Health care Atlas for Mental Health care for Children and Adolescents

Annually, an average of 68,000 children and adolescents receive outpatient treatment for mental health challenges. While the number of patients accessing outpatient mental health care services remained stable from 2014 and 2018 (Bale et al., 2020), this figure has risen significantly in subsequent years. Nationally, approximately 16% of outpatient activity is attributed to the somatic health care sector; however, this proportion demonstrates considerable regional variation, ranging from 9% to 24% across different referral areas. 

There is low geographical variation in the patient rate. However, patients residing in the Helgeland, Finnmark, UNN, and Førde referral areas exhibit significantly higher rates compared to other regions. In contrast, Vestre Viken reports a markedly lower patient rate, while the remaining referral areas with low rates show comparatively smaller differences. 

While geographical variation in patient rates is relatively small, temporal changes during the period from 2018 to 2023 are more pronounced. Nationwide, the number of patients increased by approximately 20%. This trend was observed across all referral areas except Vestfold, with the highest rates reported in Ahus, Østfold, Bergen, and Finnmark. 

A high patient rate indicates a greater number of children and adolescents receiving outpatient treatment relative to the population of the same age group in a given area. However, this metric does not account for the intensity of care provided, as it is based on a single count per patient per year, regardless of the number of consultations. Regional variations in service delivery are evident, with some referral areas focusing on periodic check-ups for patients whose conditions have improved, while others may not adopt similar practices. Consequently, incorporating measures of treatment intensity would provide a more comprehensive understanding of these regional disparities in mental health care provision.

The number of outpatient contact days exhibits low geographical variation across referral areas. Patients in the Telemark and Helgeland referral areas have the highest number of outpatient contact days, while Møre og Romsdal reports the lowest rate. 

In the analysis, the number of contact days, rather than outpatient contacts, was used as a measure of activity. This decesion is grounded in the observation that the number of outpatient contacts per patient can vary substantially within a single day across different referral areas. Contact days provide a more consistent measure of activity, aligning more effectively with resource allocation models that utilize activity-based funding. 

While the number of contacts in mental health care, interdisciplinary specialized addiction treatment, and contracted specialists in mental health care remained stable from 2014 to 2018 (Bale et al., 2020), a nationwide increase in the number of contact days has been observed since then. This upward trend is evident in most referral areas; however, Sørlandet, Ahus, and Stavanger deviate from this pattern. Significant differences exists in the number of contact days per patient across regions. For instance, referral areas such as OUS, Vestre Viken, Telemark, and Bergen report an average of approximately 13 contact days per patient, whereas Nord-Trøndelag, Førde, St. Olav, and Finnmark report an average closer to 10 contact days per patient. These variations are substantial and likely reflect differences in the organization and delivery of services across regions. 

Despite its utility, the use of contact days as a metric may obscure variations in treatment intensity within referral areas, particularly when considering practices occurring on a single day. For example, a patient may have multiple contacts with different therapists on the same day. Additionally, it is a common practice in mental health care for children and adolescents for discussions involving the patient's relatives to occur concurrently with the therapist's session with the patient.

Children aged 0-5 years constitute a smaller subset of patients within mental health care services for children and adolescents. From 2019 to 2023, the number of contact days for this age group increased significantly at the national level. However, this trend was not uniform, as not all health trusts experienced an increase over the five-year period. 

Consistent with the patterns observed between 2014 and 2018, Vestfold and Telemark stand out for their notably higher contact rates compared to other referral areas. Vestfold reports approximately 300 contact days per 1,000 population, a rate roughly five times higher than that of St. Olavs, the area with the lowest rate. 

Both Vestfold and Telemark also exhibit the highest number of contact days per patient, with averages of 13.1 and 11.5, respectively. In contrast, Østfold and St. Olavs report the lowest figures, at 4.8 and 5 contact days per patient. These substantial variations in the number of contact days per patient are a key factor contributing to the observed disparities in contact rates. Such differences are significant and likely reflect regional variations in the organization, and delivery of mental health care services for young children.

During the period from 2019 to 2023, a slight increase in the rate of contact days was observed for this age group. However, similar to trends observed among younger children, this increase was not uniform across all referral areas, with some regions experiencing a decline in activity. Notably, Finnmark and UNN saw a significant rise in activity for this age group. 

Geographical variation in the rates of contact days is relatively limited. The Telemark and Helgeland referral areas exhibit the highest rates, with 858 and 829 contact days per 1,000 population, respectively. In contrast, many other referral areas report consistently low rates. 

Interestingly, there is no consistent relationship between the referral areas with the highest and lowest rates of contact days per population and those with the highest and lowest numbers of contact days per patient. For instance, while Telemark reports both a high rate of contact days per population and a high number of contact days per patient, Helgeland demonstrates a relatively low number of contact days per patient despite its high contact days per population. This discrepancy is likely attributable to the larger number of patients in Helgeland within this age group. Additionally, OUS reports the highest number of contact days per patient, even though it does not rank among the top three areas for contact days per population. This suggests that patients in OUS experience significantly more frequent contact with mental health services throughout the year compared to other referral areas with high population-based contact rates.

During the period from 2019 to 2023, approximately 32,000 adolescents in this age group accounted for around 450,000 outpatient contact days annually, resulting in a national average of 13.8 contact days per patient. While geographical variation in the number of contact days was limited, significant temporal trends were observed over this five-year period.

Nationwide, the number of contact days for adolescents increased markedly, a trend reflected in most referral areas. However, some referral areas experienced a reduction in rates by 2023 compared to earliear years. This pattern aligns with findings reported in Two Years with the Pandemic - Status of Mental Health Services for Children and Adolescents (Ukom, 2022), which highlighted a backlog resulting from a prolonged mismatch between demand and capacity. Contributing factors included pre-pandemic capacity challenges, reduced service availability during the initial phases of the pandemic, and the extraordinary demands created during the pandemic. These factors collectively exacerbated the need for mental health support, placing additional strain on service delivery systems (ibid.).

The patients included in this analysis reflect activity in outpatient clinics and/or general practice over the entire five-year period from 2019-2023. 

During this time, approximately 71,000 children and adolescents received treatment annually from general practitioners (GPs) for mental health concerns. The national patient rate for such contacts increased by approximately 25%, with significant growth observed across all referral areas. This rise in GP utilization outpaced the growth in outpatient treatment rates during the same period. Notably, the Helgeland referral area exhibited less pronounced changes compared to other regions. 

Among these patients, about one-third were treated for a diagnosed mental disorder, while the remaining two-thirds sought care for symptoms or complaints without a formal diagnosis. Although geographical variation in patient rates was relatively low, notable differences were observed in specific referral areas. For instance, Stavanger demonstrated a patient rate approximately 60% higher than Førde, the region with the lowest rate. Additionally, significant variation was evident in the proportion of patients receiving care exclusively through GPs. Referral areas such as Helgeland and Førde recorded low proportions, whereas Vestre Viken, Nordland, and Stavanger reported relatively higher proportions. 

Effective mental health care for children and adolescents relies on collaboration among municipal health stations, general practitioners, child welfare services, and specialist mental health care services. The organization of these services varies across municipalities, influenced by factors such as population size, demographics, and disease burden. While assessment and treatment of more severe mental health issues predominantly occur within specialist healthcare services, general practitioners primarily manage milder mental health conditions. 

To achieve a comprehensive understanding of the health care provided to children and adolescents, access to data from multiple components of the municipal health service is essential. It is important to note that referral areas with the highest GP activity do not necessarily exhibit the highest overall health care activity when considering follow-up care provided by health stations.

Annually, approximately 71,000 children and adolescents receive treatment through general practice services, accounting for around 129,000 consultations nationwide. This translates to an average of two consultations per patient per year. Patients requiring assessments or treatments for mental health conditions are primarily managed within specialist healthcare services, while general practitioners typically address milder mental disorders, often in conjunction with somatic conditions.

Although geographical variation in GP consultation rates was minimal, significant growth was observed over the five-year period from 2019 to 2023. The overall rate of GP contact days per patient remained low, closely aligning with trends in patient rates over time. Referral areas such as Førde exhibited significantly lower average rates of GP contact days compared to other regions, while other areas demonstrated smaller differences. Additionally, the Helgeland referral area experienced less pronounced changes over the same timeframe.

Approximately 2,700 children and adolescents received inpatient treatment annually for mental disorders, representing about 5% of all patients utilizing specialist health care services for mental health condition

Notable geographical variation was observed in the patient rate for inpatient treatment. Referral areas within Helse Nord, as well as Nord-Trøndelag, Møre og Romsdal, and Innlandet, exhibited significantly higher rates compared to other regions in the country. In contrast, the lowest patient rates were recorded in the Oslo area and Vestfold.

Annually, approximately 2,700 patients accounted for around 4,500 admissions, resulting in an average of 1.7 admissions per patient per year. The admission rate remained relatively stable across the country and in most referral areas; however, Nordland, Finnmark, and Akershus experienced a significant increase in the admission rate during the study period. 

A substantial proportion of children and adolescents receive treatment for mental disorders in somatic care settings. The geographical variation in this proportion is considerable, ranging from approximately 15% in Lovisenberg to around 40% in the Sørlandet referral area. Notably, Sørlandet also reports a high proportion of patients treated in the somatic sector for outpatient care. 

The overall geographical variation in the admission rate is significant, as indicated by an SCV2 value of 7.8. Most referral areas within Helse Nord exhibit considerably higher admission rates, consistent with the higher patient rates for inpatient treatment observed in these regions. While the differences in admission rates are substantial, it cannot be concluded that this variation is unwarranted, since hospitalization represents a small portion of the total treatment offerings, and patient needs, as well as the organizational structure of services, may vary significantly across referral areas.

On average, approximately 16,000 children and adolescents received outpatient treatment for ADHD annually during the period from 2019 to 2023. This patient group represents the largest segment of mental health care services for children and adolescents. 

Moderate to high geographical variation was observed in the rate of patients receiving outpatient treatment for ADHD, as indicated by an SCV2 of 5.6. Referral areas such as Sørlandet, Lovisenberg, and Diakonhjemmet reported a patient rate of approximately 10 per 1,000 population, while Bergen, St. Olavs, Fonna, UNN, Nordland, and Finnmark exhibited rates roughly double that figure. Referral areas within Helse Nord, along with most regions in Helse Vest, had patient rates notably above the national average. 

These findings align with a recent study on geographical differences in ADHD diagnoses (Widding-Havneraas et al., 2022), which revealed that municipalities in Nordland, Sør-Trøndelag, Innlandet, Stavanger, Fonna, and Bergen have higher ADHD diagnosis rates compared to other municipalities in the country. The same study further highlighted variations in diagnoses, adjusting for geographical differences in symptom presentation (ibid.). 

Among children and adolescents diagnosed with ADHD, a significant proportion also received outpatient treatment for specific developmental disorders over the five-year period. The proportion ranged from 14% to 37% across different referral areas, with a national average of 22%.

During the period 2019 to 2023, approximately 16,000 patients received a total of around 162,000 contact days annually, equating to an average of 9.9 contact days per patient nationwide. This patient group represents the largest cohort within mental health care services for children and adolescents. 

Moderate geographical variation was observed in the contact day rate for ADHD during this period, with SCV2 value of 3.4. Referral areas in the Oslo region, along with Akershus and Sørlandet—areas exhibiting the lowest rates—had approximately half the contact day rates observed in Bergen and Fonna. However, there is insufficient evidence to conclude that this geographical variation is unwarranted. 

Over the five-year period, the rate of contact days for ADHD increased significantly, with a national increase of approximately 50%. Certain referral areas experienced even more substantial growth, with Diakonhjemmet, Lovisenberg, Førde, and Finnmark reporting a near doubling of their rates. 

Differences in diagnostic practices for ADHD are more thoroughly documented compared to other mental disorders (Widding-Havneraas et al., 2022; Surén et al., 2018). The fact that morbidity only partially correlates with diagnostic practices across geographical regions suggests the possibility of both over- and under-treatment of ADHD (Widding-Havneraas et al., 2022; Biedermann, 2012). Comorbid conditions, which are highly prevalent among children and adolescents with ADHD, may also contribute to variations in contact day rates. Specific developmental disorders represent the most common comorbid conditions and are particularly relevant in this context. The data further suggests that referral areas with high contact day rates for ADHD also tend to exhibit high contact day rates for specific developmental disorders. 

• St. Olavs' rate for 2023 does not reflect the outpatient activity for that year. Following the introduction of the Health Platform, many outpatient contacts were registered without corresponding condition codes.

Anxiety disorders represent one of the largest groups within mental health care services for children and adolescents. On average, approximately 6,200 patients receive treatment for anxiety disorders in specialist healthcare services each year. 

A substantial proportion of children and adolescents with anxiety disorders also experience comorbid mental health conditions. Over the five-year period from 2019-2023, 19% of patients received outpatient care for ADHD, while 18% had outpatient contact for depression. The proportion of patients with comorbid ADHD varied between 10% and 30%, while comorbid depression, it ranged from 9% to 26% across different referral areas. Notably, Nordland exhibited a significantly higher proportion of ADHD comorbidity compared to other referral areas, which aligns with its status as one of the regions with the highest overall contact rates for ADHD. Differences among other referral areas were less pronounced,

Finnmark and Lovisenberg recorded the highest patient rates for anxiety disorders during the five-year period, while Sørlandet and Førde had the lowest. The geographical variation in patient rates for anxiety disorders was moderate, as indicated by SCV2 value of 5.6.

From 2019 to 2023, approximately 6,200 patients received around 83,000 contact days annually for the treatment of anxiety disorders in specialist health care services This corresponds to an average of 13.3 contact days per patient nationwide, which is relatively high.  

The rate of contact days exhibited significant geographical variation, with SCV2 value of 8. Lovisenberg stands out with a markedly higher rate compared to other referral areas, while several regions report around 80 contact days per 1,000 population. A general upward trend in contact day rates was observed over the five-year period; however, the Sørlandet, Stavanger, and Helgeland referral areas deviated from this trend. Nationally, and in many referral areas, the contact day rate in 2023 was lower than in previous years. 

As previously noted, many children and adolescents with anxiety disorders also have comorbid mental health conditions, with ADHD and depression being the most prevalent. ADHD demonstrates the greatest variation in comorbidity rates across referral areas, while developmental disorders, although less common, also show significant regional variation. Notably, children and adolescents in Nordland with anxiety disorders exhibit the highest overall comorbidity, while those in Førde, Sørlandet, and Telemark report among the lowest rates. 

Significant differences in the number of contact days per patient were also observed. Lovisenberg and OUS had averages exceeding 17 contact days per patient, while Førde and Nord-Trøndelag reported 10.4 and 10.6 contact days per patient, respectively. Most referral areas were closer to the national average of 13.3 contact days. While Lovisenberg demonstrates both a high patient rate and a high contact day rate, OUS recorded a higher number of contact days despite having a patient population similar to the national average. These disparities in follow-up care contribute to varying contact day rates. Although the variation is substantial, there is insufficient evidence to conclude that it is unwarranted. 

• St. Olavs' rate for 2023 does not reflect the outpatient activity for that year. Following the introduction of the Health Platform, many outpatient contacts were registered without corresponding condition codes.

On average, approximately 6,500 children and adolescents receive treatment for autism annually within specialist health care services. 

The variation in patient rates between geographical regions is relatively small, as indicated by SCV2 value of 1.7. Møre og Romsdal, the referral area with the highest patient rate, reports less than double the rate of Sørlandet, which has the lowest rate. These geographical differences align with findings from a recent study on autism spectrum disorder diagnoses (Surén et al., 2019), which identified elevated diagnosis rates in counties such as Rogaland, Møre og Romsdal, Vestfold, and Østfold, while counties such as Hedmark, Agder, and Nordland exhibited lower rates. 

Compared to other groups within mental health care services for children and adolescents, those with autism exhibit a relatively high proportion of comorbid mental disorders. Nationwide, 25% of patients had outpatient contact for ADHD, and 17% had outpatient contact for developmental disorders during the 2019–2023 period. Among referral areas, Nordland shows a notably higher proportion of patients with specific developmental disorders, with 46% falling into this category. Additionally, approximately one-third of children and adolescents with autism in the St. Olav, Fonna, Møre og Romsdal, Bergen, and Nordland referral areas had outpatient contact for ADHD. However, the geographical variation in ADHD comorbidity is less pronounced than for developmental disorders.

On average, approximately 6,500 children and adolescents with autism accounted for 60,000 outpatient contact days annually. The number of contact days per patient exhibited notable variability, ranging from 5.2 in Sørlandet to 14.5 in Telemark. These differences are significant when compared to other mental disorders. With SCV of 7.2 and SCV2 of 5.3, the variation in the rate of contact days for autism is categorized as moderate to high; however, it remains within the lower range of variability observed among mental disorders in children and adolescents. Assuming equal prevalence across regions, there is no evidence to suggest that the observed geographical variation is unwarranted. 

Treatment for autism in specialist health care services spans both psychiatric and somatic care, with a substantial proportion of patients managed outside conventional psychiatric practice. Sørlandet and Nord-Trøndelag exhibit the highest proportions of patients treated in somatic care, with 82% and 55%, respectively. Other health trust also report significant proportions, ranging from 20% to 30%. 

As previously noted, a considerable proportion of children and adolescents with autism are also diagnosed with comorbid conditions, particularly ADHD and developmental disorders. Nationwide, 25% of patients with autism have comorbid ADHD, and 17% have comorbid developmental disorders. These proportions vary considerably across referral areas. Nordland, in particular, shows a notably high proportion of children and adolescents with comorbid specific developmental disorders and autism. For ADHD, approximately one-third of patients with autism have this comorbidity in many referral areas. 

The treatment rates for autism in specialist health care services have shifted significantly between 2019 and 2023. Nationwide, the rate of outpatient contact days increased by nearly 50%. While Stavanger experienced an unusual decline, referral areas such as Lovisenberg, Vestre Viken, Finnmark, and Sørlandet showed substantial increases in the rate of outpatient contact days over this period.

Nationwide, approximately 3,500 children and adolescents received outpatient treatment for depression annually during the years 2019–2023. The geographical variation in patient rates is exceptionally high, with an SCV2 of 14.9, representing the highest variation among all mental health disorders analyzed. In the Finnmark and Lovisenberg referral areas, the rate of children and adolescents treated for depression was nearly three times higher than in Sørlandet, which reported the lowest rate. Referral areas in Helse Nord, the Oslo area, along with Bergen and Stavanger, demonstrated patient rates exceeding the national average.  

Depression frequently co-occurs with anxiety disorders. Nationwide, 30% of children and adolescents diagnosed with depression had outpatient contacts for anxiety disorders during the five-year study period. ADHD was identified as a comorbid condition in 16% of patients, whereas comorbidity with other mental disorders was less common. The proportion with anxiety disorders varied between referral areas, ranging from 20% in Østfold to 40% in Nord-Trøndelag.

Over the five-year period from 2019 to 2023, approximately 3,500 children and adolescents received an annual average of 55,000 outpatient contact days as part of their treatment for depressive disorders. While the national rate showed no clear trend over time, some referral areas experienced marked increases in the number of contact days. Notably, Lovisenberg and Diakonhjemmet in the Oslo area, as well as Bergen and Nord-Trøndelag, reported significant growth in the number of contact days for depression. 

Anxiety disorders represent the most common comorbid condition among children and adolescents with depression. For instance, 20% of patients with depression in Østfold also had anxiety disorders, compared to 40% in Nord-Trøndelag. Although comorbidity with other conditions, such as ADHD and developmental disorders, occurs less frequently, these comorbidities display significant geographical variation. For ADHD and developmental disorders, differences of approximately 15% were observed between areas with the highest and lowest proportions. These variations may be attributed to differences in diagnostic practices and underlying prevalence. Such factors, particularly in the presence of high comorbidity, likely contribute to differences in contact day rates and their variability. 

Geographical variation in the rate of contact days for depression was exceptionally pronounced, with SCV2 value representing the highest among all mental disorders. For instance, Lovisenberg recorded a contact day rate four times higher than Sørlandet. Assuming equal prevalence of depressive disorders across regions, such high variability in contact day rates must be considered undesirable. 

• St. Olavs' rate for 2023 does not reflect the outpatient activity for that year. Following the introduction of the Health Platform, many outpatient contacts were registered without corresponding condition codes.