The Health Atlas for Mental Health care for Children and Adolescents examines the activities within primary and specialist health care services from 2019–2023. Building upon the foundational insights 2020 Healthcare Atlas for Mental Healthcare and Substance Abuse Treatment, this updated atlas offers comprehensive data on treatments for children and adolescents in Norway. COVID-19 pandemic has influenced patterns of morbidity and health care activities both during and in the aftermath of the pandemic. The atlas is structured into two main sections: (1) an overview of patients and health care activities at an aggregated level, and (2) an analysis of treatments within the principal diagnostic groups in mental health care services for children and adolescents. Both sections explore the treatment of mental disorders across various health care settings, including mental health care services, somatic care, interdisciplinary addiction treatment, and private specialists under public funding contracts.
Main findings
- Overall, there are small regional differences in the number of patients receiving outpatient treatment, with significant disparities for some mental disorders.
- Significant disparities are observed in the duration of treatment and waiting times among different hospital referral areas.
- Treatment rates for autism and ADHD have substantially increased. Although there are moderate variations in activity between referral areas, a significantly higher proportion of boys than girls receive treatment for these conditions.
- Considerable geographical variation is observed for patients receiving treatment for depression.
Assessment of variation in patient rates
Indicator | Number | Rate per 1000 | Lowest rate | Highest rate | EQ | EQ2 | CV | SCV | SCV2 |
|---|---|---|---|---|---|---|---|---|---|
Outpatient treatment | 67 603 | 60.6 | 53.8 | 80.1 | 1.5 | 1.4 | 11.5 | 1.5 | 1.1 |
General practioners | 70 998 | 63.7 | 47.8 | 71.4 | 1.5 | 1.4 | 10.4 | 1.3 | 1 |
Inpatient treatment | 2 790 | 2.5 | 1.5 | 5.5 | 3.6 | 2.7 | 38.6 | 16.6 | 11.5 |
ADHD | 16 319 | 14.6 | 8.3 | 20.0 | 2.4 | 2.3 | 25.8 | 6.6 | 5.6 |
Anxiety | 6 226 | 5.6 | 4.2 | 8.5 | 2.0 | 1.9 | 20.7 | 6.7 | 5.6 |
Autism | 6 531 | 5.9 | 4.4 | 7.3 | 1.7 | 1.5 | 15.5 | 2.2 | 1.7 |
Depression | 3 488 | 3.1 | 1.9 | 5.8 | 3.1 | 2.6 | 35.1 | 15.6 | 14.9 |
Eating disorders | 1 857 | 1.7 | 1.2 | 2.8 | 2.3 | 1.9 | 22.3 | 14.5 | 13.0 |
Adjustment disorders | 4 200 | 3.8 | 2.1 | 6.3 | 3.0 | 2.6 | 32.2 | 10.1 | 8.5 |
Specific developmental disorders | 7 364 | 6.6 | 3.7 | 12.6 | 3.4 | 2.1 | 30.3 | 9.1 | 5.3 |
Substance use disorders, 0-17 year | 502 | 0.5 | 0.3 | 0.8 | 2.7 | 2.0 | 28.2 | 8.3 | 7.8 |
Substance use disorders,18-24 year | 4 409 | 9.4 | 5.7 | 12.8 | 2.2 | 1.9 | 20.6 | 6.3 | 5.1 |
About the Variation Measures
The extremal quotient (EQ) are simple measures of variation, representing the relationship between the highest and lowest rate of referral areas. While EQ2, reflects the relationship between the second highest and the second lowest rate. Higher ratios indicate greater variation between referral areas.
The coefficient of variation, CV, provides a more comprehensive measure of variation among referral areas. It is calculated as the standard deviation of the rates divided by the mean rate, multiplied by 100.
The systematic component of variation (SCV) is of particular importance, as it isolates systematic variation and is thus considered the most precise measure of variation in this context. SCV represents the total variation minus random variation across referral areas. For SCV2, the highest and lowest values are excluded to reduce sensitivity to extreme data points.
We categorize variation levels as follows: SCV less than 3 is small variation, between 3.1-5.4 is moderate variation, between 5.5-10.0 is large variation. SCV values above 3 are likely indicative of practice differences within healthcare services (Appelby, 2011).
Assessment of variation in activity rates
Indicator | Number | Rate per 1000 | Lowerst rate | Highest rate | EQ | EQ2 | CV | SCV | SCV2 |
|---|---|---|---|---|---|---|---|---|---|
Contact days, outpatient | 792 435 | 711 | 601.0 | 903.2 | 1.5 | 1.4 | 11.9 | 1.4 | 1.1 |
Contact days, outpatient (0-5 year) | 44 375 | 129 | 58.9 | 297.8 | 5.1 | 3.7 | 44.1 | 19.4 | 12.0 |
Contact days, outpatient (6-12 year) | 298 235 | 667 | 566.2 | 858.3 | 1.5 | 1.4 | 11.0 | 1.4 | 0.9 |
Contact days, outpatient (13-17 year) | 449 825 | 1 401 | 1 150.5 | 1 952.7 | 1.7 | 1.4 | 13.6 | 2.0 | 1.5 |
Contact days, general practioners | 129 462 | 116 | 83.5 | 134.6 | 1.6 | 1.5 | 12.7 | 2.3 | 1.9 |
Admission rate | 4 411 | 4 | 2.5 | 8.6 | 3.4 | 2.6 | 36.3 | 12.4 | 7.8 |
ADHD | 161 730 | 145 | 87.5 | 216.9 | 2.5 | 2.0 | 24.5 | 5.3 | 3.4 |
Anxiety | 82 931 | 74 | 53.1 | 140.9 | 2.7 | 1.9 | 27.1 | 8.4 | 8.0 |
Autism | 60 002 | 54 | 23.0 | 81.7 | 3.6 | 2.7 | 30.1 | 7.2 | 5.3 |
Depression | 54 871 | 49 | 28.2 | 109.7 | 3.9 | 2.5 | 41.6 | 17.4 | 17.0 |
Eating disorders | 37 460 | 34 | 18.1 | 73.7 | 4.1 | 2.1 | 35.0 | 17.5 | 16.1 |
Adjustment disorders | 47 566 | 43 | 21.3 | 73.2 | 3.4 | 2.4 | 31.1 | 10.4 | 9.0 |
Specific developmental disorders | 52 126 | 47 | 27.6 | 88.8 | 3.2 | 2.4 | 32.4 | 9.6 | 6.5 |
Substance use disorders, 0-17 year | 2 640 | 2 | 0.8 | 5.9 | 7.4 | 6.0 | 58.7 | 12.3 | 12.0 |
Substance use disorders, 18-24 year | 45 933 | 98 | 37.1 | 167.0 | 4.5 | 3.1 | 36.8 | 12.3 | 7.9 |
About the Variation Measures
The extremal quotient (EQ) are simple measures of variation, representing the relationship between the highest and lowest rate of referral areas. While EQ2, reflects the relationship between the second highest and the second lowest rate. Higher ratios indicate greater variation between referral areas.
The coefficient of variation, CV, provides a more comprehensive measure of variation among referral areas. It is calculated as the standard deviation of the rates divided by the mean rate, multiplied by 100.
The systematic component of variation (SCV) is of particular importance, as it isolates systematic variation and is thus considered the most precise measure of variation in this context. SCV represents the total variation minus random variation across referral areas. For SCV2, the highest and lowest values are excluded to reduce sensitivity to extreme data points.
We categorize variation levels as follows: SCV less than 3 is small variation, between 3.1-5.4 is moderate variation, between 5.5-10.0 is large variation. SCV values above 3 are likely indicative of practice differences within healthcare services (Appelby, 2011).
Patients in Mental Health care Services for Children and Adolescents
Mental health challenges are common among children and adolescents. Such challenges as depression or anxiety, encompass a spectrum of severity from mild to severe. In contrast, mental disorders are distinguished by a pronounced burden of symptoms and are frequently associated with significant functional impairments (Norwegian Institute of Public Health).
Children and adolescents with mental health issues or disorders seek help in both primary and specialist health care services. While the treatment of mental disorders typically occurs within specialist health care services, general practitioners (GPs) play a critical role in the early identification and management of mental health issues and milder mental disorders. GPs often collaborate with child welfare services and health stations to provide follow-up care. Data on general practitioner activity offers valuable insights into the proportion of children and adolescents engaging with primary healthcare services due to mental health concerns.
Mental comorbidity, defined as the co-occurrence of multiple mental disorders, is prevalent among children and adolescents. Common combinations include depression with anxiety and attention-deficit/hyperactivity disorder (ADHD) with specific developmental disorders. Data from the period 2019–2023 indicates that 30% of children and adolescents receiving outpatient treatment for depression were also treated for anxiety disorders, while 39% of those treated for ADHD were concurrently receiving treatment for specific developmental disorders.
The presence of comorbidity adds significant complexity to treatment, often challenging care processes and rendering treatment outcomes less predictable (Roth and Fonagy, 2005). The high prevalence of comorbidity among this population underscores its substantial influence on variations in patient needs and clinical practices, highlighting its critical importance in the planning and provision of mental healthcare services.
A substantial proportion of patients in mental health care services are in the age groups 6-12 and 13-17 years. In the age group 6-12 are twice as many boys as girls, whereas in the age group 13–17 are 30% more girls.
Distribution of patients in mental health care services for children and adolescents by age and sex groups, annual average during 2019-2023 in Norway
Outpatient treatment
Referral and Follow-up with General Practitioners
Intensity of care
During and following the COVID-19 pandemic, there was a significant increase in the number of patients referred to specialist health care services. This surge in referrals exceeded the capacity of existing services, leading to prolonged waiting periods for treatment
The intensity of treatment (care) is clinically relevent for certain mental health diagnoses, particularly anxiety disorders, depression, and eating disorders. The following analysis focuses on patients receiving outpatient care for these conditions, with at least one documented contact during their treatment pathway. The analysis encompasses the duration of the treatment course, measured within the same year as the referral. Given that the referral date often constitutes a component of the treatment course for most patients, the year 2022 is the latest year for which comparable data is available.
The table presents key metrics related to treatment timelines and intensity. Column 1 displays the median number of days from the date of referral to the initial contact. Subsequent columns show the median number of days between the second, third, fourth, and fifth contact dates and the referral date. Additional columns illustrate the median intervals for the 6th to 11th and 11th to 15th contact dates. The difference between the average intervals for the 3rd to 15th contact dates and the 0th to 15th contact dates provides insight into the relative intensity of care from the 3rd contact onwards, compared to the overall intensity across the entire treatment course up to the 15th contact.
The median is employed as the primary measure for analyzing waiting times and treatment intervals, as it offers a more representative measure of the typical treatment intensity and frequency of care experienced by patients across different referral areas. By sorting all referral periods in ascending order, the median provides a robust metric that mitigates the influence of outliers, ensuring a more accurate reflection of patient experiences.
A significant disparity in waiting times was observed across different referral areas during the study period. The longest waiting time were recorded in St. Olavs, Nordland, and Finnmark, while patients in Vestfold experienced waiting times that were less than half the duration of those in the St. Olavs referral area. The data presented in the right-hand columns of the analysis reveal that Førde, Fonna, and Finnmark had longer intervals between each care contact compared to other referral areas. Additionally, UNN, Nord-Trøndelag, Finnmark, and St. Olavs exhibited slightly higher values for the time to the second contact, indicating delays in early-stage treatment progression.
The discrepancy between the two measures of treatment pathway intensity—initial waiting times and intervals between subsequent contacts—underscores the variation across referral areas in terms of patient progression along the treatment course. A substantial difference between these measures suggests delays in patients' access to timely health care, whereas a small difference indicates more consistent planning and treatment scheduling throughout the course of care. Referral areas such as UNN, Bergen, Sørlandet, and Vestfold exhibited lower variances, demonstrating a parallel trend in both waiting times and treatment intensity. Notably, UNN deviates from this pattern, with a higher median waiting time for the third patient contact, despite maintaining a comparatively brief overall duration of care. In contrast, Førde demonstrated relatively low treatment intensity, with shorter waiting times compensating for the reduced intensity over time.
St. Olavs is characterized by prolonged waiting times, extended intervals to the second patient visit, and a failure to reduce time gaps throughout the subsequent treatment course up to the 15th visit. Finnmark and Nord-Trøndelag exhibit similar patterns. Conversely, OUS, despite long waiting times, maintains the highest treatment intensity of all referral areas at the outset of the treatment course.
Inpatient Treatment
ADHD
Children and adolescents in the 6-12 and 13-17 age groups represent two substantial cohorts receiving treatment for ADHD. While boys constitute the majority of patients in the 6-12 age group, the sex disparity becomes smaller in the 13-17 age group.
Annual average patient for ADHD treatment during 2019–2023 in Norway.
Anxiety
The prevalence of treatment for anxiety disorders is relatively low among children in the 0-5 age group, with a significant increase in the 13-17 age group. Among adolescents in the latter group, a notable sex disparity is observed, with a substantially higher number of girls than boys receiving outpatient treatment for anxiety disorders.
Annual average patient for anxiety treatment during 2019-2023 in Norway
Autism
A considerably higher proportion of boys than girls receive treatment for autism in the 0–5 and 6–12 age groups, whereas the gender disparity diminishes significantly in the 13–17 age group.
Annual average patient for autism treatment during 2019-2023 in Norway.
Depression
The majority of children and adolescents receiving outpatient treatment for depression are within the 13–17 year age group. Notably, more than twice as many girls as boys are treated for depression in this age range.
Annual average patient for depression treatment during 2019-2023 in Norway.
Eating Disorder
The majority of patients under 18 years of age receiving outpatient treatment for eating disorder are girls aged 13 to 17 years. Boys represent only a small proportion of this age group.
Annual average patient for eating disorder treatment during 2019-2023 in Norway.
Substance Use Disorders
The number of patients aged 13-17 years is lower compared to those up to 24 years. In the 13–17 age group, the proportion of boys and girls is relatively similar. However, in the age groups up to 24 years, a majority of patients are boys.
Annual average patient for substance use disorder treatment during 2019-2023 in Norway.
Specific Developmental Disorder
The majority of patients receiving outpatient treatment for specific developmental disorders fall within the age groups 6–12 years and 13–17 years. In the 13–17 age group, the proportion of boy and girl patients is relatively similar. However, among patients aged 6–12 years, the number of boys is more than twice that of girls.
Annual average patient for specific developmental disorder treatment during 2019-2023 in Norway.
Adjustment Disorder
The majority of patients receiving treatment for adjustment disorder are in the 13–17 age group. Within this group, twice as many girls as boys receive treatment. In contrast, in the 6–12 age group, the number of boys and girls receiving treatment is relatively similar.
Annual average patient for adjustment disorder treatment during 2019-2023 in Norway.
About the Atlas
The Healthcare Atlas for Mental Health care Services for Children and Adolescents is based on data from the Norwegian Patient Register (NPR) and the Municipal Patient and User Register (KPR) for the period 2019 to 2023. The data is provided by the Norwegian Institute of Public Health.
The KPR data encompass consultations with general practitioners and emergency services, while other analyses are derived from data provided by NPR.
Population statistics used in this atlas are sourced from Statistics Norway (SSB).
Cover image: AI-generated.
Disclaimer
Helse Førde is solely responsible for the interpretation and presentation of the data included in this atlas. NPR and KPR are not accountable for any analyses or interpretations made using the data they have provided.
Outpatient Contact: All contacts where the patient was admitted and discharged on the same date, irrespective of the care level provided.
Contact Day: A single calendar day with one or more outpatient contacts. Multiple contacts on the same day are collectively counted as one contact day.
Admission: All institutional stays/admissions lasting more than zero days.
The four regional health authorities have a statutory responsibility to provide equitable specialist health care services to the population, regardless of geographic location (Specialist Health Services Act). To assess geographical variation in health care utilization, the country is therefore divided according to the health authorities' referral areas.
The analyses presented in this atlas are based on the referral area where the patient resides rather than where treatment was received. Since the populations within referral areas differ in terms of age and sex composition, the rates in this atlas are age- and sex-adjusted. This adjustment ensures the comparison of health care service utilization across more homogeneous population groups than would be possible without such standardization. Patients with missing information on their municipality of residence in the datasets were excluded from the analyses. The results of these analyses allow regional health authorities to evaluate how effectively they are fulfilling their statutory responsibilities.
Details on the division into referral areas, population statistics, and the median age of the population (2021) used in this atlas are presented below.
Total population in 2021 (0-17 year).
The table below lists the health authorities and hospitals with defined referral areas, along with their abbreviations as used in the atlas. A detailed breakdown of municipalities and districts within each referral area can be found here.
Regional health trust | Hospital referral area | Short name |
|---|---|---|
Helse Nord | Finnmarkssykehuset HF | Finnmark |
Universitetssykehuset i Nord-Norge HF | UNN | |
Nordlandssykehuset HF | Nordland | |
Helgelandssykehuset HF | Helgeland | |
Helse Midt-Norge | Helse Nord-Trøndelag HF | Nord-Trøndelag |
St. Olavs hospital HF | St. Olavs | |
Helse Møre og Romsdal HF | Møre og Romsdal | |
Helse Vest | Helse Førde HF | Førde |
Helse Bergen HF | Bergen | |
Helse Fonna HF | Fonna | |
Helse Stavanger HF | Stavanger | |
Helse Sør-Øst | Sykehuset Østfold HF | Østfold |
Akershus universitetssykehus HF | Akershus | |
Oslo universitetssykehus HF | OUS | |
Lovisenberg diakonale sykehus | Lovisenberg | |
Diakonhjemmet sykehus | Diakonhjemmet | |
Sykehuset Innlandet HF | Innlandet | |
Vestre Viken HF | Vestre Viken | |
Sykehuset i Vestfold HF | Vestfold | |
Sykehuset Telemark HF | Telemark | |
Sørlandet sykehus HF | Sørlandet |
The Health care Atlas for Mental Health care for Children and Adolescents is developed in collaboration with a resource group comprising of following members:
- Ina Heiberg, Analyst, SKDE
- Anne Høye, Special Advisor in psychiatry, SKDE, and Professor, UNN
- Lars Ravn Øhlckers, Psychologist/Advisor, Helse Stavanger
- Børge Mathiassen, Head, National Quality Register for Child and Adolescent Psychiatry
- Hubertus A.M. Jonkers, Operations Consultant, BUP, Helse Nord-Trøndelag
- Per Arne Holman, Head of Analysis, Lovisenberg Diakonale Hospital
During the project period, input was gathered from professional environments and individuals across the country to ensure that the analysis results provide the most accurate and comprehensive picture of current practices.
We extend our gratitude for the valuable contributions that have helped make the atlas both practice-oriented and relevant.
The health atlas is developed by Helse Førde HF by Oddne Skrede, Jagrati Jani-Bølstad, Haji Kedir Bedane, Sweta Tiwari, and Knut Ivar Osvoll.
Do You Have Questions?
For inquiries or comments, please contact the Health Atlas Service at Helse Førde HF via helseatlas@helse-forde.no.