incidence of the full spec- of interest.
trum of mental disorders in children and adolescents is lack-
ing. The objective of this study was to estimate the incidence Study Design
rates and cumulative incidences of any diagnosed mental dis- In this nationwide cohort study, all included children were fol-
order and 27 specific categories of diagnosed mental disor- lowed up from birth. Follow-up was terminated at the date of
ders during childhood and adolescence, with age- and sex- the first diagnosis of the disorder (for each disorder sepa-
specific estimates, in a nationwide cohort in Denmark. rately), death, emigration from Denmark, or December 31, 2016,
whichever came first. Ignoring censoring from emigration
and/or death would have biased the incidence rates toward
underestimation and the cumulative incidences toward
Methods overestimation.33 Competing risk is present when the failure
Study Population event may be one of several distinct failure types, in this case
The Danish Civil Registration System,30 established in 1968, date of onset, death, disappearance, or emigration.
holds data on the personal identification number, sex, date of
birth, and continuously updated information on vital status Statistical Analysis
of all persons in Denmark. This enables accurate linkage of in- Data were analyzed from September 14, 2018, through June
dividual-level data across all registers and prevents duplica- 11, 2019. We estimated sex- and age-specific incidence rates
tion of prior events. Our study population included all live- (incident cases per 10 000 person-years) and cumulative in-
born singletons born in Denmark from January 1, 1995, through cidences (probability per 100 persons in the population diag-
December 31, 2016. This study was approved by the Danish Data nosed before a given age) of any psychiatric disorder (ICD-10-
Protection Agency. By Danish law, informed consent is not DCR codes F00-F99) and each of the separate mental disorders

156 JAMA Psychiatry February 2020 Volume 77, Number 2 (Reprinted) jamapsychiatry.com

© 2019 American Medical Association. All rights reserved.

Incidence Rates of Diagnosed Mental Disorders in Childhood and Adolescence Original Investigation Research

before 6, 13, and 18 years of age. We refer to cumulative inci-

Table 1. Diagnostic Classification of Mental Disorders
dence as the risk of a disorder. In Figures 1, 2, and 3, inci- According to the ICD-10-DCR and the Number
dence rates are shown in 1-year age intervals (or expanded in- of New Cases During Follow-up of the Cohorta
tervals including >10 cases). In a sensitivity analysis, we
No. of Incident Cases
estimated the cumulative incidences at 13 years of age, includ- ICD-10-DCR With Mental Disorders
Diagnostic Group Code During Follow-upb
ing only individuals born from 1995 through 2003 for whom
Any mental disorder F00-99 99 926
complete follow-up data were available to examine possible
Organic mental disorders F00-09 413
cohort effects.34
Substance use disorders F10-19 6122
We used the GENMOD procedure in SAS software, release
Alcohol abuse F10 3951
9.4 (SAS Institute, Inc),35 to perform a Poisson regression analy-
Cannabis use F12 1323
sis with the logarithm of person-years as an offset and to pro-
Schizophrenia F20-29 2678
duce likelihood ratio–based incidence rates, 95% CIs, and spectrum disorder
2-sided P values at a significance level of .05. This level is Schizophrenia F20 610
equivalent to a Cox proportional hazards regression under the Acute psychoses F23 620
assumption of piecewise constant incidence rates. The cumu- Mood disorders F30-39 7396
lative incidence was estimated in the presence of competing Bipolar disorder F30-31 314
risk using the SAS-macro comprisk.36 Depressive episode F32-33 6940
Anxiety disorders F40-48 plus F93 33 541
OCD F42 4359
Results Eating disorders F50 5429
Anorexia nervosa F50.0 1649
The study population consisted of 1.3 million children born in
Bulimia F50.2 291
Denmark from 1995 through 2016 and was followed up until
Personality disorders F60-69 2631
December 31, 2016, resulting in 14 million person-years of ob-
Intellectual disability F7 9236
servation. In total, 99 926 individuals (41 350 girls and 58 576
Other developmental F80-83 15 493
boys) had a diagnosis of a mental disorder before 18 years of disorders
age. Among the overall study population, 2.7% were cen- Autism spectrum F84.x excluding 21 602
sored before the end of follow-up owing to death (n = 4962), disorders F84.2-F84.4
Childhood autism F84.0 7844
disappearance (n = 515), and emigration from Denmark
Asperger syndrome F84.5 5074
(n = 31 019).
ADHD F90.0 plus F98.8 30 776
Combined type F90 26 285
Risks of Mental Disorders by 18 Years of Age
The risk of being diagnosed with any mental disorder before 18 Inattentive type F98.8 5973

years of age was 15.01% (95% CI, 14.98%-15.17%) in all individu- ODD/CD F91 plus F90.1 6094

als, 14.63% (95% CI, 14.48%-14.77%) in girls, and 15.51% (95% Attachment disorders F94.x excluding F94.0 4518
CI, 15.18%-15.84%) in boys (Table 2). The disorder with the high- Tic disorders F95 6793
est cumulative incidence by 18 years of age in girls was anxiety Abbreviations: ADHD, attention-deficit/hyperactivity disorder; ICD-10-DCR,
disorder (7.85%; 95% CI, 7.74%-7.97%); in boys, attention-deficit/ ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for
Research; OCD, obsessive-compulsive disorder; ODD/CD, oppositional defiant
hyperactivity disorder (ADHD) (5.90%; 95% CI, 5.76%-6.03%).
disorder/conduct disorder.
Figures 1 through 3 and eFigures 1 through 4 in the Supplement a
Participants were born in Denmark from January 1, 1995, through December
show the age-specific incidence rates and cumulative inci- 31, 2016, and followed up until 18 years of age or date of death, emigration, or
dences for any mental disorder and each of the specific mental December 31, 2016, whichever came first.
disorders investigated for boys and girls separately. b
Individuals with more than 1 disorder were included in the numerator for each
of the separate disorders.

Sex Differences
The incidence rate of schizophrenia spectrum disorders 1.86%] vs 0.28% [95% CI, 0.19%-0.41%]) (Figure 2B), and per-
(Figure 1B) was low before 13 years of age, after which it in- sonality disorders (1.05% [95% CI, 1.00%-1.10%] vs 0.30% [95%
creased in girls and boys. By 18 years of age, the cumulative CI, 0.18%-0.49%]) (eFigure 3C in the Supplement). In most of
incidence was higher in girls (0.76%; 95% CI, 0.72%-0.80%) these individuals, incidence peaked in late adolescence (ap-
than in boys (0.48%; 95% CI, 0.39%-0.59%). Similar patterns proximately at 17-18 years of age).
showing higher risks in girls were found for mood disorders Compared with girls, boys had higher risks of intellectual
(2.54% [95% CI, 2.47%-2.61%] vs 1.10% [95% CI, 0.84%- disability (1.52% [95% CI, 1.46%-1.59%] vs 0.88% [95% CI,
1.21%) (Figure 1C), depression (2.41% [95% CI, 2.34%-2.48%] 0.85%-0.92%]), autism spectrum disorders (ASD) (4.26% [95%
vs 0.92% [95% CI, 0.76%-1.12%]) (Table 2), anxiety disorders CI, 4.16%-4.36%] vs 1.77% [95% CI, 1.72%-1.82%]), other de-
(7.85% [95% CI, 7.74%-7.97%] vs 4.58% [95% CI, 4.33%- velopmental disorders (2.74% [95% CI, 2.67%-2.81%] vs 1.41%
4.84%]) (Figure 1D), obsessive-compulsive disorder (OCD) [95% CI, 1.37%-1.46%]), ADHD (5.90% [95% CI, 5.76%-
(0.96% [95% CI, 0.92%-1.00%] vs 0.63% [95% CI, 0.56%- 6.03%] vs 3.04% [95% CI, 2.97%-3.11%]), oppositional
0.72%]) (Figure 2A), eating disorders (1.80% [95% CI, 1.74%- defiant disorder/conduct disorder (ODD/CD) (1.28% [95% CI,

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 Research Original Investigation Incidence Rates of Diagnosed Mental Disorders in Childhood and Adolescence

Figure 1. Sex- and Age-Specific Incidence Rates and Cumulative Incidences for Any Mental Disorder,
Schizophrenia Spectrum Disorder, Mood Disorders, and Anxiety Disorder

A Any mental disorder B Schizophrenia spectrum

300 30 0.8
Incidence Rate per 10 000 Person-Years

Incidence Rate per 10 000 Person-Years

Cumulative Incidence per 100 Persons

Cumulative Incidence per 100 Persons

15 Incidence rate
Girls 0.7
Boys
0.6
Cumulative incidence
200 20
10 Girls 0.5
Boys
0.4
Any mental disorder was identified
0.3 as ICD-10 Classification of Mental and
100 5 10
0.2
Behavioral Disorders: Diagnostic
Criteria for Research (ICD-10-DCR),
0.1 codes F00 to F99; schizophrenia
0 0 0 0 spectrum disorder, as ICD-10-DCR
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
codes F20 to F29; mood disorders,
as ICD-10-DCR codes F30 to F39; and
Age, y Age, y
anxiety disorder, as ICD-10-DCR codes
F40 to F48 and F93. Error bars show
C Mood disorders D Anxiety disorder the 95% CIs in designated age
80 160 8
ranges. Owing to the large sample
Incidence Rate per 10 000 Person-Years

Incidence Rate per 10 000 Person-Years

Cumulative Incidence per 100 Persons

Cumulative Incidence per 100 Persons

3 size, the 95% CIs for the cumulative
70 140 7 incidences are very close to the
60 120 6 estimates and are therefore not
shown. Because the cumulative
50 2 100 5
incidences are estimated
40 80 4 continuously with respect to age and
the incidence rates are estimated in
30 60 3
1 1-year age intervals, the abscissa for
20 40 2 the cumulative incidence measures
10 20 1 the exact age, whereas the abscissa
for the incidence rates measures the
0 0 0 0 lowest cutoff point for the age
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18 interval. The y-axis scales differ by
Age, y Age, y disorder to correspond to the range
of observed outcomes.

1.23%-1.33%] vs 0.46% [95% CI, 0.44%-0.49%]), attachment [95% CI, 0.13%-0.67%] and 2.17% [95% CI, 1.93%-2.44%], re-
disorders (0.71% [95% CI, 0.66%-0.75%] vs 0.52% [95% CI, spectively) than in girls (0.27% [95% CI, 0.26%-0.29%] and
0.49%-0.54%]), and tic disorders (1.36% [95% CI, 1.32%- 1.88% [95% CI, 1.83%-1.92%], respectively). However, by 18
1.41%] vs 0.42% [95% CI, 0.40%-0.45%]) (Table 2). For boys, years of age, the pattern was reversed, with a higher risk of anxi-
the ASD incidence sharply increased from birth to peak at 4 ety disorders in girls (7.85%; 95% CI, 7.74%-7.97%) than in boys
years of age, after which it was almost constant until 15 years (4.58%; 95% CI, 4.33%-4.84%).
of age, when it declined (Figure 2D). For girls, the ASD inci-
dence was low until 10 years of age, then increased and peaked Sensitivity Analyses
in early adolescence. In ADHD (Figure 3A), the incidence in boys When including only individuals with complete follow-up data
increased steadily until it peaked at 8 years of age, then steadily available, the estimated cumulative incidence of mental dis-
declined, whereas the incidence in girls was almost constant orders tended to be lower than in our main analyses (eTable 4
from 7 to 12 years of age, after which it increased to peak at 17 in the Supplement). In girls, risks were lower for 8 of the 27
years of age, where the incidence of ADHD in girls was higher mental disorders investigated; in boys, risks were lower for 5
than in boys. Similar patterns with a late adolescent peak in of the disorders. For girls and boys, the largest difference from
girls (but not in boys) were seen in ODD/CD (Figure 3C), other our main analyses was seen in the cumulative incidence of
developmental disorders (eFigure 3D in the Supplement), and childhood autism (sensitivity analysis, 0.20% [95% CI, 0.19%-
attachment disorders (eFigure 4D in the Supplement). 0.22%] in girls and 0.85% [95% CI, 0.80%-0.89%] in boys; main
analysis, 0.44% [95% CI, 0.42-0.46] in girls and 1.48% [95%
Risks of Mental Disorders by 6 and 13 Years of Age CI, 1.43%-1.53%] in boys).
The cumulative incidence of any mental disorder before 6 and
13 years of age was higher in boys (2.78% [95% CI, 2.44%-
3.15%] and 10.23% [95% CI, 9.90%-10.57%], respectively) than
in girls (1.45% [95% CI, 1.42%-1.49%] and 5.17% [95% CI, 5.10%-
Discussion
5.24%], respectively) (eTables 2 and 3 in the Supplement). Risk Worldwide, this nationwide study is the first, to our knowl-
in total of being diagnosed before 6 years of age was 2.13% (95% edge, of the incidence of the full spectrum of diagnosed
CI, 2.11%-2.16%) (eTable 3 in the Supplement). The risk of anxi- mental disorders in childhood and adolescence. Herein, we
ety disorders by 6 and 13 years of age was higher in boys (0.31% will discuss 4 key findings.

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Incidence Rates of Diagnosed Mental Disorders in Childhood and Adolescence Original Investigation Research

Figure 2. Sex- and Age-Specific Incidence Rates and Cumulative Incidences for Obsessive-Compulsive Disorder,
Eating Disorders, Intellectual Disability, and Autism Spectrum Disorders

A Obsessive-compulsive disorder B Eating disorders

16 1.0 40 1.8
Incidence Rate per 10 000 Person-Years

Incidence Rate per 10 000 Person-Years

Cumulative Incidence per 100 Persons

Cumulative Incidence per 100 Persons

Incidence rate
14 Girls 1.6
0.8 Boys 1.4
12 30
Cumulative incidence 1.2
10 0.6 Girls
Boys 1.0
8 20
0.8 Obsessive-compulsive disorder was
0.4
6 identified as ICD-10 Classification of
0.6
4 10
Mental and Behavioral Disorders:
0.2 0.4 Diagnostic Criteria for Research
2 0.2 (ICD-10-DCR), code F42; eating
0 0 0 0 disorders, as ICD-10-DCR code F50;
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
intellectual disability, as ICD-10-DCR
codes F70 to F79; and autism
Age, y Age, y
spectrum disorders, as ICD-10-DCR
codes F84.x, excluding F84.2 to
C Intellectual disability D Autism spectrum disorder F84.4. Error bars show the 95% CIs in
14 40 5
designated age ranges. Owing to the
Incidence Rate per 10 000 Person-Years

Incidence Rate per 10 000 Person-Years

Cumulative Incidence per 100 Persons

Cumulative Incidence per 100 Persons

1.5 large sample size, the 95% CIs for the
12 cumulative incidences are very close
4
30 to the estimates and are therefore
10 not shown. Because the cumulative
1.0 3 incidences are estimated
8 20 continuously with respect to age and
2 the incidence rates are estimated in
6 0.5 1-year age intervals, the abscissa for
10 the cumulative incidence measures
1
4 the exact age, whereas the abscissa
for the incidence rates measures the
2 0 0 0 lowest cutoff point for the age
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18 interval. The y-axis scales differ by
Age, y Age, y disorder to correspond to the range
of observed outcomes.

Risk of Mental Disorders set. Cumulative incidence of any mental disorders by 13 years
We found that 15.01% of all children and adolescents were of age was also higher in boys than in girls but equal between
diagnosed with a mental disorder before reaching 18 years of sexes by 18 years of age. These findings suggest a delayed de-
age, which is consistent with the overall prevalence of 13% to tection of mental disorders in girls. In support of this possi-
20% in US surveys26,37-40 and the estimated worldwide preva- bility, studies of time trends42,43 have found larger increases
lence of mental disorders in young people of 13.4%.41 The in the number of girls being diagnosed with ASD and ADHD
prevalence of anxiety disorders in US surveys was 4.4% in girls compared with the increase in the number of boys being di-
and 5.0% in boys (7.85% and 4.58%, respectively, in our agnosed. Further, compared with boys, girls have been found
study).40 Depression was more prevalent in the United States to be more likely to have undiagnosed ADHD.44
(3.7% in girls and 4.1% in boys)40 compared with our sample Previous studies on the incidence rates of OCD in chil-
(2.41% and 0.92%, respectively), especially in boys. Our study dren and adolescents have found no differences or mixed sex
is likely biased toward capture of the more severe cases with differences in occurrence45 or higher rates in boys.46,47 We
depression, whereas surveys in the US studies are often based found equal incidence rates before 10 years of age, after which
on retrospective information from the participating parents the incidence rate increased more in girls than in boys; by 18
(potentially leading to misclassification and recall and selec- years of age, the risk of OCD was higher in girls than boys. The
tion bias), and the methodological aspects may explain some incidence of OCD peaked in both sexes in early adolescence
of these differences. rather than in late adolescence, contrary to previous reports.45
For eating disorders48-50 and mood disorders,51 our findings
Sex Differences in Peaks in Incidence Rates on age at peak of incidences were consistent with previous
Although we obtained statistically significantly different es- studies.
timates of the risk of any mental disorder in girls and boys, these
rates were conceptually identical. Our study is the first, to our Sex Differences in the Risk of Selected Mental Disorders
knowledge, to report girls having later peaks in the incidence We found that girls were more likely to be diagnosed with
of ASD, ADHD, ODD/CD, other developmental disorders, and schizophrenia spectrum disorder (ie, early-onset), mood dis-
attachment disorders compared with boys. Indeed, most girls orders, anxiety disorders, OCD, eating disorders, and person-
with neurodevelopmental disorders were diagnosed during late ality disorders, and boys were more likely to be diagnosed with
adolescence despite these disorders having an early age of on- intellectual disability, ASD, other developmental disorders,

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 Research Original Investigation Incidence Rates of Diagnosed Mental Disorders in Childhood and Adolescence

Figure 3. Sex- and Age-Specific Incidence Rates and Cumulative Incidences for Attention-Deficit/Hyperactivity
Disorder (ADHD), ADHD-Inattentive Type, Oppositional Defiant Disorder/Conduct Disorder, and Tic Disorders

A Attention-deficit/hyperactivity disorder B ADHD-inattentive type

80 6 18 Incidence rate 1.1
Incidence Rate per 10 000 Person-Years

Incidence Rate per 10 000 Person-Years

Cumulative Incidence per 100 Persons

Cumulative Incidence per 100 Persons

16 Girls 1.0
70
5 Boys 0.9
60 14
Cumulative 0.8
4 12 incidence
50 0.7
Girls
10 0.6
40 3 Boys
8 0.5 ADHD was identified as ICD-10
30 0.4 Classification of Mental and
2 6
20 0.3 Behavioral Disorders: Diagnostic
4 Criteria for Research (ICD-10-DCR),
1 0.2
10 2 codes F90 and F98.8;
0.1
0 0 0 0 ADHD-inattentive type, as
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
ICD-10-DCR code F98.8; oppositional
defiant disorder/conduct disorder, as
Age, y Age, y
ICD-10-DCR codes F91 plus F90.1; and
tic disorders, as ICD-10-DCR code
C Oppositional defiant disorder/conduct disorder D Tic disorders F95. Error bars show the 95% CIs in
15 1.3 20 1.4
designated age ranges. Owing to the
Incidence Rate per 10 000 Person-Years

Incidence Rate per 10 000 Person-Years

Cumulative Incidence per 100 Persons

Cumulative Incidence per 100 Persons

1.2 large sample size, the 95% CIs for the
18
1.1 1.2 cumulative incidences are very close
16
1.0 to the estimates and are therefore
0.9 14 1.0
10 not shown. Because the cumulative
0.8 12 incidences are estimated
0.8
0.7
10 continuously with respect to age and
0.6
8 0.6 the incidence rates are estimated in
0.5
5 0.4 6 1-year age intervals, the abscissa for
0.4
0.3 the cumulative incidence measures
4
0.2 0.2 the exact age, whereas the abscissa
0.1 2
for the incidence rates measures the
0 0 0 0 lowest cutoff point for the age
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18 interval. The y-axis scales differ by
Age, y Age, y disorder to correspond to the range
of observed outcomes.

ADHD, ODD/CD, attachment disorders, and tic disorders. De- ders before 18 years of age, which contrasts with findings from
spite girls having a higher risk of anxiety disorder by 18 years studies of adults.8
of age, boys had a higher risk of anxiety disorders by 13 years
of age compared with girls, which has also, to our knowledge, Risk of Mental Disorders in Preschool Children
not previously been reported. In preschool children, the overall risk of being diagnosed with
Our finding of the female preponderance of early-onset a mental disorder was 2.78% in boys and 1.45% in girls (2.13%
schizophrenia spectrum disorder is novel. A meta-analysis of in total). Apart from a handful of studies related to tic
incident cases of schizophrenia52 found male preponderance disorders14 and ASD,14,42 our study, to our knowledge, pro-
in all age groups, including those with the first diagnosis vides the most detailed estimates for the risk of being diag-
before 20 years of age. Three other studies examining nosed with a broader range of mental disorder in children
changes in the incidence of schizophrenia53,54 and early- younger than 6 years of age.
onset schizophrenia55 over time have pointed toward sex dif-
ferences similar to those found in our study, with higher inci- Relevance
dence rates in girls than in boys in the youngest group. Another We believe the novelty of this report is the comprehensive es-
study56 has also found the mean age of onset of schizophrenia timates of risks of diagnosed mental disorders throughout
to be lower in girls compared with boys. Still, the sex differ- childhood and adolescence in a total nationwide population,
ence in risk of early-onset schizophrenia spectrum disorder and this adds new knowledge to the field of mental health. The
to date has not previously been estimated as accurately as in existing literature mainly reports prevalence rates in a popu-
our sample. lation alive at a certain point, only obtaining data on surviv-
To our knowledge, the incidences and risks of attach- ing individuals, thereby potentially missing data on those with
ment disorders and personality disorders in children and ado- the most severe psychopathologic diagnoses who did not sur-
lescents have not been previously reported. As in adults,57 we vive until start of the study. Surveys estimating lifetime preva-
found female preponderance in personality disorders. Very few lence rates retrospectively are also prone to recall bias and se-
individuals were diagnosed with personality disorder before lection bias, and the occurrence of episodic or remitting
13 years of age, which is in accordance with diagnostic classi- disorders may be underestimated in prevalence studies.
fications and international clinical guidelines.32,58,59 Finally, However, to fully understand the epidemiology of mental
we found no sex difference in the risk of substance use disor- disorders in children and adolescents, surveys on prevalence

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© 2019 American Medical Association. All rights reserved.

Incidence Rates of Diagnosed Mental Disorders in Childhood and Adolescence Original Investigation Research

Table 2. Cumulative Incidences of Diagnosed Mental Disorders in Childhood and Adolescence

in a Nationwide Cohorta

No. of Incident Cases Cumulative Incidence, % (95% CI)b

Diagnostic Group Girls Boys Girls Boys
Any mental disorderc 41 350 58 576 14.63 (14.48-14.77) 15.51 (15.18-15.84)
Organic mental disorders 179 234 0.07 (0.06-0.08) 0.07 (0.05-0.11)
Substance use disorders 2897 3225 1.53 (1.47-1.59) 1.63 (1.46-1.82)
Alcohol abuse 1874 2077 1.01 (0.96-1.06) 1.07 (0.94-1.22)
Cannabis use 558 765 0.31 (0.28-0.33) 0.42 (0.35-0.49)
Schizophrenia spectrum disorderd 1569 1109 0.76 (0.72-0.80) 0.48 (0.39-0.59)
Schizophrenia 360 250 0.19 (0.17-0.21) 0.12 (0.07-0.21)
Acute psychoses 346 274 0.16 (0.14-0.18) 0.12 (0.08-0.16)
Abbreviations:
Mood disordersd 5047 2349 2.54 (2.47-2.61) 1.01 (0.84-1.21)
ADHD, attention-deficit/
Bipolar disorder 185 129 0.10 (0.09-0.12) 0.06 (0.02-0.15) hyperactivity disorder;
Depressive episoded 4793 2147 2.41 (2.34-2.48) 0.92 (0.76-1.12) ICD-10-DCR, ICD-10 Classification
of Mental and Behavioral Disorders:
Anxiety disordersd 19 259 14 282 7.85 (7.74-7.97) 4.58 (4.33-4.84)
Diagnostic Criteria for Research;
d
OCD 2432 1927 0.96 (0.92-1.00) 0.63 (0.56-0.72) OCD, obsessive-compulsive disorder;
Eating disordersd 4297 1132 1.80 (1.74-1.86) 0.28 (0.19-0.41) ODD/CD, oppositional defiant
disorder/conduct disorder.
Anorexia nervosad 1506 143 0.68 (0.64-0.71) 0.05 (0.02-0.13) a
Participants were born in Denmark
Bulimiad 282 9 0.16 (0.14-0.18) 0.00 (0.00-1.67) from January 1, 1995, through
Personality disordersd 1982 649 1.05 (1.00-1.10) 0.30 (0.18-0.49) December 31, 2016, and followed up
until 18 years of age or date of
Intellectual disabilityc 3091 6145 0.88 (0.85-0.92) 1.52 (1.46-1.59)
death, emigration, or December 31,
Other developmental disordersc 4545 10 948 1.41 (1.37-1.46) 2.74 (2.67-2.81) 2016, whichever came first.
b
Autism spectrum disordersc 5354 16 248 1.77 (1.72-1.82) 4.26 (4.16-4.36) Measures the probability of being
Childhood autism 1600 6244 0.44 (0.42-0.46) 1.48 (1.43-1.53) treated for the disorder before
18 years of age. Individuals with
Asperger syndrome 1260 3814 0.50 (0.47-0.53) 1.14 (1.07-1.21) more than 1 disorder were included
ADHDc 8815 21 961 3.04 (2.97-3.11) 5.90 (5.76-6.03) in the numerator for each of the
separate disorders.
Combined typec 6995 19 290 2.35 (2.29-2.41) 5.13 (5.00-5.25)
c
Boys had a higher probability of
Inattentive typec 2311 3662 0.89 (0.85-0.93) 1.09 (1.02-1.15) being diagnosed with the disorder
ODD/CDc 1393 4701 0.46 (0.44-0.49) 1.28 (1.23-1.33) by 18 years of age than girls.
d
Attachment disordersc 1705 2813 0.52 (0.49-0.54) 0.71 (0.66-0.75) Girls had higher probability of being
c diagnosed with the disorder by
Tic disorders 1486 5307 0.42 (0.40-0.45) 1.36 (1.32-1.41)
18 years of age than boys.

rates and register-based studies on incidence rates are both ber states had a plan or strategy for child and adolescent
required. mental health.63 We believe the evidence presented in this
As such, with unprecedented comprehensiveness (cov- study of the patterns of distribution and probabilities of all
ering an entire nation) examining the broad diagnostic spec- diagnosed mental disorders across ages and sexes during
trum and reporting detailed sex- and age-specific patterns, childhood and adolescence may strengthen advocacy and
our study offers additional new knowledge on the occur- governance for child and adolescent mental health and form
rence of mental disorders in children and adolescents. Our an important platform to guide future policies on access to
estimates of incidence and risks would likely be broadly mental health care, planning of services, prioritizing of
representative of many high-income nations. Many of the resources in public health care, the promotion of human
presented findings, including our main finding of 15.01% rights of young people with mental disorders, and future
being diagnosed with a mental disorder at younger than 18 research on preventive measures, risk factors, course, and
years, concurs with estimates of prevalence rates obtained outcome of mental disorders in this age group.
in the previous surveys using the most rigorous methods.
Our findings may also be thought of as important compari- Strengths and Limitations
sons for studies evaluating prevalence rates of mental disor- This study has some strengths. The applied design has previ-
ders in children in low-income countries or living in situa- ously been used in a study of adults,8 and its main strength
tions of extreme circumstances, such as war, natural lies in the complete and nationwide data coverage during
disasters, or other humanitarian emergencies, all of which several decades and in the high quality of the diagnostic
may influence the occurrence of mental disorders in data, which is based on comprehensive clinical assessments
children.60-62 of all mental disorders by cross-disciplinary clinical teams,
According to the World Health Organization’s most including child and adolescent psychiatrists. Public health
recent Mental Health Atlas from 2017, only 18% of the mem- care in Denmark is free of charge, and monetary factors are

jamapsychiatry.com (Reprinted) JAMA Psychiatry February 2020 Volume 77, Number 2 161

© 2019 American Medical Association. All rights reserved.

 Research Original Investigation Incidence Rates of Diagnosed Mental Disorders in Childhood and Adolescence

thus less likely to affect the likelihood of receiving treatment tion may be lower. In Denmark, only licensed child and ado-
in our study compared with studies performed in other lescent psychiatrists (not general practitioners) are autho-
countries. rized to initiate pharmacological treatment of mental
However, the applied methods also have limitations. Our disorders in individuals younger than 18 years, as stipulated
study was not aimed at examining time trends, and, as in by the Danish health authorities.65-67 Finally, although some
other observational studies, our estimates may be biased by diagnoses have been validated in Danish registers (eg,
cohort effects.34 Our sensitivity analyses suggest slight over- schizophrenia, depression, mood disorder, ADHD, and child-
estimation of the risk of a few mental disorders in the main hood autism),68-75 not all of the diagnostic categories have
analysis. This overestimation may be related to higher inci- been validated, especially not in preschool children.
dence rates in younger cohorts and changes over time in
thresholds for referral, attitudes toward mental illness, avail-
able resources, and/or environmental risk factors. The risks
may also be underestimated because register-based studies
Conclusions
are unable to detect mental disorders for which the patients This population-based study provides, to our knowledge, a
or their families do not seek help (eg, “wait and see”). Fur- first comprehensive nationwide assessment of the incidence
ther, we did not include individuals with mental disorders and risks of all mental disorders in childhood and adoles-
diagnosed outside hospital departments (by psychiatrists in cence. For many mental disorders, we believe we have iden-
private practices). However, in Denmark, most children and tified age- and sex-specific patterns of occurrence that, to
adolescents assessed and treated for mental disorders our knowledge, have not been previously reported. The dis-
receive such care within public hospital departments. For tinct signatures of the different mental disorders with
instance, for ADHD, more than 86% of all cases are assessed respect to sex and age may have important implications for
in a hospital setting;64 for anxiety and depression, this frac- service planning and etiological research.

ARTICLE INFORMATION Statistical analysis: Thorsteinsson, Plana-Ripoll, approval of the manuscript; and decision to submit
Accepted for Publication: September 1, 2019. Wimberley, Pedersen. the manuscript for publication.
Obtained funding: Mortensen.
Published Online: November 20, 2019. Administrative, technical, or material support: REFERENCES
doi:10.1001/jamapsychiatry.2019.3523 Trabjerg, Madsen, Timmerman, Schendel, 1. Whiteford HA, Degenhardt L, Rehm J, et al.
Author Affiliations: The Lundbeck Foundation Mortensen, Pedersen. Global burden of disease attributable to mental and
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(iPSYCH), Aarhus, Denmark (Dalsgaard, Wimberley, Pedersen. Burden of Disease Study 2010. Lancet. 2013;382
Thorsteinsson, Trabjerg, Brikell, Wimberley, Conflict of Interest Disclosures: Dr Schullehner (9904):1575-1586. doi:10.1016/S0140-6736(13)
Thygesen, Madsen, Timmerman, Schendel, reported receiving grants from Aarhus University 61611-6
Mortensen, Pedersen); National Centre for Research Foundation during the conduct of the
Register-Based Research, Department of 2. Naghavi M, Abajobir AA, Abbafati C, et al;
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Economics and Business Economics, Aarhus the Lundbeck Foundation during the conduct of the
University, Aarhus, Denmark (Dalsgaard, regional, and national age-sex specific mortality for
study. No other disclosures were reported. 264 causes of death, 1980-2016: a systematic
Thorsteinsson, Trabjerg, Schullehner, Plana-Ripoll,
Brikell, Wimberley, Thygesen, Madsen, Funding/Support: This study was supported by analysis for the Global Burden of Disease Study
Timmerman, Schendel, McGrath, Mortensen, grants R102-A9118, R155-2014-1724, and 2016. Lancet. 2017;390(10100):1151-1210. doi:10.
Pedersen); Centre for Integrated Register-based R248-2017-2003 from the Lundbeck Foundation; 1016/S0140-6736(17)32152-9
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(Trabjerg, Thygesen, Timmerman, Mortensen, University Research Foundation (Dr Dalsgaard); (IHME). GBD Compare Data Visualization. Seattle,
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Greenland, Aarhus, Denmark (Schullehner); Foundation (Dr Dalsgaard); grant agreement No. https://vizhub.healthdata.org/gbd-compare.
Department of Public Health, Aarhus University, 667302 from the European Union’s Horizon 2020 Accessed June 1, 2018.
Aarhus, Denmark (Schendel); Queensland Centre Research and Innovation Programme (Dr Dalsgaard;
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for Mental Health Research, The Park Centre for Plan 2013-2020. Geneva, Switzerland: World Health
Mental Health, Wacol, Australia (McGrath); National Institutes of Health (Dr Dalsgaard); grant
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Queensland Brain Institute, University of
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Author Contributions: Ms Thorsteinsson and National Research Foundation (Dr McGrath); John children and adolescents. Epidemiol Psychiatr Sci.
Dr Pedersen had full access to all the data in the Cade Fellowship APP1056929 from National Health 2017;26(4):395-402. doi:10.1017/
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the data and the accuracy of the data analysis. Stanley Medical Research Institute (Drs Mortensen
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and Pedersen); advanced grant 294838 from the of Mental Health (EuroPoPP-MH); Institute of
Acquisition, analysis, or interpretation of data: European Research Council (Dr Pedersen); and
Dalsgaard, Thorsteinsson, Trabjerg, Schullehner, Mental Health. Mental Health Systems in the
Marie Sklodowska-Curie grant agreement 837180 European Union Member States, Status of Mental
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Thygesen, Madsen, Timmerman, Schendel, interpretation of the data; preparation, review, or pdf. Accessed October 24, 2019.
McGrath, Mortensen, Pedersen.

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