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Diagnoses of mental illness and neurodevelopmental disorders among publicly insured children in the United States rose significantly between 2010 and 2019, with the sharpest increases in attention-deficit/hyperactivity disorder (ADHD), anxiety, trauma-related disorders, and autism spectrum disorders (ASDs), new data showed.

The higher need — coupled with documented gaps in access to care, shortages of mental health professionals, and declining psychiatrist participation in Medicaid — may contribute to the adverse outcomes observed in recent studies, including more mental health–related emergency department visits and hospitalizations, investigators noted.

“The significant increase in the diagnosis of mental health and neurodevelopmental disorders has important implications for the healthcare delivery systems that serve publicly insured children,” lead investigator Janet R. Cummings, PhD, with Rollins School of Public Health, Emory University, Atlanta, and colleagues wrote.

The study was published online on April 24 in JAMA.

Data Gap

In the United States, 16% of children live in poverty, which puts them at a higher risk for mental health and neurodevelopmental disorders. A lack of data on trends in mental health diagnoses among children covered by public insurance, such as Medicaid and the Children’s Health Insurance Program (CHIP), prompted researchers to launch a study to fill the gap.

Cummings and colleagues analyzed administrative claims data from 2010 to 2019 in 22 states, including over 129 million child-year observations (nearly 30 million unique children) covered by public insurance.

They found that the percentage of publicly insured children diagnosed with any mental health or neurodevelopmental disorder rose from 10.7% in 2010 to 16.5% in 2019. This change remained significant after adjustment for covariates.

Statistically significant increases were seen in 9 of 13 diagnostic categories — with the largest absolute increases observed for ADHD, trauma- and stressor-related disorders, anxiety disorders, ASDs, depressive disorders, and other neurodevelopmental disorders.

The percentage of children with more than one diagnosis also increased substantially.

Diagnoses of bipolar disorder and schizophrenia declined, potentially reflecting changes in diagnostic criteria and/or the coding system, the study team said.

“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 investigators reported.

The lower diagnosis rates among other race and ethnic minority groups vs White families align with prior research highlighting disparities in access and may reflect barriers to care, such as greater stigma associated with seeking diagnosis and treatment and/or greater fear or mistrust of the mental health system, they noted.

At the system level, prior research has documented less geographic availability of mental health services in communities with a higher percentage of racially and ethnically minoritized residents, they added.

“These findings highlight the need for access to appropriate services in safety net systems and other settings that serve this population,” Cummings and colleagues said.

Investing in Child Mental Health

“These trends are of national import and add to growing and justified concern about the well-being of US children,” wrote Vikki Wachino, MPP, with Health and Reentry Project, Chevy Chase, Maryland, and Richard G. Frank, PhD, with The Brookings Institution, Washington, DC, in a linked editorial.

They noted that Medicaid and CHIP cover more than 37 million children in families with low incomes, or nearly 40% of all US children, making it the largest insurer of this age group.

“The increase in mental illness diagnosis rates is concerning, whether it reflects prevalence of illness, better screening, or both factors. The potential implications of these high rates of treatment for mental health conditions among children will likely ripple across this generation’s educational attainment, workforce, and social relationships as they grow into adulthood,” Wachino and Frank noted.

In their view, additional investments in the mental health and well-being of children and their families are “badly needed,” but whether that will happen is an open question.

“Congress is currently considering making large reductions to federal Medicaid funding. If enacted, the magnitude of any cuts and the policy design behind them may constrain additional federal and state investment in promoting the mental health of the children Medicaid covers,” Wachino and Frank wrote.

“The findings of Cummings and colleagues strongly suggest that more, not less, commitment to improving the mental health of children is needed,” they concluded.

This study was supported by the Synergy Award program at Emory University. The authors and editorial writers had no relevant conflicts of interest.