Morbidity and Mortality Weekly Report

Supplement / Vol. 71 / No. 2 February 25, 2022

Mental Health Surveillance Among Children —

United States, 2013–2019

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
 Supplement

CONTENTS
Introduction.............................................................................................................1
Methods.....................................................................................................................3
Results..................................................................................................................... 13
Discussion.............................................................................................................. 30
Future Directions and Public Health Implications................................... 36
Conclusion ............................................................................................................ 36
References.............................................................................................................. 36

The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Title]. MMWR Suppl 2022;71(Suppl-#):[inclusive page numbers].
Centers for Disease Control and Prevention
Rochelle P. Walensky, MD, MPH, Director
Debra Houry, MD, MPH, Acting Principal Deputy Director
Daniel B. Jernigan, MD, MPH, Deputy Director for Public Health Science and Surveillance
Rebecca Bunnell, PhD, MEd, Director, Office of Science
Jennifer Layden, MD, PhD, Deputy Director, Office of Science
Leslie Dauphin, PhD, Acting Director, Center for Surveillance, Epidemiology, and Laboratory Services
MMWR Editorial and Production Staff (Serials)
Charlotte K. Kent, PhD, MPH, Editor in Chief Martha F. Boyd, Lead Visual Information Specialist Ian Branam, MA,
Christine G. Casey, MD, Editor Alexander J. Gottardy, Maureen A. Leahy, Acting Lead Health Communication Specialist
Mary Dott, MD, MPH, Online Editor Julia C. Martinroe, Stephen R. Spriggs, Tong Yang, Shelton Bartley, MPH, Leslie Hamlin,
Terisa F. Rutledge, Managing Editor Visual Information Specialists Lowery Johnson, Amanda Ray,
David C. Johnson, Lead Technical Writer-Editor Quang M. Doan, MBA, Phyllis H. King, Health Communication Specialists
Catherine B. Lansdowne, Project Editor Terraye M. Starr, Moua Yang, Will Yang, MA,
Information Technology Specialists Visual Information Specialist

MMWR Editorial Board

Timothy F. Jones, MD, Chairman
Matthew L. Boulton, MD, MPH William E. Halperin, MD, DrPH, MPH Carlos Roig, MS, MA
Carolyn Brooks, ScD, MA Jewel Mullen, MD, MPH, MPA William Schaffner, MD
Jay C. Butler, MD Jeff Niederdeppe, PhD Nathaniel Smith, MD, MPH
Virginia A. Caine, MD Celeste Philip, MD, MPH Morgan Bobb Swanson, BS
Jonathan E. Fielding, MD, MPH, MBA Patricia Quinlisk, MD, MPH Abbigail Tumpey, MPH
David W. Fleming, MD Patrick L. Remington, MD, MPH
 Supplement

Mental Health Surveillance Among Children —

United States, 2013–2019
Rebecca H. Bitsko, PhD1; Angelika H. Claussen PhD1; Jesse Lichstein, PhD2; Lindsey I. Black, MPH3; Sherry Everett Jones, PhD, JD4;
Melissa L. Danielson, MSPH1; Jennifer M. Hoenig, PhD5; Shane P. Davis Jack, PhD6; Debra J. Brody, MPH7; Shiromani Gyawali, MS5;
Matthew J. Maenner, PhD1; Margaret Warner, PhD8; Kristin M. Holland, PhD9; Ruth Perou, PhD10; Alex E. Crosby, MD11; Stephen J. Blumberg, PhD3;
Shelli Avenevoli, PhD12; Jennifer W. Kaminski, PhD1; Reem M. Ghandour, DrPH2

1Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, CDC; 2Office of Epidemiology and Research,
Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland; 3Division of Health Interview Statistics, National Center
for Health Statistics, CDC; 4Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC; 5Division of
Surveillance and Data Collection, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville,
Maryland; 6Division of Violence Prevention, National Center for Injury Prevention and Control, CDC; 7Division of Health Nutrition Examination Surveys, National
Center for Health Statistics, CDC; 8Division of Vital Statistics, National Center for Health Statistics, CDC; 9Division of Overdose Prevention, National Center
for Injury Prevention and Control, CDC; 10Office of the Director, National Center on Birth Defects and Developmental Disabilities, CDC; 11Division of Injury
Prevention, National Center for Injury Prevention and Control, CDC; 12National Institute of Mental Health, Bethesda, Maryland

Summary
Mental health encompasses a range of mental, emotional, social, and behavioral functioning and occurs along a continuum from good to poor.
Previous research has documented that mental health among children and adolescents is associated with immediate and long-term physical
health and chronic disease, health risk behaviors, social relationships, education, and employment. Public health surveillance of children’s
mental health can be used to monitor trends in prevalence across populations, increase knowledge about demographic and geographic
differences, and support decision-making about prevention and intervention. Numerous federal data systems collect data on various indicators
of children’s mental health, particularly mental disorders. The 2013–2019 data from these data systems show that mental disorders begin
in early childhood and affect children with a range of sociodemographic characteristics. During this period, the most prevalent disorders
diagnosed among U.S. children and adolescents aged 3–17 years were attention-deficit/hyperactivity disorder and anxiety, each affecting
approximately one in 11 (9.4%–9.8%) children. Among children and adolescents aged 12–17 years, one fifth (20.9%) had ever experienced
a major depressive episode. Among high school students in 2019, 36.7% reported persistently feeling sad or hopeless in the past year, and
18.8% had seriously considered attempting suicide. Approximately seven in 100,000 persons aged 10–19 years died by suicide in 2018 and
2019. Among children and adolescents aged 3–17 years, 9.6%–10.1% had received mental health services, and 7.8% of all children and
adolescents aged 3–17 years had taken medication for mental health problems during the past year, based on parent report. Approximately
one in four children and adolescents aged 12–17 years reported having received mental health services during the past year. In federal data
systems, data on positive indicators of mental health (e.g., resilience) are limited. Although no comprehensive surveillance system for children’s
mental health exists and no single indicator can be used to define the mental health of children or to identify the overall number of children
with mental disorders, these data confirm that mental disorders among children continue to be a substantial public health concern. These
findings can be used by public health professionals, health care providers, state health officials, policymakers, and educators to understand
the prevalence of specific mental disorders and other indicators of mental health and the challenges related to mental health surveillance.

Introduction effective regulatory and coping skills; mentally healthy children

function well in various settings including the home, school,
Mental health is a broad label that encompasses a range of and community (4–7). Poor mental health and patterns of
mental, emotional, social, and behavioral functioning. Mental symptoms that are severe, are persistent, and cause impairment
health, like physical health, occurs along a continuum from or dysfunction can develop into mental disorders (1). Mental
good to poor and varies over time, in different conditions, and disorders are defined by the Diagnostic and Statistical Manual of
at different ages (1–3). Good mental health in children includes Mental Disorders, 5th Edition (DSM-5) as clinically significant
indicators such as the timely achievement of developmental cognitive, emotional regulation, or behavior disturbances
milestones, healthy social and emotional development, and that reflect dysfunction in psychological, biological, or
developmental mental function processes (1). Mental disorders
Corresponding author: Rebecca H. Bitsko, National Center on Birth
are typically conceptualized as categorical (i.e., above or below a
Defects and Developmental Disabilities, CDC. Telephone: 404-498-3556; clinical cutoff of symptom or impairment scales), and children
Email: [email protected]. receive a diagnosis of a disorder when they have specific

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 25, 2022 / Vol. 71 / No. 2 1
 Supplement

symptoms that meet specified criteria (1). Common mental from the National Survey of Drug Use and Health; however,
disorders in children include anxiety, depression, attention- treatment for anxiety, behavior problems, and trauma have
deficit/hyperactivity disorder (ADHD), and behavioral not been monitored in national surveillance efforts (31).
disorders (8). Good mental health is not simply the absence Challenges associated with surveillance of children’s mental
of a mental disorder; persons with diagnosed mental disorders health might include a separation among public health and
can still have good mental health (e.g., if receiving adequate mental health agencies at the federal, state, and local levels;
treatment and support) (3,7,9). stigma and privacy related to mental health data collection;
Throughout life, mental health and mental disorders are and varying case definitions across surveillance systems (8,29).
associated with immediate and long-term measures of physical Estimates from previous surveillance efforts and research
health and chronic disease and with social determinants studies indicate that approximately one in five children and
of health such as racial and ethnic minority status and any adolescents experience a mental disorder each year (32,33);
associated racial bias, social relationships, presence or absence approximately two in five children and adolescents will meet
of crime, and factors that determine access to resources such criteria for a mental disorder by age 18 years (34,35), and one
as education level, income level, and employment status half of mental disorders have an onset before age 14 years (32).
(10–22). These and other social determinants of health that Although children in all sociodemographic groups are affected
affect the environments in which children develop contribute by mental disorders, the prevalence of different disorders varies
to wide health disparities (23). Because of the direct connection by the child’s sex, age, residence (e.g., urban versus rural areas),
between mental and physical health, promoting mental race or ethnicity, and other sociodemographic characteristics
health, particularly in the context of social determinants of (8,33,34,36,37). Prevalence estimates of diagnosed mental
health, is essential to promoting health equity (24). Research disorders have increased since 2000 for ADHD (38), anxiety
has documented that policies and programs provided during (17), ASD (38), and depression (19). Similarly, since 2000,
childhood that improve children’s mental health also improve symptoms of mental disorders and indicators of poor mental
longer-term health and functioning and also might prevent health, including reports by youths of feeling sad or hopeless,
children from developing a diagnosable disorder (2,25–27). suicidal ideation, and suicide attempts, as well as suicides
Thus, promoting good mental health and addressing mental among adolescents, have increased (39,40). During 2011–
disorders among children are critical public health issues. 2019, suicide was the second leading cause of death among
Data on indicators of good and poor mental health, including persons aged 10–29 years in the United States (41).
mental disorders, can indicate where mental health promotion A 2013 report described federal surveillance efforts that
strategies are needed and how programs are affecting the mental included measures of children’s mental health and mental
health of the population. disorders (8). The report identified gaps in children’s mental
Public health surveillance focuses on determining the health surveillance, including the need for 1) standard case
prevalence of health conditions, can be used to monitor trends definitions of mental disorders to improve comparability and
and changes in prevalence across subpopulations, and increases reliability of estimates across surveillance systems; 2) surveillance
knowledge about sociodemographic and geographic differences of mental disorders among preschool-age children; and
in health indicators, which in turn increases knowledge of 3) surveillance of anxiety disorders (overall and by specific type),
social determinants of health that affect health equity (23,24). bipolar disorder, and other mental disorders that occur less
Thus, public health surveillance provides the foundation for commonly in children. Since then, available information about
decision-making (28). Although mental health has increasingly children’s mental health has increased. For example, although the
become a focus of public health, surveillance efforts regarding need for standard case definitions has not yet been systematically
mental health and mental disorders both among adults and addressed, more attention has been paid to the mental health of
children have faced various challenges, including insufficient preschool-age children (36,42–45) and the prevalence of anxiety
timeliness; limited availability of data sources, particularly for in children (17,42), and understanding of the impact of health
state and local data; and lack of measures that are consistent and equity on the development and diagnosis of mental disorders
include a full set of specific disorders (8,29,30). For example, has increased (2,37,46,47).
attempts at monitoring progress on effective treatments for In addition to increased attention to mental health,
mental disorders in the United States are often limited because prevalence estimates might reflect revised diagnostic criteria
of lack of adequate data sources. Treatment for ADHD or published in DSM-5 in 2013 (1). Surveillance also might
autism spectrum disorder (ASD) has been monitored using be affected by policy changes at the national and state levels
the National Survey of Children’s Health, and treatment for a regarding access to care, including the promotion of integrating
major depressive episode (MDE) can be monitored with data primary and behavioral health services (48–50) and specific

2 MMWR / February 25, 2022 / Vol. 71 / No. 2 US Department of Health and Human Services/Centers for Disease Control and Prevention
provisions for children with preexisting conditions (e.g., the on Drug Use and Health (NSDUH), the National Violent
Mental Health Parity and Addiction Equity Act and the Patient Death Reporting System (NVDRS), the National Vital
Protection and Affordable Care Act) (51–54). Statistics System (NVSS), the School-Associated Violent
This report updates and expands the 2013 surveillance Death Surveillance System (SAVD-SS), and the national Youth
report on mental health among children (8). Similar to the Risk Behavior Survey (YRBS). Each of the data systems was
2013 report, this report provides an overview of nine federal designed to address different objectives, and the systems vary in
surveillance systems that collect data related to children’s mental methods (e.g., in-person interview, online questionnaire, vital
health in the United States and the most recent estimates statistics data, and parent report or self-report). Each system
(2013–2019) available from these systems, including estimates assesses different aspects of mental health, and the specific
according to selected sociodemographic characteristics indicators included vary by survey; for example, although
linked to social determinants of health, such as age, sex, four systems include indicators of depression, the specific
race and ethnicity, economic resources, parent education, indicator is unique to each system. The data include persons
access to health insurance, and geographic classification (23). ranging in age from 6 months to 19 years; although 17 years
In addition, whereas the 2013 report focused on national was the maximum age for most surveys, YRBS also included
estimates of mental disorders and indicators of poor mental high school students aged ≥18 years, and data on suicides
health among children, this report also includes data on included persons aged 10–19 years for consistency with how
1) receipt of mental health services among children, 2) positive these data are typically presented. Parents, guardians, and
indicators of mental health, and 3) state-level estimates. First, caregivers who answered survey questions as proxies for youths
this report includes data on receipt of mental health services are collectively referred to as parents in this report. Following
among all children. These data are an indicator of the impact is a detailed description of the nine federal data systems and
of mental disorders or symptoms of mental disorders on the their associated data that are presented in this report, as well as
service system, the costs associated with mental disorders, a summary of each system (Tables 1 and 2). State-level ranges
and access to specialized health services. Describing patterns are presented when available; individual state prevalences are
of mental health services by subgroups might identify gaps in also available in the supplementary tables (Supplementary
access to services or treatment for mental disorders and provide Tables 1–4; https://stacks.cdc.gov/view/cdc/113924). The
information to address health inequities (30,55,56). Second, most recent data available at the time the report was written
this report includes several positive indicators of mental health are described and presented.
that are measured on a continuum to provide a more inclusive
picture of children’s mental health status. Third, this report Autism and Developmental Disabilities
includes state-level estimates when possible. State estimates Monitoring Network
are important because they describe the heterogeneity of The ADDM Network is an active surveillance program
smaller geographic units, can reflect the results of state-level conducted by CDC that provides estimates of the prevalence
practices and policies, and provide actionable information of ASD among children aged 4–8 years whose parents or
for program planning and resource allocation at a more local guardians live in geographically defined areas of the United
level (57,58). The findings in this report can be used by public States. The ADDM Network has reported population-based
health professionals, health care providers, state health officials, estimates of ASD prevalence among children aged 8 years in
policymakers, and educators to understand the prevalence of even-numbered years since 2000. The most recent data at the
specific mental disorders and other indicators of mental health time the report was written are from 11 geographically diverse
and the challenges related to mental health surveillance. sites that conducted population-based ASD surveillance for
2016. Surveillance is conducted in two phases. The first phase
involves review and abstraction of comprehensive evaluations
Methods that were completed by medical and educational service
providers in the community. In the second phase, experienced
Description of Surveillance Systems clinicians systematically review all abstracted information to
Nine data systems with indicators of children’s mental health determine ASD case status. The case definition is based on
were identified, including the Autism and Developmental ASD criteria described in DSM-5 (1).
Disabilities Monitoring Network (ADDM), the National Although not nationally representative, ASD prevalence
Health and Nutrition Examination Survey (NHANES), the estimates are available by site, and the sample size allows
National Health Interview Survey (NHIS), the National for estimation and comparisons of sociodemographic
Survey of Children’s Health (NSCH), the National Survey characteristics within each participating community. Although

MMWR / February 25, 2022 / Vol. 71 / No. 2 3

TABLE 1. Federal surveys and surveillance systems that collect data on children’s mental health — United States
Child-related mental health Populations and
Name, website, sponsor Description Method of data collection Topics related to children topics and questions periodicity

Autism and The ADDM Network is a group Screening and abstraction of Baseline data on ASD Describes the population of Ongoing since 2000,
Developmental of programs funded by CDC to existing health and education prevalence in participating children with ASDs in terms with data available for
Disabilities determine the prevalence of records containing professional communities; comparisons of 1) documented even-numbered years
Monitoring (ADDM) ASDs in U.S. communities. assessments of the child’s between different groups of co-occurring conditions and through 2016
Network The ADDM sites collect data developmental progress at children and different areas 2) timing of earliest Population-based,
https://www.cdc.gov/ using the same surveillance health care or education of the country evaluation and diagnosis geographically
ncbddd/autism/addm. methods, which are modeled facilities Characteristics of the population defined communities
html after CDC’s Metropolitan of children with ASDs in different U.S. states,
CDC, National Center on Atlanta Developmental Changes in ASD identification selected through
Birth Defects and Disabilities Surveillance over time competitive process
Developmental Program. Impact of autism and related In 2016, monitored ASD
Disabilities conditions in selected U.S. among 275,000
communities children aged 8 yrs
Risk factors and 72,000 aged 4 yrs
National Health and NHANES is an ongoing In-person household interviews Nutrition and nutritional Alcohol and drug use Ongoing since 1999
Nutrition Examination cross-sectional survey by trained interviewers using disorders Depression (PHQ-9 since 2005) Nationally
Survey (NHANES) designed to assess the health computer-assisted personal Environmental risk factors Use of mental health care services representative sample
https://www.cdc.gov/ and nutritional status of interviewing; private interviews Health care use Psychotropic medication use 5,000 persons per year,
nchs/nhanes noninstitutionalized persons in medical examination center Mental, behavioral, and Functional limitations caused including
CDC, National Center for of all ages in the United States. Nutritional assessments emotional problems of children by long-term physical, approximately 1,600
Health Statistics Laboratory tests Infectious diseases mental, and emotional persons aged 3–17 yrs
Physical examinations Weight and physical activity conditions or illness Oversampling, which
Dietary supplements and Mental disorder diagnosis for changes periodically; in
prescription medications specific disorders using the 2013–2014, 2015–2016,
Medical conditions and Diagnostic Interview and 2017–2018,
health indicators, including Schedule for Children oversampled persons
disability (measured and (1999–2004) with low incomes and
self-report) Mentally unhealthy days Hispanic, Black, and
Health insurance status and type (2001–2014) Asian persons
National Health NHIS monitors a broad range of In-person household interview (of Health status, selected health ASD (ever and current) and Ongoing household
Interview Survey health topics among the U.S. parent or knowledgeable adult conditions and illnesses, ADHD or ADD (ever and survey representative
(NHIS) civilian noninstitutionalized who lives in the household and disability, selected current) of the U.S. civilian
https://www.cdc.gov/ population, including children answers on behalf of one randomly educational services, health Use of mental health care or noninstitutionalized
nchs/nhis aged 0–17 yrs. selected child in the family) insurance status and type, counseling population
CDC, National Center for conducted by trained interviewers and health care access Strengths and Difficulties Has collected data for
Health Statistics using computer-assisted personal Questionnaire children annually
interviewing, with telephone since 1997
follow-up when needed
National Survey of NSCH is a cross-sectional, Parent/caregiver-administered Physical and mental health Diagnosis (ever and current) Annual survey
Children’s Health address-based survey questionnaire online and on paper status and severity of depression, representative of
(NSCH) conducted by the Census Health and functional status, anxiety problems, behavioral noninstitutionalized
http://mchb.hrsa.gov/ Bureau that collects including approximately 20 or conduct problems, children aged 0–17 yrs
data-research/ information on the health and current or lifelong Tourette syndrome, and ADD at the national and
national-survey- well-being of children aged conditions or ADHD state levels
childrens-health 0–17 yrs and related health Health insurance status, type, Diagnosis (ever and current) and
Health Resources and care, family, and community- and adequacy severity of ASD, as well as age at
Services level factors that can influence Access to and use of health diagnosis and type of provider
Administration, health. care services who made first diagnosis
Maternal and Child Data from NSCH are the only Preventive and specialty care Current medication treatment
Health Bureau source of both national- and Medical home for autism, ASD, Asperger’s
state-level estimates on School readiness (3–5 yrs) disorder, PDD, and ADHD
specified measures of child Transition to adult health Receipt of behavioral
health. care (12–17 yrs) treatment in past year for
NSCH was redesigned for 2016, Family health and activities ASD and ADHD
combining two previously Impact of child’s health on Receipt of treatment or
separate Maternal and Child family counseling in past year from
Health Bureau quadrennial Parent/caregiver health a mental health professional
surveys, the National Survey status Medication use in past year
of Children with Special Parent/caregiver perceptions because of difficulties with
Health Care Needs, and NSCH. of neighborhood emotions, concentration,
characteristics or behavior
Access to community-based Positive indicators (indicate
services child is flourishing):
affectionate and tender,
bounces back quickly, smiles
and laughs, interest in and
curiosity about learning new
things, works to finish tasks,
stays calm and in control
when faced with a challenge
See table footnotes on page 6.

4 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 1. (Continued) Federal surveys and surveillance systems that collect data on children’s mental health — United States
Child-related mental health Populations and
Name, website, sponsor Description Method of data collection Topics related to children topics and questions periodicity

National Survey on NSDUH provides up-to-date In-person household interviews Timing and frequency of use Major depressive episode ever Began in 1971 and has
Drug Use and Health information on tobacco, by trained interviewers using of tobacco products, (lifetime) and in past year been administered by
(NSDUH) alcohol, and drug use; mental audio computer-assisted alcohol, marijuana, cocaine, Substance use disorder, overall SAMHSA since 1992
https://www.samhsa. health; and other health- self-interviewing (ACASI) heroin, inhalants, and by substance type (e.g., Conducted every year
gov/data/data-we- related issues in the United hallucinogens, and illicit drug use disorder or in all 50 states and the
collect/ States. prescription drugs alcohol use disorder) and District of Columbia,
nsduh-national-survey- Information from NSDUH is Risk and protective factors treatment with approximately
drug-use-and-health used to support prevention Health care use Level of impairment resulting 70,000 people aged
SAMHSA, Center for and treatment programs, Health insurance status and type from major depressive ≥12 yrs interviewed
Behavioral Health monitor substance use trends, episodes each year
Statistics and Quality estimate the need for Treatment for depression National and state
treatment, and guide public Mental health service use representative sample
health policy. Parental mental illness,
substance use, and
substance use disorder
National Violent Death NVDRS is a state-based active Death certificates, coroner/ Violent deaths: suicides, Numerous precipitating Expanded in 2018 with
Reporting System surveillance system that medical examiner reports, law homicides, deaths from circumstances that are the addition of 10
(NVDRS) collects data on the enforcement reports, and legal intervention (a associated with suicide, new states (Arkansas,
https://www.cdc.gov/ characteristics and secondary sources (e.g., child subtype of homicide), child including history of mental Florida, Idaho,
violenceprevention/ circumstances associated with fatality review team data, maltreatment deaths, and health problems or Mississippi, Montana,
datasources/nvdrs/ violence-related deaths in supplemental homicide reports, intimate partner homicides substance abuse; current North Dakota, South
index.html participating states and hospital data, and crime Other deaths: deaths from diagnosis or treatment for Dakota, Tennessee,
CDC, National Center for territories. laboratory data) undetermined intent and mental health problems; Texas, and Wyoming)
Injury Prevention and unintentional firearm history of suicide, thoughts, that began data
Control deaths plans, or attempts; collection in 2019; in
interpersonal problems; life 2019, all 50 states, the
stressors; and suicide District of Columbia,
disclosure and Puerto Rico
collected data for
the system
National Vital Statistics Vital statistics mortality data are Death certificates, which are Underlying cause of death Information for children who Ongoing since 1900
System (NVSS) a fundamental source of completed by funeral directors, Multiple causes of death die as a result of suicide or to present
https://www.cdc.gov/ demographic, geographic, attending physicians, medical Year, month, and day of week from other causes of death Did not include all
nchs/nvss/deaths.htm and cause-of-death examiners, and coroners, with of death that are related to mental states before 1933
CDC, National Center for information in the United causes of death processed in Residence of decedent (state, health (e.g., drug overdose) Includes information on
Health Statistics States. The data are used to accordance with the county, city, population size) all deaths occurring in
present characteristics of International Classification of State and county of the United States
those dying in the United Diseases, Tenth Revision occurrence Final annual data
States, to understand causes Demographic information published yearly;
of death, to determine life about decedent (e.g. age at provisional data
expectancy, and to compare death, sex, education, race, released quarterly,
mortality trends with those in ethnicity, marital status, and monthly, and weekly for
other countries. state of birth) specific cause of death
School-Associated SAVD-SS is an active Potential SAVD cases are Circumstances that Whether the victim and Since 1994
Violent Death surveillance system that identified through a systematic precipitated incidents (e.g., perpetrator had a suspected Identifies and collect
Surveillance System collects data on the media scan of newspaper and dating partner problems, or diagnosed mental health data on all U.S.
(SAVD-SS) characteristics and broadcast media databases via other relationship condition, suicidal ideation, incidents in which
https://www.cdc.gov/ circumstances surrounding LexisNexis using keywords to problems, disciplinary or history of suicide attempt lethal violence occurs
violenceprevention/ school-associated violent capture reports of violent issues, bullying or other Whether victim and 1) on the campus of a
youthviolence/ deaths (homicides, suicides, deaths. Cases are then problems experienced in perpetrator were using functioning public or
schoolviolence/savd.html and legal intervention deaths) confirmed with local law the school setting, and alcohol or substances at the private primary or
CDC, National Center for that occur in and around enforcement or school officials history of criminal or legal time of death or regularly secondary school,
Injury Prevention and school settings throughout familiar with the incident to problems) used alcohol or substances 2) while the victim was
Control the United States. ascertain whether they meet Potential risk factors for Whether victim and on the way to or from
SAVD-SS inclusion criteria, and perpetration and perpetrator were victimized regular sessions at such
the law enforcement report is victimization or had perpetrated violence a school, or 3) while the
obtained when possible. Possible prevention measures in the past victim was attending
Demographic and circumstance Warning signs or traveling to or from
data are abstracted from law an official school-
enforcement reports, death sponsored event
certificates, coroner and medical Beginning in 2021,
examiner reports (if contained in will collect data via
the law enforcement report), NVDRS (described in
interviews with law enforcement previous row)
and school officials, or articles
published in the media when a
reliable source is cited (i.e., a law
enforcement or school official or
judicial proceedings regarding
the incident).
See table footnotes on page 6.

MMWR / February 25, 2022 / Vol. 71 / No. 2 5

TABLE 1. (Continued) Federal surveys and surveillance systems that collect data on children’s mental health — United States
Child-related mental health Populations and
Name, website, sponsor Description Method of data collection Topics related to children topics and questions periodicity
National Youth Risk The Youth Risk Behavior Anonymous, school-based survey Behaviors that contribute to Persistent feelings of sadness Biennial since 1991
Behavior Survey Surveillance System monitors unintentional injuries and or hopelessness (odd years)
(YRBS) health behaviors and violence Suicidal ideation and suicide Nationally
https://www.cdc.gov/ experiences among U.S. high Tobacco use attempts representative
yrbss school students that Alcohol and other drug use samples of public and
CDC, National Center for contribute to the leading Sexual behaviors that private high school
HIV, Viral Hepatitis, STD, causes of mortality, morbidity, contribute to unintended students
and TB Prevention and social problems among pregnancy and sexually (grades 9–12)
youths and adults. transmitted infections State, tribal, territorial,
The system includes a national Unhealthy dietary behaviors and local school
YRBS conducted by CDC and Inadequate physical activity district data also
separate state, tribal, Prevalence of obesity and available
territorial, and local school asthma and other
district YRBSs. health-related behaviors
and experiences

Abbreviations: ADD = attention-deficit disorder; ADHD = attention-deficit/hyperactivity disorder; ASD = autism spectrum disorder; PDD = pervasive developmental disorder; PHQ-9 = nine-item
Patient Health Questionnaire; SAMHSA = Substance Abuse and Mental Health Services Administration.

individual-level ADDM Network data are not publicly and adolescents aged 12–17 years (collectively referred to as
available, various site-level or group-level results are available adolescents in this report), are available to researchers through
(https://www.cdc.gov/ncbddd/autism/addm.html), and CDC the CDC Research Data Center (https://www.cdc.gov/rdc).
has an interactive website that allows ADDM data to be For this report, the data have been pooled for NHANES cycles
visualized or downloaded along with other state-based sources 2013–2014, 2015–2016, and 2017–2018. The 2019–2020
of ASD prevalence data (https://www.cdc.gov/ncbddd/autism/ NHANES cycle was not completed because of the onset of
data/index.html). the COVID-19 pandemic, and the data for the cycle collected
The results presented in this report are based on 2016 in 2019 through March 2020 have been combined with the
data. Among 275,409 children aged 8 years living in the prepandemic 2017–2018 data for future analysis; however,
geographically defined areas comprising the 11 sites, a total of these data were not available for this report. Across these cycles,
5,108 children were identified as having ASD. For other mental overall NHANES interview response rates ranged from 71.0%
health indicators, the ADDM Network sites review children’s to 51.9%; MEC examination response rates ranged from
medical and educational evaluations and collect information 68.5% to 48.8%. Response rates for adolescents and young
on co-occurring diagnoses of mental disorders such as ADHD, adults aged 12–19 years were approximately 5 percentage
anxiety, and depression among children with ASD. points higher than the overall response rates in every cycle.
NHANES estimates for this report are based on data collected
National Health and Nutrition Examination Survey during the in-home interview and private in-person MEC interview.
NHANES is a continuous cross-sectional survey on health Since the 2005–2006 administration, NHANES has included
and nutrition conducted by CDC (https://www.cdc.gov/nchs/ the nine-item Patient Health Questionnaire (PHQ-9) to measure
nhanes). NHANES uses a multistage probability household depression symptoms (60). The PHQ-9 screening instrument
sampling design to obtain nationally representative estimates consists of nine questions about depression symptoms during the
of health indicators for the U.S. civilian noninstitutionalized past 2 weeks followed by a single question that assesses associated
population of all ages. Since 2011, NHANES has oversampled impairment; the resulting scores are used to determine depression
Hispanic, non-Hispanic Asian (Asian), and non-Hispanic severity and range from 0 to 27 (60). Adolescent self-reports on
Black or African American (Black) persons to increase the depression symptoms were collected during the MEC interview.
reliability and precision of estimates for these subgroups. The PHQ-9 has been estimated to have a sensitivity of 89.5%
Data are collected through examination and assessments in and a specificity of 77.5% for detecting adolescents who meet
a mobile examination center (MEC), as well as interviews the DSM-IV (61) criteria for major depression on the Diagnostic
in the home. Health indicators have included cardiovascular Interview Schedule for Children, Version IV (DISC-IV) (62,63).
disease, diabetes, obesity, environmental exposures, infectious In this report, weighted estimates of depression are based on a score
diseases and vaccination, mental health, oral health, dietary of ≥10 for adolescents aged 12–17 years who completed the MEC
intake, and supplement and prescription medication use interview for NHANES during 2013–2018. In past NHANES
(59). NHANES data are released in 2-year cycles. Most data cycles, other mental health assessments were administered to youths,
are available online (https://www.cdc.gov/nchs/nhanes); such as diagnostic modules from DISC during 1999–2004 (64).
restricted data, such as depression symptoms for children

6 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 2. Mental disorders and indicators among persons aged 0–19 years, by surveillance system and age group — United States, 2013–2019
Surveillance system and age group (yrs)
ADDM
Network NHANES NHIS NSCH NSDUH NVDRS NVSS SAVD-SS National YRBS
Disorder or
indicator 8 12–17 3–17 0–17 12–17 10–19 10–19 10–18 ~14–18*
Attention-deficit/ NA NA Parent report of Parent report of NA NA NA NA NA
hyperactivity diagnosis by a diagnosis by a
disorder health care health care
provider (ever, provider (ever,
current) current)
Behavior NA NA NA Parent report of NA NA NA Law enforcement NA
problems diagnosis by a or school
health care official report of
provider (ever, decedents’
current) history of
behavior
problems at
home or in
school
Depression NA Youth self-report of NA Parent report of Youth self-report NA Depression Law enforcement Youth self-report
current depression diagnosis by a of major might be or school of feeling so
(depression health care depressive inconsistently official report of sad or hopeless
during past 2 wks, provider (ever, episode (ever, reported on decedents’ almost every
score of ≥10 on current) past year)† the death history of day for ≥2 wks
PHQ-9 depression certificate depressed in a row that
screener) mood or they stopped
documented doing some
diagnosis of usual activities
depression
Anxiety NA NA NA Parent report of NA NA Anxiety might be NA NA
diagnosis by a inconsistently
health care reported on the
provider (ever, death certificate
current)
Autism spectrum Medical NA Parent report of Parent report of NA NA NA NA NA
disorder record diagnosis by a diagnosis by a
abstraction, health care health care
surveillance provider (ever, provider (ever,
case criteria current) current)
met§
Tourette NA NA NA Parent report of NA NA NA NA NA
syndrome diagnosis by a
health care
provider (ever,
current)
Substance use NA NA NA —¶ Youth self-report NA Substance use NA NA
disorder of dependence disorder might
on or abuse of be
alcohol or one inconsistently
or more illicit reported on
drugs (in past the death
year) based on certificate
DSM-IV criteria
Suicidality NA NA NA NA NA Death records; Death records; Surveillance of Youth self-report
deaths per deaths per school- of seriously
100,000 100,000 associated considering
suicide based attempting
on systematic suicide, making
media scan of a suicide plan,
computerized attempting
newspaper and suicide ≥1 time,
broadcast and making a
media suicide attempt
databases and ≥1 time that
confirmation resulted in
with local law injury,
enforcement poisoning, or
Law enforcement overdose that
or school official had to be
report of treated by a
decedents’ physician or
history of nurse (during
suicidal the 12 months
thoughts and before the
suicide attempts survey for all
four measures)
See table footnotes on the next page.

MMWR / February 25, 2022 / Vol. 71 / No. 2 7

TABLE 2. (Continued) Mental disorders and indicators among persons aged 0–19 years, by surveillance system and age group — United States,
2013–2019
Surveillance system and age group (yrs)
ADDM
Network NHANES NHIS NSCH NSDUH NVDRS NVSS SAVD-SS National YRBS
Disorder or
indicator 8 12–17 3–17 0–17 12–17 10–19 10–19 10–18 ~14–18*
Treatment NA Parent report of Parent report of Parent report of Youth self-report NA NA Law enforcement NA
child currently child receiving child receiving of child or school
using mental health mental health receiving official report of
psychotherapeutic consultation treatment by a mental health decedents’
agents (in past with professional§§ services history of
30 days) professional** and past year (specialty or mental health
Parent report of or general medication for nonspecialty) treatment
child receiving physician †† mental health provided by a
mental health problems¶¶ counselor
consultation with (including a
a professional** school
counselor) or
clinician
Positive indicators NA NA NA Parent report of NA NA NA NA NA
affection, resilience,
and positivity (for
children aged
6 mos–5 yrs);
curiosity
(6 mos–17 yrs); and
persistence and
self-control
(6–17 yrs)
Abbreviations: ADDM = Autism and Developmental Disabilities Monitoring; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; MDE = major depressive episode;
NA = not applicable; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSCH = National Survey of Children’s Health; NSDUH = National
Survey on Drug Use and Health; NVDRS = National Violent Death Reporting System; NVSS = National Vital Statistics System; PHQ-9 = nine-item Patient Health Questionnaire; SAVD-SS = School-
Associated Violent Death Surveillance System; YRBS = Youth Risk Behavior Survey.
* Survey participants were public and private high school students in grades 9–12 (i.e., primarily aged 14–18 years).
† Ever MDE: reported at least five or more of nine symptoms nearly every day in the same 2-week period during their lifetime, in which at least one of the symptoms was depressed mood
or loss of interest or pleasure in daily activities; MDE in past year: 1) had ever had an MDE, as well as 2) had a period of time in the past 12 months when they felt depressed or lost interest
or pleasure in daily activities for ≥2 weeks and 3) during this period of ≥2 weeks, they had some of the other problems they reported associated with ever having had an MDE.
§ Case definition based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria for autism spectrum disorder. Clinicians applied the case definition through a review of
information systematically collected from developmental evaluations completed by medical and educational service providers in the community.
¶ NSCH included a question about parent report of a health care provider diagnosis for substance use disorder for children aged 6–17 years in the 2016–2019 surveys. These data are not
included in this report because NSCH removed this item as of 2020 due to small samples and concerns about validity with parental report.
** “During the past 12 months, have you seen or talked to...a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker...about child’s health?”
†† “Did you see or talk to this general doctor because of an emotional or behavioral problem that [child] may have?”
§§ “During the past 12 months, has this child received any treatment or counseling from a mental health professional?”
¶¶ “During the past 12 months, has this child taken any medication because of difficulties with his or her emotions, concentration, or behavior?”

Information on use of mental health services, including classification of the youth as using psychotropic medication:
receiving care from a mental health professional (ages 4–17 years) antidepressant medications; central nervous system stimulants;
and use of psychotropic medication (ages 3–17 years), was anxiolytics, sedatives, and hypnotics; antimanic medications;
obtained during the NHANES home interview, with self- and antipsychotic medications.
reports from adolescents aged ≥16 years and from parents
for those aged <16 years. Use of mental health services was National Health Interview Survey
assessed by the questions, “During the past 12 months, have NHIS is a survey of a nationally representative sample of the
you seen or talked to a mental health professional such as a civilian noninstitutionalized U.S. population and is conducted
psychologist, psychiatrist, psychiatric nurse, or clinical social continuously throughout the year by CDC to monitor the
worker about (his/her/your) health?” and “In the past 30 days, health of the U.S. population (https://www.cdc.gov/nchs/
have you used or taken any medication for which a prescription nhis). NHIS is an in-person interview conducted in the
is needed?” Those who responded “yes” to the medication respondent’s home; in some instances, a follow-up to complete
question were asked to provide containers of all prescription the interview is conducted via telephone. For interviews
medications, and interviewers recorded the product name. completed during 1997–2018, families were identified within
Products were identified using a proprietary, comprehensive each sampled household, and a family member completed a
database of prescription and certain nonprescription drugs brief questionnaire on selected demographic and broad health
(Lexicon Plus, Cerner Multum, Inc.) and classified according measures. From each family in the household, one adult and
to a three-level classification scheme (65). Reported use of one child were randomly selected to receive a more detailed
any of the following psychotropic medications resulted in the health questionnaire. A parent answered questions for one

8 MMWR / February 25, 2022 / Vol. 71 / No. 2

randomly selected child or adolescent aged 0–17 years. NHIS and is conducted by the Census Bureau using both online
data are publicly available online (https://www.cdc.gov/nchs/ and paper methods. Data are collected from a parent in the
nhis); restricted data are available to researchers through the household who is knowledgeable about the health and health
NCHS Research Data Center (https://www.cdc.gov/rdc). care of one randomly selected child. Data provide both
Data included in this report are pooled from the 2017 and national and state estimates on key measures of child health.
2018 surveys, which included 8,845 and 8,269 children and The data are subject to error arising from various sources,
adolescents aged 0–17 years, respectively. The total household including sampling and nonsampling errors. Additional general
response rate was 66.5% in 2017 and 64.2% in 2018, and the information is available (https://mchb.hrsa.gov/data/national-
final response rate for the sample child component was 60.6% surveys), and NSCH data and questionnaires are publicly
in 2017 and 59.2% in 2018. available online (https://mchb.hrsa.gov/data/national-surveys/
NHIS has included questions on ASD and ADHD annually questionnaires-datasets-supporting-documents).
since 1997, with some changes in the ASD measure over NSCH was redesigned for 2016, combining two previously
time. For ADHD, parents were asked, “Has a doctor or separate HRSA MCHB quadrennial surveys, the National
health professional ever told you that [child] had attention- Survey of Children with Special Health Care Needs
deficit/hyperactivity disorder (ADHD) or attention-deficit (NS-CSHCN) and NSCH (66). Because of changes in
disorder (ADD)?” Since 2014, the ASD question wording the mode of data collection and sampling frame, as well as
has been consistently phrased as, “Has a doctor or health adjustments to item wording as needed, estimates from the
professional ever told you that [child] had autism, Asperger’s redesigned 2016 survey cannot be directly compared with
disorder, pervasive developmental disorder, or autism spectrum those from earlier years, nor can trend analyses using data
disorder?” Beginning in 2016, follow-up questions were added collected before and after 2016 be conducted (66). Since
to determine current diagnoses: “Does [child] currently have 2016, NSCH data have been collected annually. A total of
attention-deficit/hyperactivity disorder (ADHD) or attention- 50,212 questionnaires were completed for the 2016 NSCH,
deficit disorder (ADD)?” and “Does [child] currently have followed by 21,599 in 2017, 30,530 in 2018, and 29,433 in
autism, Asperger’s disorder, pervasive developmental disorder, 2019. The overall weighted response rate was 40.7% in 2016,
or autism spectrum disorder?” 37.4% in 2017, 43.1% in 2018, and 42.4% in 2019; the
To assess use of mental health services, NHIS included the weighted interview completion rate (or the probability that a
following question on mental health care consultations for household that initiates the survey completes it) was 69.7%,
emotional or behavioral problems: “During the past 12 months, 70.9%, 78.0%, and 79.5%, respectively. Approximately 75%
have you seen or talked to any of the following health care of questionnaires were completed online each year.
providers about [child’s] health? A mental health professional NSCH assesses and reports data on the presence of
such as a psychiatrist, psychologist, psychiatric nurse, or clinical diagnosed mental health problems or conditions in children
social worker?” In addition, for those who reported having and adolescents aged 0–17 years. Parents were asked about
consulted with a general physician in the past 12 months, a 1) depression, 2) anxiety problems, 3) behavioral or conduct
follow-up question was used to address whether the physician problems, 4) autism or ASD, 5) Tourette syndrome, and
was consulted specifically for emotional or behavioral problems: 6) attention-deficit disorder (ADD) or ADHD. For each
“Did you see or talk to this general doctor because of an condition, parents were asked whether they had ever been told
emotional or behavioral problem that [child] may have?” The by a doctor or other health care provider that their child had the
denominator included all children, regardless of whether they condition and whether the child currently had the condition;
had consulted a general physician in the past 12 months. for behavioral or conduct problems, parents also were asked to
consider reports from educators, including teachers and school
National Survey of Children’s Health nurses. For children with current problems or conditions,
NSCH is an annual, cross-sectional, address-based survey parents were asked to rate the severity of their child’s condition
that collects information on the health and well-being of as mild, moderate, or severe. NSCH also assesses and reports
children and adolescents aged 0–17 years, as well as related data on receipt of mental health treatment among children and
health care, family, and community factors that can influence adolescents aged 0–17 years. Parents were asked whether their
health (https://mchb.hrsa.gov/data-research/national-survey- children received mental health treatment or counseling or took
childrens-health). NSCH is funded and directed by the medications for a problem with emotions, concentration, or
Health Resources and Services Administration’s Maternal and behavior. Additional treatment indicators that were available
Child Health Bureau (HRSA MCHB), with co-sponsorship from NSCH only for a selected subset of disorders such as
from CDC, the U.S. Department of Agriculture, and others, medication or behavioral treatment specifically for ADHD

MMWR / February 25, 2022 / Vol. 71 / No. 2 9

and ASD were not included. Data included in this report for household screening, 66.6% for interviewing, and 48.8% overall
diagnoses and treatment are from the 2016–2019 surveys. (69). In 2019, screening was completed at 148,023 addresses,
NSCH also includes parent responses to items that can and 67,625 completed interviews were obtained, including
be used as positive indicators of mental health (67,68). 16,894 interviews from adolescents aged 12–17 years. The
For children aged 6 months–5 years, parents were asked weighted response rates were 70.5% for household screening,
how often the child 1) is affectionate and tender (labeled 64.9% for interviewing, and 45.8% overall (70).
affection), 2) bounces back quickly when things do not go NSDUH uses ACASI to assess whether adolescents aged
his or her way (labeled resilience), and 3) smiles and laughs 12–17 years ever experienced an MDE (i.e., lifetime MDE)
a lot (labeled positivity). For children and adolescents aged as defined by DSM-IV (61) or experienced an MDE in the
6 months–17 years, parents were asked how often the child past year. Lifetime MDE is defined as ever having at least five
shows interest and curiosity in learning new things (labeled or more of nine symptoms of depression in the same 2-week
curiosity). For children and adolescents aged 6–17 years, period, in which at least one of the symptoms was a depressed
parents were asked how often the child 1) works to finish mood or loss of interest or pleasure in daily activities. An
tasks that have been started (labeled persistence) and 2) stays adolescent was defined as having an MDE in the past year if
calm and in control when faced with a challenge (labeled self- they met all of the following criteria: 1) had ever had an MDE,
control). Beginning in 2018, response options for the positive as well as 2) had a period of time in the past 12 months when
indicators were always, usually, sometimes, and never. Children they felt depressed or lost interest or pleasure in daily activities
were considered to meet the indicator criteria if the parent for ≥2 weeks and 3) during this period of ≥2 weeks, they had
answered usually or always. Data included in this report for some of the other problems they reported associated with ever
positive indicators are from the 2018–2019 surveys. having had an MDE.
NSDUH collects data on substance use disorders and types
National Survey on Drug Use and Health of substance use disorders (e.g., alcohol use disorder and illicit
NSDUH is the primary source of statistical information on drug use disorder) annually. In the 2018 and 2019 surveys,
the use of illicit drugs, alcohol and tobacco use, substance use substance use disorder was defined as meeting the DSM-IV
disorders, MDEs, and receipt of mental health and substance use criteria for either dependence or abuse for alcohol or one or
services among the civilian, noninstitutionalized population aged more illicit drug. NSDUH also used DSM-IV dependence or
≥12 years in the United States, all 50 states, and the District of abuse criteria to define alcohol use disorder and illicit drug use
Columbia (DC) (https://www.samhsa.gov/data/data-we-collect/ disorder (61). Additional information on the criteria NSDUH
nsduh-national-survey-drug-use-and-health). Conducted by the uses for substance use disorders are available online (70). Illicit
federal government since 1971 (annually since 1990), NSDUH drug use disorder included dependence or abuse of one or
is sponsored by the Substance Abuse and Mental Health Services more of the following illicit drugs: marijuana, cocaine, heroin,
Administration (SAMHSA). For the years analyzed, NSDUH hallucinogens, inhalants, methamphetamine, or prescription
collected data through in-person interviews of household psychotherapeutic drugs that were misused (i.e., pain relievers,
residents, persons living in noninstitutional group settings, tranquilizers, stimulants, and sedatives). One clinical validation
and civilians living on military bases. NSDUH collects data study compared the NSDUH instrument with the Pittsburgh
using audio computer-assisted self-interviewing (ACASI) for Adolescent Alcohol Research Center’s Structured Clinical
sensitive items in which respondents read or listen to questions Interview (71). The level of agreement was fair to moderate
through headphones and then enter their answers directly into overall, with sensitivity values of 81%–95% and specificity
an NSDUH laptop computer. values of 48%–63% for substance abuse or dependence
NSDUH is a state and nationally representative survey with (71). The 2006 NSDUH Reliability Study, which compared
approximately 150,000 addresses screened and approximately responses on interviews conducted 5–15 days apart, reported
67,500 respondents interviewed each year. Adolescents and a Kappa value of 0.67 for illicit drug or alcohol use disorders
young adults are oversampled. Additional general information and was 0.62 for illicit drug use disorders (72).
about NSDUH is available (https://www.samhsa.gov/data/ The 2018 and 2019 NSDUH survey years included
data-we-collect/nsduh-national-survey-drug-use-and-health), questions to estimate the use of mental health services among
and NSDUH data are publicly available online (https://www. adolescents aged 12–17 years. In addition to asking about
datafiles.samhsa.gov). In 2018, screening was completed at treatment for depression, the surveys also included questions
141,879 addresses, and 67,791 completed interviews were about receipt of any services for emotional or behavioral
obtained, including 16,852 interviews from adolescents aged problems not caused by substance use. The NSDUH interview
12–17 years. The weighted response rates were 73.3% for section on use of mental health services among youths asks

10 MMWR / February 25, 2022 / Vol. 71 / No. 2

adolescent respondents whether they received any treatment or collection in 2009; in 2017, California collected NVDRS data
counseling in the 12 months before the interview in specialty from all three required sources (i.e., death certificates, coroner
and nonspecialty settings. Specialty mental health settings or medical examiner reports, and law enforcement reports)
include services in outpatient or inpatient settings. Outpatient from four counties (Los Angeles, Sacramento, Shasta, and
services include 1) a private therapist, psychologist, psychiatrist, Siskiyou). NVDRS received funding in 2018 for a nationwide
social worker, or counselor; 2) a mental health clinic or center; expansion that included the remaining 10 states (Arkansas,
3) a partial day hospital or day treatment program; or 4) an Florida, Idaho, Mississippi, Montana, North Dakota, South
in-home therapist, counselor, or family preservation worker. Dakota, Tennessee, Texas, and Wyoming), which began data
Inpatient or residential specialty mental health services in collection in 2019. CDC now provides NVDRS funding to all
which adolescents stayed overnight or longer include services 50 states, DC, and Puerto Rico (74). State health departments
in a hospital or a residential treatment center. Nonspecialty or their bona fide agents manage the state violent death
mental health settings for adolescents include the education, reporting systems and serve as the point of contact to collect
general medical, juvenile justice, and child welfare settings. information from the major data sources.
NVDRS obtains data from multiple complementary data
National Violent Death Reporting System sources, including death certificates, medical examiner and
NVDRS is a population-based active surveillance system coroner records, law enforcement reports, and toxicology
conducted by CDC to collect data on violent deaths that occur reports. Individual-level data include manner of death, injury
within participating states and territories (https://www.cdc. mechanism, whether the person involved in an incident
gov/violenceprevention/datasources/nvdrs/index.html). For was a victim, and circumstances, which are defined as the
the purposes of NVDRS, violence is defined as the intentional precipitating events that contributed to the fatal injury.
use of threatened or actual physical force or power against a Numerous types of circumstance data are collected for
person, group, or community that causes or is likely to cause suicide in NVDRS, including factors such as mental health
injury, death, psychological harm, developmental harm (e.g., history and status (e.g., current depressed mood, current
arrested physical, mental, intellectual, emotional, or social mental health problems, current treatment for mental health
development), or deprivation. Violent deaths include child problems, whether treatment has ever been received for mental
maltreatment deaths, intimate partner homicides and other health problems, and history of suicide attempts), whether a
homicides, suicides, and legal intervention deaths (i.e., when decedent disclosed the intent to die by suicide, interpersonal
a decedent is killed by a police officer or other person with conflicts, alcohol or other substance use, other addictions, and
specified legal authority to use deadly force) (73). Unintentional criminal acts. Short narratives are also written by abstractors,
firearm injury deaths and deaths of undetermined intent also which provide more details about the incident, summarizing
are included in the system. States are required to begin entering the sequence of events from the perspectives of the medical
all deaths into the online system within 4 months from the examiner or coroner and law enforcement. Aggregate counts,
date the violent death occurred. States then have an additional percentages, and crude rates are available for all deaths by
14 months from the end of the calendar year in which the abstractor-assigned manner of death. Because no sampling
violent death occurred to complete each incident record. is involved, all identified violent deaths in states that meet
Additional information on NVDRS is available (https://www. the reporting criteria are included. Data for persons aged
cdc.gov/violenceprevention/datasources/nvdrs/index.html). 10–19 years in 18 states during 2014–2018 are included in
NVDRS data collection began in 2003 with six participating this report (Alaska, Colorado, Georgia, Kentucky, Maryland,
states (Maryland, Massachusetts, New Jersey, Oregon, South Massachusetts, Minnesota, New Jersey, New Mexico, North
Carolina, and Virginia). Seven additional states began data Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South
collection in 2004 (Alaska, Colorado, Georgia, North Carolina, Utah, Virginia, and Wisconsin). NVDRS data are
Carolina, Oklahoma, Rhode Island, and Wisconsin), three publicly accessible through CDC’s Web-based Injury Statistics
in 2005 (Kentucky, New Mexico, and Utah), two in 2010 Query and Reporting System (WISQARS; https://www.cdc.
(Ohio and Michigan), and 14 in 2015 (Arizona, Connecticut, gov/injury/wisqars/nvdrs.html) (41). Deidentified case-level
Hawaii, Illinois, Indiana, Iowa, Kansas, Maine, Minnesota, data are also available by formal request to eligible researchers
New Hampshire, New York, Pennsylvania, Vermont, and via access to the NVDRS Restricted Access Database
Washington). Eight additional states (Alabama, California, (https://www.cdc.gov/violenceprevention/datasources/nvdrs/
Delaware, Louisiana, Missouri, Nebraska, Nevada, and West dataaccess.html).
Virginia), DC, and Puerto Rico began data collection in
2017. California began collecting data in 2005 but ended data

MMWR / February 25, 2022 / Vol. 71 / No. 2 11

National Vital Statistics System incidents involving firearms) are coded from law enforcement
Vital statistics mortality data from NVSS are a fundamental reports, interviews with law enforcement or school officials
source of demographic, geographic, and cause-of-death familiar with each incident, or articles published in the media
information in the United States (https://www.cdc.gov/nchs/ when a reliable source is cited (i.e., a law enforcement or
nvss/index.htm). The data are used to present characteristics of school official or judicial proceedings regarding the incident).
persons who have died in the United States, understand leading SAVD-SS also collects information about whether the victim
causes of death, determine life expectancy, and compare the and perpetrator had a suspected or diagnosed mental health
U.S. mortality data with those in other countries. The NVSS condition, experienced suicidal ideation or had a history of
mortality data include information on all deaths occurring suicide attempts, were using alcohol or substances at the time
within the United States annually and have been collected since of death or regularly used alcohol or substances, and had been
1900. Mortality data are collected from information reported victimized or perpetrated violence in the past.
on death certificates, which are completed by funeral directors Because SAVDs are relatively rare and SAVD-SS includes
(the demographic portion) and the attending physicians, personally identifiable information, data are not made publicly
medical examiners, or coroners (the medical portion). National available; however, aggregate data are reported every school year
data for vital statistics are provided through contracts between (July 1–June 1) in the U.S. Department of Education’s Annual
CDC’s NCHS and state vital registration systems that are Indicators of School Crime and Safety Report. Additional
legally responsible for the registration of deaths. Information information about SAVD-SS is available (https://www.cdc.gov/
on demographics, geographic details, and cause of death is violenceprevention/youthviolence/schoolviolence/SAVD.html).
provided for all decedents. State- and county-level information This report provides data on school-associated suicides
is available by place of occurrence as well as place of residence. among persons aged 10–18 years during 2013–2018.
Causes of death, including suicide, are processed in accordance Beginning in January 2021, SAVD-SS data from 2021 and
with the International Classification of Diseases, Tenth Revision later will be collected through CDC’s NVDRS and will be
(ICD-10). Data are available in various formats, including publicly available in 2023.
reports, downloadable data files (https://www.cdc.gov/nchs/
data_access/vitalstatsonline.htm), restricted use data files National Youth Risk Behavior Survey
(https://www.cdc.gov/nchs/nvss/nvss-restricted-data.htm), and The Youth Risk Behavior Surveillance System (YRBSS)
online query systems (https://wonder.cdc.gov). Data for persons monitors health behaviors and experiences among U.S. high
aged 10–19 years for 2018–2019 are included in this report. school students that contribute to the leading causes of mortality,
morbidity, and social problems among youths and adults
School-Associated Violent Death Surveillance System (https://www.cdc.gov/yrbss). The system includes a national
SAVD-SS is maintained by CDC and was designed to monitor YRBS, conducted by CDC, and separate state, tribal, territorial,
incidents of lethal violence, including suicides, homicides, and local school district school-based YRBSs. National YRBS
and legal intervention deaths, that occur in and around data and data for many state, territorial, and local school districts
school settings (https://www.cdc.gov/violenceprevention/ are publicly available (https://www.cdc.gov/yrbss).
youthviolence/schoolviolence/SAVD.html). Data on school- Since 1991, the national YRBS has been conducted
associated violent deaths (SAVDs) are available for 1994–2018. biennially, using independent, three-stage cluster sample
Incidents are identified through a systematic media scan of designs to produce representative samples of public and
computerized newspaper and broadcast media databases. private high school students in grades 9–12 (primarily aged
SAVD-SS cases include incidents in which a death occurred 14–18 years) in the 50 states and DC. Student participation
1) on the campus of a functioning U.S. public or private in the YRBS is anonymous and voluntary, and local parental
primary or secondary school, 2) while the victim was on the permission procedures are used. Survey participants complete
way to or from regular sessions at such a school, or 3) while a self-administered pencil-and-paper questionnaire during a
the victim was attending or traveling to or from an official regular class period and record their responses on a computer-
school-sponsored event. Identified incidents are confirmed scannable answer sheet. In 2019, the number of students in
with local law enforcement or school officials familiar with the sample was 13,677, the school response rate was 75%, the
the incident, and law enforcement reports are collected when student response rate was 80%, and the overall response rate
possible. Incident, victim, and perpetrator characteristics (e.g., (the product of the school and student response rates) was 60%.
incident location, cause and manner of death, circumstances Indicators of mental health included in the national YRBS
precipitating the incident, and firearm-related information for include persistent feelings of sadness or hopelessness and
suicide-related behaviors. To assess persistent feelings of

12 MMWR / February 25, 2022 / Vol. 71 / No. 2

sadness or hopelessness, students were asked if during the past by age group, sex, race and ethnicity, household federal
12 months, they had ever felt so sad or hopeless almost every poverty level (FPL), highest level of education among parents,
day for ≥2 weeks in a row that they stopped doing some usual health insurance status, and geographic classification (urban/
activities. To assess suicidal ideation and suicide attempts, suburban versus rural) as available and applicable within
students were asked if during the past 12 months they ever each surveillance system. Subgroup estimates by race and
seriously considered attempting suicide, whether they made ethnicity were calculated for non-Hispanic White (White),
a plan about how they would attempt suicide, the number non-Hispanic Black (Black), Hispanic, and non-Hispanic
of times they had actually attempted suicide, and whether Asian (Asian) children; for a limited number of indicators
they had made a suicide attempt that resulted in an injury, with sufficient sample size, estimates are presented for non-
poisoning, or an overdose that had to be treated by a physician Hispanic American Indian or Alaska Native (AI/AN) children
or nurse. Although not included in this report, YRBS also and non-Hispanic Native Hawaiian or other Pacific Islander
monitors the prevalence of alcohol, tobacco, and other drug (NH/OPI) children. Estimates for children in other racial
use; however, the questions are not designed to identify drug and ethnic groups were not calculated because the sample
use disorders. These data and the prevalence of other health sizes were too small to produce stable estimates and are not
risk behaviors and experiences examined by the national YRBS presented in the tables. Estimates by health insurance status are
and many state, territorial, and local school district YRBSs are presented for children with any type of public health insurance,
publicly available (www.cdc.gov/yrbss). children with any private health insurance, and children with
no health insurance. Children with both public and private
Analysis health insurance were represented in both subcategories. The
information used to indicate geographic classification differed
Similar indicators from different surveillance systems are among surveillance systems*; the urban/suburban subgroup
grouped together and described (Tables 3–13), using data consists of persons living in large metropolitan areas with a
from the most recent years available, as defined in previous metropolitan statistical area (MSA) population of ≥1 million
sections. Weighted prevalence estimates and 95% CIs were and suburban areas including medium and small metropolitan
calculated overall and by sociodemographic characteristics for areas with MSA populations of <1 million; the rural subgroup
the population represented by each surveillance system. No consists of those living in all other areas.
statistical tests were conducted. The 95% CIs were compared,
and estimates with nonoverlapping CIs were considered to
be significantly different. This is an inherently conservative
approach to the identification of differences between estimates
Results
and might not have detected certain significant differences Descriptions of mental disorders and mental health indicators
that would have been identified using other methods. Most are included in this report, as well as prevalence estimates of the
estimates included children and adolescents aged 3–17 years, disorders and indicators (including rates of suicide) among children
although certain surveillance systems were limited to data on and adolescents available from national surveillance systems. State
children and adolescents with a narrower age range (ADDM: prevalence estimates and rates are provided when available. Overall
8 years; NSDUH: 12–17 years; and YRBS: high school prevalence estimates, including weighted population estimates of
students, primarily aged 14–18 years); indicators related the number of U.S. children and adolescents with each disorder or
to suicide include persons aged 10–19 years (NVDRS and indicator, are presented (Table 3); rates per 100,000 are presented
NVSS) and 10–18 years (SAVD-SS), and NSCH included
certain positive mental health indicators for children as * NHIS and NVSS: 2013 NCHS urban/rural classification (https://www.cdc.
gov/nchs/data/series/sr_02/sr02_166.pdf ); urban/suburban includes large,
young as age 6 months. Indicators of mental health services medium, and small metropolitan areas, whereas rural includes nonmetropolitan
are presented as the estimated percentage of all children who areas with population <50,000. NSCH: 2010 Office of Management and Budget
received a particular mental health service (e.g., consultations MSA and micropolitan statistical area standards (https://www.govinfo.gov/
content/pkg/FR-2010-06-28/pdf/2010-15605.pdf ); urban/suburban includes
or medication), rather than the percentage of children with MSAs associated with at least one urbanized area of at least 50,000 population;
a diagnosed disorder, to allow for more comparable estimates rural is defined as non-MSA. NSDUH: Rural-Urban Continuum Codes
(RUCC) (https://www.ers.usda.gov/data-products/rural-urban-continuum-
across surveillance systems. Mental health services data are codes); urban/suburban includes large, medium, and small metropolitan areas;
included from surveillance systems that also include prevalence rural includes nonmetropolitan counties. YRBS: MDR (formerly Market Data
of disorders. (Data sources that only included treatment data Retrieval) propriety information, determined by an MDR formula based on
the National Center for Education Statistics Locale Code classification and zip
without other indicators of mental health were not included.) code. The urban category includes the urban, suburban, and town groups, and
Estimates by sociodemographic characteristics were calculated the rural category includes the rural/nonmetropolitan group.

MMWR / February 25, 2022 / Vol. 71 / No. 2 13

TABLE 3. Estimated number and prevalence of persons aged 0–19 years with certain mental disorders and indicators of mental health, by
surveillance system, year of data collection, and age group — United States, 2013–2019
Weighted no.†
Surveillance No. of Weighted of children
system and data persons prevalence with reported
Disorder or indicator collection years Age group surveyed (%)* indicator
ADHD
Ever (parent ever told by health care provider child had ADHD) NSCH 2016–2019 3–17 yrs 114,476 9.8 5,964,000
NHIS 2017–2018 3–17 yrs 14,316 9.6 5,952,000
Current (parent reported child currently had ADHD) NSCH 2016–2019 3–17 yrs 114,476 8.7 5,319,000
NHIS 2017–2018 3–17 yrs 14,292 8.2 5,043,000
Behavioral or conduct problems
Ever (parent ever told by health care provider child had behavioral or
NSCH 2016–2019 3–17 yrs 114,476 8.9 5,478,000
conduct problems)
Current (parent reported child currently had behavioral or conduct problems) NSCH 2016–2019 3–17 yrs 114,476 7.0 4,265,000
Depression
Ever depression (parent ever told by health care provider child had depression) NSCH 2016–2019 3–17 yrs 114,476 4.4 2,729,000
Current depression (parent reported child currently had depression) NSCH 2016–2019 3–17 yrs 114,476 3.4 2,093,000
Ever had MDE (self-report)§ NSDUH 2018–2019 12–17 yrs 33,678 20.9 5,068,000
Past year MDE (self-report)§ NSDUH 2018–2019 12–17 yrs 33,678 15.1 3,633,000
Current depression (self-reported depression during past 2 wks; score of ≥10 NHANES 2013–2018 12–17 yrs 2,771 5.8 2,168,000
on PHQ-9 depression screener)
Sadness or hopelessness (self-reported feeling so sad or hopeless almost every National YRBS 2019 ~14–18 yrs¶ 13,677 36.7 6,145,000
day for ≥2 wks in a row that they stopped doing some usual activities)
Anxiety
Ever (parent ever told by health care provider child had anxiety problems) NSCH 2016–2019 3–17 yrs 114,476 9.4 5,769,000
Current (parent reported child currently had anxiety) NSCH 2016–2019 3–17 yrs 114,476 7.8 4,768,000
Autism spectrum disorder
Ever (parent ever told by health care provider child had ASD) NSCH 2016–2019 3–17 yrs 114,476 3.1 1,881,000
NHIS 2017–2018 3–17 yrs 14,324 2.4 1,468,000
Current (parent reported child currently had ASD) NSCH 2016–2019 3–17 yrs 114,476 2.9 1,766,000
NHIS 2017–2018 3–17 yrs 14,320 2.0 1,266,000
Met ASD surveillance case definition** ADDM Network 2016 8 yrs 275,419†† 1.9 NA§§
Tourette syndrome
Ever (parent ever told by health care provider child had Tourette syndrome) NSCH 2016–2019 3–17 yrs 114,476 0.3 174,000
Current (parent reported child currently had Tourette syndrome) NSCH 2016–2019 3–17 yrs 114,476 0.2 136,000
Substance use disorder¶¶
Past year substance use disorder NSDUH 2018–2019 12–17 yrs 33,678 4.1 1,017,000
Past year alcohol use disorder NSDUH 2018–2019 12–17 yrs 33,678 1.6 407,000
Past year illicit drug use disorder NSDUH 2018–2019 12–17 yrs 33,678 3.2 788,000
Suicidality
Seriously considered attempting suicide (during 12 mos before survey) YRBS 2019 ~14–18 yrs¶ 13,677 18.8 3,148,000
Made a suicide plan (during 12 mos before survey) YRBS 2019 ~14–18 yrs¶ 13,677 15.7 2,629,000
Attempted suicide ≥1 time (during 12 mos before survey) YRBS 2019 ~14–18 yrs¶ 13,677 8.9 1,490,000
Made a suicide attempt ≥1 time (during 12 mos before survey) that resulted in YRBS 2019 ~14–18 yrs¶ 13,677 2.5 419,000
injury, poisoning, or overdose that had to be treated by physician or nurse
No. of suicides NVSS 2018–2019 10–19 yrs 5,744 deaths 6.9/100,000 NA
No. of suicides NVDRS*** 2014–2018 10–19 yrs 4,903 deaths 7.0/100,000 NA
Mental health services
Mental health treatment, professional††† NSCH 2016–2019 3–17 yrs 114,476 10.1 6,197,000
Mental health consultation, professional§§§ NHIS 2017–2018 3–17 yrs 14,287 9.6 5,939,000
Mental health consultation, general physician¶¶¶ NHIS 2017–2018 3–17 yrs 14,253 5.2 3,222,000
Mental health services received (specialty and nonspecialty) NSDUH 2018–2019 12–17 yrs 33,678 25.9 6,358,000
Mental health consultation, professional**** NHANES 2013–2018 4–17 yrs 8,071 9.8 5,664,000
Past year medication for mental health problems†††† NSCH 2016–2019 3–17 yrs 114,476 7.8 4,724,000
Current use of psychotherapeutic agents in past 30 days for mental NHANES 2013–2018 3–17 yrs 8,637 6.6 4,082,000
health problems
Positive indicators of child mental health
Affectionate (usually or always affectionate and tender with parent) NSCH 2018–2019 6 mos–5 yrs 15,844 97.3 21,055,000
Resilient (usually or always bounces back quickly when things do not go their way) NSCH 2018–2019 6 mos–5 yrs 15,844 89.8 19,457,000
Positivity (usually or always smiles and laughs a lot) NSCH 2018–2019 6 mos–5 yrs 15,844 99.0 21,451,000
Curious (usually or always shows interest and curiosity in learning new things) NSCH 2018–2019 6 mos–17 yrs 59,057 91.3 64,912,000
Persistent (usually or always works to finish tasks) NSCH 2018–2019 6–17 yrs 43,213 84.5 40,457,000
Self-control (usually or always stays calm and in control when faced with NSCH 2018–2019 6–17 yrs 43,213 76.8 37,757,000
a challenge)
See table footnotes on the next page.

14 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 3. (Continued) Estimated number and prevalence of persons aged 0–19 years with certain mental disorders and positive indicators of
mental health, by surveillance system, year of data collection, and age group — United States, 2013–2019
Abbreviations: ADDM = Autism and Developmental Disabilities Monitoring; ADHD = attention-deficit hyperactivity disorder; ASD = autism spectrum disorder;
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, MDE = major depressive episode; NA = not applicable; NHANES = National Health and Nutrition
Examination Survey; NHIS = National Health Interview Survey; NSCH = National Survey of Children’s Health; NSDUH = National Survey on Drug Use and Health; NVDRS = National
Violent Death Reporting System; NVSS = National Vital Statistics System; PHQ-9 = nine-item Patient Health Questionnaire; YRBS = Youth Risk Behavior Survey.
* All estimates are weighted, except for 1) the prevalence of ASD from ADDM, calculated as number of cases identified divided by number of children living in
catchment area and 2) suicide rates for NVSS and NVDRS, calculated as number of suicides per 100,000 persons aged 10–19 years
† NSCH: weighted using sample child weights that adjust for sampling probability, nonresponse, and raking adjustments. Raking adjustments used population
controls from the 2015–2018 Census Bureau’s American Community Survey. NHIS: weighted using sample child weights that adjust for the probability of selection,
nonresponse, and poststratification. Poststratification adjustments for this report use population estimates derived from the 2010 Census by the Census Bureau.
NHANES: weighted using interview and examination sample weights, adjusted for the probability of selection, non-response, and calibration. Calibration
adjustments and population estimates are based on age-specific Census Bureau American Community Surveys from 2013, 2015, and 2017. NSDUH: individual
observations weighted so that the weighted sample represents the civilian, noninstitutionalized population in the United States. The person-level weights in
NSDUH are calibrated by adjusting for nonresponse and poststratifying to known population estimates (or control totals) obtained from the Census Bureau. YRBS:
estimates multiplied by 16,745,000, the number of public and private high school students in the United States in 2019.
§ Ever MDE: reported at least five or more of nine symptoms nearly every day in the same 2-week period during their lifetime, in which at least one of the symptoms
was depressed mood or loss of interest or pleasure in daily activities; MDE in past year: 1) had ever had an MDE, as well as 2) had a period of time in the past
12 months when they felt depressed or lost interest or pleasure in daily activities for ≥2 weeks and 3) during this period of ≥2 weeks, they had some of the other
problems they reported associated with ever having had an MDE.
¶ Survey participants were public and private high school students in grades 9–12 (i.e., primarily aged 14–18 years).
** Case definition based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria for autism spectrum disorder. Clinicians applied the case definition
through a review information systematically collected from developmental evaluations completed by medical and educational service providers in the community.
†† Population denominator for ADDM catchment areas.
§§ ADDM estimates are not weighted or intended to be extrapolated to the entire U.S. population.
¶¶ Substance use disorder: meets DSM-IV criteria for either dependence or abuse for one or more illicit drugs or alcohol; alcohol use disorder: meets criteria for
either alcohol dependence or abuse; illicit drug use disorder: meets criteria for either dependence or abuse for one or more illicit drugs.
*** States (n = 18) included Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma,
Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin.
††† “During the past 12 months, has this child received any treatment or counseling from a mental health professional?”
§§§ “During the past 12 months, have you seen or talked to...a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social
worker...about child’s health?”
¶¶¶ “Did you see or talk to this general doctor because of an emotional or behavioral problem that [child] may have?”
**** “During the past 12 months, have you seen or talked to...a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social
worker...about child’s health?”
†††† “During the past 12 months, has this child taken any medication because of difficulties with his or her emotions, concentration, or behavior?”

for suicide. NSCH 2016–2019 data indicated that ADHD (9.8%) Attention-Deficit/Hyperactivity Disorder
and anxiety (9.4%) were the most common mental disorders among
ADHD is a neurodevelopmental disorder characterized
U.S. children and adolescents aged 3–17 years; NHIS 2017–2018
by symptoms of inattention, hyperactivity, and impulsivity
data indicated an estimate of 9.6% for ADHD. Among adolescents,
that are present in multiple contexts, such as at home, at
data from NSDUH 2018–2019 data indicated that 15.1% of
school, or with friends, and cause significant impairment
adolescents aged 12–17 years had an MDE in the past year, and
(1,75). On the basis of the predominant symptoms at the
YRBS 2019 data indicated that 36.7% of high school students aged
time of diagnosis, children can be classified into one of the
primarily 14–18 years experienced persistent feelings of sadness or
three following categories: inattentive, hyperactive/impulsive,
hopelessness during the past year. In addition, YRBS data indicated
or combined (75). However, symptoms can change over
that during the past year, 18.8% of high school students had
time (76). ADHD is associated with a substantial risk for
seriously considered attempting suicide, and 8.9% had attempted
educational and occupational failure, criminality, social
suicide one or more times. Approximately 10% (9.6%–10.1%
disability, substance use, other mental disorders, injuries,
across NSCH 2016–2019 survey years, NHIS 2017–2018 survey
illness, and lower life expectancy (77–79). Both the NSCH
years, and NHANES 2013–2018 survey years) of U.S. children and
and NHIS questionnaires asked parents whether a health care
adolescents aged 3–17 years received mental health services from
provider had ever told them that their child had ADHD (ever
a mental health professional in the past year, and 7.8% had taken
ADHD) and whether the child currently had this condition
medication because of difficulties with emotions, concentration, or
(current ADHD).
behavior in the past year according to NSCH data. Approximately
Data from the 2016–2019 survey years of NSCH indicate
one fourth (25.9%) of adolescents aged 12–17 years reported
that among children and adolescents aged 3–17 years, parents
receiving mental health services in the past year, according to self-
reported that 9.8% had ever received a diagnosis of ADHD,
reported responses from NSDUH. Positive indicators of mental
and 8.7% currently had ADHD (Table 4). These prevalence
health were reported for at least three fourths of children aged
estimates were very similar to the results from the 2017 and
6 months–17 years.
2018 survey years of NHIS (Table 4), which assessed the same

MMWR / February 25, 2022 / Vol. 71 / No. 2 15

TABLE 4. Weighted prevalence estimates of attention-deficit/hyperactivity disorder among children and adolescents aged 3–17 years, by
sociodemographic characteristics and surveillance system — United States, 2016–2019
Ever had ADHD Current ADHD
NSCH 2016–2019 NHIS 2017–2018 NSCH 2016–2019 NHIS 2017–2018
Characteristic % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Age group (yrs) 3–17 3–17 3–17 3–17
Sample size (no.) 114,476 14,316 114,476 14,292
Total 9.8 (9.4–10.1) 9.6 (9.0–10.2) 8.7 (8.4–9.1) 8.2 (7.6–8.7)
Age group (yrs)
3–5 2.2 (1.8–2.8) 1.8 (1.2–2.6) 2.0 (1.6–2.5) 1.6 (1.1–2.3)
6–11 10.0 (9.4–10.6) 9.7 (8.8–10.7) 9.3 (8.7–9.8) 8.7 (7.8–9.6)
12–17 13.2 (12.6–13.8) 13.4 (12.4–14.4) 11.5 (10.9–12.0) 10.8 (10.0–11.8)
Sex
Male 13.3 (12.8–13.9) 12.9 (12.0–13.8) 11.9 (11.3–12.4) 11.0 (10.2–12.0)
Female 6.1 (5.7–6.5) 6.2 (5.6–6.9) 5.5 (5.1–5.9) 5.2 (4.6–5.8)
Race/Ethnicity*
Hispanic 7.5 (6.7–8.5) 7.0 (5.9–8.2) 6.6 (5.9–7.5) 5.4 (4.5–6.5)
Black, non-Hispanic 12.0 (10.8–13.4) 11.4 (9.7–13.5) 10.5 (9.4–11.8) 9.9 (8.1–11.9)
White, non-Hispanic 10.9 (10.6–11.3) 10.9 (10.1–11.7) 9.9 (9.5–10.3) 9.4 (8.7–10.2)
Asian, non-Hispanic 2.6 (2.0–3.3) 2.1 (1.3–3.3) 2.2 (1.7–2.9) 1.6 (0.9–2.6)
FPL†
≤100% FPL 11.2 (10.3–12.2) 11.5 (10.0–13.2) 10.2 (9.3–11.1) 10.0 (8.6–11.6)
>100% to ≤ 200% FPL 10.5 (9.6–11.5) 11.2 (9.9–12.7) 9.3 (8.4–10.1) 9.6 (8.4–11.0)
>200% FPL 9.0 (8.6–9.4) 8.5 (7.8–9.2) 8.0 (7.7–8.4) 7.1 (6.4–7.8)
Highest level of parent education§
Less than high school 9.2 (7.6–11.2) 8.2 (6.6–10.2) 8.0 (6.5–9.9) 7.1 (5.7–9.0)
High school graduate 11.0 (10.1–12.0) 10.8 (9.3–12.4) 10.0 (9.1–11.0) 8.9 (7.6–10.4)
More than high school 9.5 (9.2–9.8) 9.2 (8.5–9.9) 8.5 (8.2–8.8) 7.8 (7.1–8.5)
Health insurance¶
Yes
Any public 13.2 (12.4–14.0) 12.4 (11.4–13.5) 12.1 (11.4–12.8) 10.7 (9.7–11.7)
Any private 8.7 (8.3–9.1) 8.3 (7.3–9.3) 7.7 (7.4–8.1) 7.2 (6.3–8.2)
No insurance 7.1 (5.9–8.7) 6.1 (4.3–8.6) 5.8 (4.8–7.1) 4.7 (3.2–7.0)
Geographic classification**
Urban/Suburban 9.5 (9.0–9.9) 9.3 (8.7–10.0) 8.4 (8.0–8.8) 7.9 (7.3–8.5)
Rural 12.0 (11.1–12.9) 12.0 (10.4–13.7) 10.7 (9.9–11.6) 10.0 (8.6–11.6)
Abbreviations: ADHD = attention-deficit/hyperactivity disorder; FPL = federal poverty level; NHIS = National Health Interview Survey; NSCH = National Survey of
Children’s Health.
* Estimates exclude other race and ethnicity groups that did not have a large enough sample size to produce stable estimates.
† FPL is based on family income and family size using the Census Bureau’s poverty thresholds for the previous calendar year. Imputed income files were used to
impute family income when it was not provided, and for NSCH, family size was imputed using other information about the household when the number of family
members was not provided (https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html).
§ The highest level of parent education is based on the highest education level among up to two adults who were identified as primary caregivers in the survey.
¶ Private included any insurance from an employer or union, directly purchased, TRICARE or other military health care, or the Affordable Care Act; coverage from any
government assistance plan was considered public, including Medicaid or other state-sponsored health plans including the Children’s Health Insurance Program.
Respondents who indicated both public and private insurance coverage were represented in both subcategories.
** Methods for determining geographic classification differed by survey. NSCH: 2010 Office of Management and Budget metropolitan and micropolitan statistical
areas standards (https://www.govinfo.gov/content/pkg/FR-2010-06-28/pdf/2010-15605.pdf ); urban/suburban includes metropolitan statistical areas associated
with at least one urbanized area of at least 50,000 population; rural was defined as counties that were not part of a metropolitan statistical area. NHIS: 2013 National
Center for Health Statistics urban/rural classification (https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf ); urban/suburban includes large metropolitan,
medium metropolitan, and small metropolitan areas, whereas rural includes nonmetropolitan areas with <50,000 population.

age range using the same survey item, with prevalence estimates and boys had approximately double the prevalence of ADHD
of 9.6% and 8.2%, respectively. State prevalence estimates diagnoses compared with girls. Among racial and ethnic
from NSCH of ever ADHD among children and adolescents groups, Hispanic and Asian children had the lowest prevalence,
aged 3–17 years ranged from 6.1% in California to 16.3% in whereas Black and White children had the highest prevalence.
Louisiana; prevalence estimates of current ADHD ranged from Certain socioeconomic indicators, specifically, being in the
5.3% in California to 14.4% in Mississippi (Supplementary lowest household income category (≤200% FPL) and having
Tables 1 and 2; https://stacks.cdc.gov/view/cdc/113924). public health insurance, were associated with higher prevalence
Data from both NSCH and NHIS indicated that the of ADHD. Parent education level was also associated with
prevalence of ADHD was higher among older age groups, ADHD prevalence, based on NSCH data; children who had

16 MMWR / February 25, 2022 / Vol. 71 / No. 2

a parent with more than a high school education had a lower who had a high school education (only) compared with those
ADHD prevalence than those who had a parent with a high with more than a high school education. The prevalence of
school education. The prevalence of ADHD among children behavior problems was higher among children living in rural
whose parents had less than a high school education was similar areas than among those in urban or suburban areas.
to that among children who had a parent with more than a
high school education; NHIS estimates of ADHD did not Depression
differ by parent education level. When examining prevalence
by geographic classification, both NSCH and NHIS data Depressive disorder is characterized by significant feelings
indicated that a higher proportion of children in rural areas had of sadness, hopelessness, or loss of interest or pleasure in daily
ADHD compared with children in urban or suburban areas. activities, with symptoms persisting on most days for a 2-week
period (1). Children and adolescents who have depression are
at higher risk for other mental disorders and health conditions,
Behavioral and Conduct Problems as well as school problems, difficulty with social relationships,
Problems with behavior and conduct (i.e., behavior problems) self-harm, and suicide (17,34). NSCH asked parents if a health
among children and adolescents are associated with risks for care provider had ever told them that their child had depression
long-term problems, including educational and occupational and whether the child currently had the condition. NSDUH
failure, substance use, mental disorders, injury, violence, identified MDEs based on adolescent self-reports of depression
delinquency, and lower life expectancy (77,80). Disruptive symptoms, identifying ever having had an MDE and having had
behaviors that cause conflict between a child and family an MDE in the past year. For NHANES, adolescents reported on
members, peers, and authority figures can be diagnosed as depression symptoms during the past 2 weeks. YRBS examined
disorders, such as oppositional defiant disorder and conduct self-reported persistent feelings of sadness or hopelessness among
disorder (1). Oppositional, inappropriate, negative, or defiant high school students, primarily aged 14–18 years.
behavior is often found in younger children (1). Conduct According to data from the 2016–2019 survey years of
problems are often found in older children and are characterized NSCH, an estimated 4.4% children and adolescents aged
by behavior focused on ignoring the rights of others and violating 3–17 years ever had diagnosed depression, and 3.4% had
social norms and rules (1). NSCH was the only survey with a current depression (Table 6). Results from the 2018–2019
question that asked parents if a health care provider or educator survey years of NSDUH indicated that 20.9% of adolescents
(including teachers and school nurses) had ever told them that aged 12–17 years ever had an MDE and 15.1% had an MDE
their child had behavioral or conduct problems, followed by a in the past year. NHANES 2013–2018 data indicated that
question on whether the child currently had this problem. 5.8% of adolescents aged 12–17 years reported having major
Data from the 2016–2019 survey years of NSCH indicated that depression during the past 2 weeks, whereas YRBS 2019 data
8.9% of children and adolescents aged 3–17 years had ever received indicated that 36.7% of high school students aged primarily
a diagnosis of behavior problems, and 7.0% had behavior problems 14–18 years experienced persistent feelings of sadness or
at the time of the survey (Table 5). State prevalence estimates of ever hopelessness during the past year. State prevalence estimates,
having had behavior problems among children and adolescents aged based on NSCH data, of ever having been diagnosed with
3–17 years ranged from 6.4% in California to 13.1% in Louisiana; depression among children and adolescents aged 3–17 years
estimates of current behavior problems ranged from 4.1% in ranged from 1.8% in Hawaii to 8.1% in Montana; estimates
California to 10.9% in Kentucky (Supplementary Tables 1 and 2; of current depression ranged from 1.4% in Hawaii to 6.6% in
https://stacks.cdc.gov/view/cdc/113924). Montana (Supplementary Tables 1 and 2; https://stacks.cdc.
Children aged 6–11 years had higher prevalences of behavior gov/view/cdc/113924). On the basis of NSDUH data, the
problems than children who were aged <6 years or >11 years. prevalence of ever having had an MDE among adolescents aged
Similar to the estimates of ADHD, boys had more than twice 12–17 years ranged from 13.1% in DC to 28.0% in Oregon.
the estimated prevalence of behavior problems compared with Similarly, the prevalence of past year MDEs among adolescents
girls. Black children had the highest estimated prevalence of aged 12–17 years ranged from 9.8% in DC to 19.9% in New
behavior problems, followed by White and Hispanic children, Mexico and Oregon (Supplementary Tables 1 and 2). YRBS
with the lowest estimates among Asian children. Regarding state estimates are available online (https://yrbs-explorer.
socioeconomic factors, the highest prevalence of behavior services.cdc.gov).
problems was among children in homes affected by poverty and Parent-reported data from NSCH during the 2016–2019
among children with public health insurance; the prevalence of survey years indicated that the prevalence of ever having had
behavior problems was also higher among children with parents a diagnosis of depression increased with age, particularly

MMWR / February 25, 2022 / Vol. 71 / No. 2 17

TABLE 5. Weighted prevalence estimates of behavioral or conduct in adolescence; the prevalence was 0.1% for children aged
problems among children and adolescents aged 3–17 years, by 3–5 years, 2.3% for children aged 6–11 years, and 8.6%
sociodemographic characteristics — National Survey of Children’s
Health, United States, 2016–2019 for adolescents aged 12–17 years. Among adolescents
Ever had behavioral or Current behavioral or
aged 12–17 years, parents reported a prevalence of 6.5%
conduct problems conduct problems for current depression, which is slightly higher than the
Characteristic % (95% CI) % (95% CI) NHANES (2013–2018) estimate of 5.8% for adolescent
Age group (yrs) 3–17 3–17 self-reported current depression symptoms but lower than
Sample size (no.) 114,476 114,476
estimates of ever having had an MDE (20.9%) and past year
Total 8.9 (8.6–9.3) 7.0 (6.6–7.3)
Age group (yrs)
MDE (15.1%) based on 2018–2019 NSDUH data. Across
3–5 5.0 (4.4–5.6) 3.8 (3.4–4.4) all measures of depression, girls had higher a prevalence than
6–11 10.4 (9.8–11.1) 8.6 (8.1–9.2) boys, with estimates derived from adolescent self-report
12–17 9.3 (8.8–9.8) 6.8 (6.3–7.3)
(2018–2019 NSDUH, 2013–2018 NHANES, and 2019
Sex
Male 12.2 (11.6–12.8) 9.4 (8.9–9.9) YRBS) approximately twice as high for girls as boys. Among
Female 5.5 (5.1–5.9) 4.4 (4.1–4.8) racial and ethnic groups, patterns differed depending on
Race/Ethnicity* the survey. The lowest prevalence of diagnosed depression
Hispanic 7.2 (6.4–8.1) 5.6 (4.9–6.4)
Black, non-Hispanic 13.1 (11.8–14.5) 10.1 (9.0–11.4) was among Asian children and adolescents aged 3–17 years
White, non-Hispanic 8.9 (8.6–9.3) 7.0 (6.7–7.4) according to NSCH data; otherwise, few differences regarding
Asian, non-Hispanic 3.4 (2.6–4.3) 2.5 (1.9–3.3) diagnosis were observed among Hispanic, White, Black,
FPL†
≤100% FPL 12.4 (11.4–13.6) 10.3 (9.4–11.4)
or AI/AN children and adolescents. Estimates of current
>100% to ≤200% FPL 9.5 (8.8–10.4) 7.6 (7.0–8.3) depression among children and adolescents aged 3–17 years
>200% FPL 7.4 (7.1–7.8) 5.5 (5.2–5.8) based on NSCH data were lower among Hispanic children and
Highest level of parent education§ adolescents than among White children and adolescents; this
Less than high school 8.9 (7.3–10.7) 7.1 (5.7–8.8)
High school graduate 10.5 (9.6–11.5) 8.7 (7.9–9.6) difference was not observed with NHANES data for current
More than high school 8.4 (8.1–8.8) 6.4 (6.1–6.7) depression among adolescents aged 12–17 years. Prevalence
Health insurance¶ estimates of MDE among adolescents aged 12–17 years based
Yes
Any public 13.9 (13.1–14.7) 11.6 (10.9–12.4) on NSDUH data were lower among Black adolescents than
Any private 7.0 (6.7–7.4) 5.2 (4.9–5.5) among Hispanic and White adolescents. YRBS data indicated
No insurance 6.3 (5.2–7.7) 4.8 (3.9–5.9) that among high school students primarily aged 14–18 years,
Geographic classification**
Urban/Suburban 8.5 (8.2–9.0) 6.6 (6.2–7.0)
the prevalence of persistent feelings of sadness or hopelessness
Rural 10.5 (9.7–11.4) 8.6 (7.9–9.4) was higher among Hispanic students than among Black, White,
Abbreviations: FPL = federal poverty level; NSCH = National Survey of Children’s Health. and Asian students. The estimated percentages of AI/AN and
* Estimates exclude other race and ethnicity groups that did not have a large NH/OPI students primarily aged 14–18 years with persistent
enough sample size to produce stable estimates.
† FPL is based on family income and family size using the Census Bureau’s feelings of sadness or hopelessness were similar to the estimates
poverty thresholds for the previous calendar year. Imputed income files were for the other racial and ethnic groups.
used to impute family income when it was not provided, and for NSCH family
size was imputed using other information about the household when the
An association was found between household poverty
number of family members was not provided (https://www.census.gov/ level and prevalence of depression (NSCH 2016–2019
topics/income-poverty/poverty/guidance/poverty-measures.html). and NHANES 2013–2018), with the lowest prevalence of
§ The highest level of parent education is based on the highest education level
among up to two adults who were identified as primary caregivers in the survey. depression among children from households with the highest
¶ Private included any insurance from an employer or union, directly purchased,
income level (>200% FPL). However, NSDUH estimates
TRICARE or other military health care, or the Affordable Care Act; coverage
from any government assistance plan was considered public, including of ever and past year MDE were higher for children from
Medicaid or other state-sponsored health plans including the Children’s households with the highest income level (>200% FPL)
Health Insurance Program. Respondents who indicated both public and
private insurance coverage were represented in both subcategories. compared with those at the lowest income level (≤100% FPL).
** Method for determining geographic classification for NSCH was based on the According to NSCH data, the prevalence of depression
2010 Office of Management and Budget metropolitan and micropolitan statistical
areas standards (https://www.govinfo.gov/content/pkg/FR-2010-06-28/
in children with any private health insurance or no health
pdf/2010-15605.pdf). Urban/suburban includes metropolitan statistical areas insurance was lower than the prevalence for children with any
associated with at least one urbanized area of at least 50,000 population; rural public health insurance; otherwise, estimates using NSDUH
was defined as counties that were not part of a metropolitan statistical area.
(2018–2019) and NHANES data on health insurance statuses

18 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 6. Weighted prevalence estimates of surveillance indicators of depression among children and adolescents aged 3–17 years, by
sociodemographic characteristics and year — four surveillance systems, United States, 2013–2019
Past year persistent
Ever had depression Ever had major Past year major feelings of sadness or
(parent reported Current depression depressive episode depressive episode Current depression hopelessness
diagnosis) (parent report) (self-report) (self-report) (self-report)* (self-report)†
NSCH 2016–2019 NSCH 2016–2019 NSDUH 2018–2019 NSDUH 2018–2019 NHANES 2013–2018 YRBS 2019
Characteristic % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Age group (yrs) 3–17 3–17 12–17 12–17 12–17 ~14–18§
Sample size (no.) 114,476 114,316 33,678 33,678 2,771 13,677
Total 4.4 (4.2–4.7) 3.4 (3.2–3.6) 20.9 (20.4–21.6) 15.1 (14.6–15.6) 5.8 (4.6–7.4) 36.7 (35.1–38.3)
Age group (yrs)
3–5 0.1 (0.1–0.3) 0.1 (0.1–0.3) NA NA NA NA
6–11 2.3 (2.0–2.6) 1.9 (1.6–2.2) NA NA NA NA
12–17 8.6 (8.1–9.1) 6.5 (6.1–6.9) 20.9 (20.4–21.6) 15.1 (14.6–15.6) 5.8 (4.6–7.4) 36.4 (34.8–38.0)
Sex
Male 4.0 (3.7–4.4) 3.0 (2.8–3.3) 11.8 (11.2–12.5) 8.2 (7.7 –8.8) 3.3 (2.3–4.6) 26.8 (25.2–28.4)
Female 4.8 (4.5–5.2) 3.8 (3.5–4.1) 30.4 (29.5–31.4) 22.3 (21.4–23.1) 8.4 (6.3–11.1) 46.6 (44.4–48.9)
Race/Ethnicity¶
Hispanic 4.0 (3.4–4.8) 2.7 (2.2–3.2) 22.4 (21.1–23.7) 16.2 (15.1–17.4) 5.3 (3.7–7.2) 40.0 (38.0–42.1)
Black, non-Hispanic 4.5 (3.8–5.3) 3.7 (3.1–4.4) 15.9 (14.6–17.4) 10.8 (9.7–12.0) 6.0 (4.1–8.4) 31.5 (28.8–34.3)
White, non-Hispanic 4.8 (4.6–5.1) 3.8 (3.6–4.1) 21.4 (20.6–22.2) 15.5 (14.8–16.2) 6.0 (4.0–8.6) 36.0 (34.1–38.0)
Asian 1.6 (1.1–2.3) 1.3 (0.8–2.0) 20.3 (17.4–23.5) 14.3 (11.8–17.2) 3.6 (1.5–7.3)** 31.6 (27.4–36.1)
American Indian or Alaska Native, NA NA 18.2 (13.5–23.9) 13.6 (9.3–19.6) NA 45.5 (32.7-58.9)
non-Hispanic
Native Hawaiian or other Pacific Islander, NA NA NA NA NA 36.8 (22.6–53.7)
non-Hispanic
FPL††
≤100% FPL 5.8 (5.1–6.6) 4.7 (4.1–5.4) 18.6 (17.4–19.8) 13.2 (12.3–14.3) 8.5 (6.4–11.0) NA
>100% to ≤200% FPL 4.6 (4.1–5.2) 3.6 (3.2–4.1) 21.8 (20.5–23.1) 15.4 (14.3–16.6) 6.3 (4.3–8.9) NA
>200% FPL 3.9 (3.6–4.2) 2.9 (2.7–3.1) 21.5 (20.7–22.3) 15.6 (15.0–16.3) 4.9 (3.2–7.2) NA
Highest level of parent education§§
Less than high school 5.3 (4.1–6.8) 3.8 (2.9–5.0) NA NA 5.1 (3.0–8.2) NA
High school graduate 5.0 (4.4–5.7) 3.8 (3.4–4.4) NA NA 12.4 (8.1–18.0) NA
More than high school 4.2 (3.9–4.4) 3.2 (3.0–3.5) NA NA 4.4 (3.2–7.0) NA
Health insurance¶¶
Yes
Any public 6.3 (5.8–6.9) 5.0 (4.6–5.5) 20.5 (19.5–21.4) 14.5 (13.7 –15.3) 7.3 (5.6–9.4) NA
Any private 3.6 (3.4–3.9) 2.8 (2.6–3.0) 21.3 (20.6–22.2) 15.4 (14.7–16.1) 4.8 (3.1–7.0) NA
No insurance 4.3 (3.1–6.0) 2.8 (2.0–4.0) 20.2 (17.5–23.2) 15.4 (13.1–18.0) 3.8 (1.7–7.0) NA
Geographic classification***
Urban/Suburban 4.3 (4.0–4.6) 3.2 (3.0–3.5) 21.0 (20.3–21.7) 15.2 (14.6–15.8) NA 36.6 (34.8–38.5)
Rural 5.6 (5.0–6.4) 4.4 (3.8–5.0) 20.7 (19.4–22.1) 14.6 (13.5–15.8) NA 36.6 (33.5–39.9)

Abbreviations: FPL = federal poverty level; NA = not available; NHANES = National Health and Nutrition Examination Survey; NSCH = National Survey of Children’s Health; NSDUH = National
Survey on Drug Use and Health; YRBS = National Youth Risk Behavior Survey.
* Depression during past 2 weeks (score of ≥10 on the nine-item Patient Health Questionnaire depression module; adolescent report).
† During the past 12 months before the survey, felt so sad or hopeless almost every day for 2 or more weeks in a row that they stopped doing some usual activities.
§ For YRBS, survey participants were public and private high school students in grades 9–12 (i.e., primarily aged 14–18 years).
¶ Estimates exclude other race and ethnicity groups that did not have a large enough sample size to produce stable estimates.
** Estimate did not meet all NCHS data presentation standards (CI width >5, relative CI width >130) and should be interpreted with caution.
†† For NSCH, NHIS, and NSDUH, FPL is based on family income and family size using the Census Bureau’s poverty thresholds for the previous calendar year. Imputed income files were used to impute
family income when it was not provided, and for NSCH, family size was imputed using other information about the household when the number of family members was not provided (https://
www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html). NHANES uses the US Department of Health and Human Services poverty guidelines (https://aspe.hhs.gov/
topics/poverty-economic-mobility/poverty-guidelines) to calculate FPLs (also known as the family income to poverty ratio) and does not impute missing incomes. NSDUH only imputes family
size when exact counts cannot be determined from the household roster.
§§ The highest level of parent education is based on the highest education level among up to two adults who were identified as primary caregivers in the survey. For NHANES, education
of household reference person and spouse of household reference person (most often primary caregiver of youth).
¶¶ Private included any insurance from an employer or union, directly purchased, TRICARE or other military health care, or the Affordable Care Act; coverage from any government assistance
plan was considered public, including Medicaid or other state-sponsored health plans including the Children’s Health Insurance Program. Respondents who indicated both public and
private insurance coverage were represented in both subcategories.
*** Methods for determining geographic classification differed by survey. NSCH: 2010 Office of Management and Budget metropolitan and micropolitan statistical areas standards (https://www.
govinfo.gov/content/pkg/FR-2010-06-28/pdf/2010-15605.pdf). Urban/suburban includes metropolitan statistical areas associated with at least one urbanized area of at least 50,000 population;
rural was defined as counties that were not part of a metropolitan statistical area; NHIS: 2013 NCHS urban/rural classification (https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf). Urban/
suburban includes large metropolitan, medium metropolitan, and small metropolitan areas, whereas rural includes nonmetropolitan areas with >50,000 population; NSDUH: Rural-Urban Continuum
Codes (https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/). Urban/suburban includes large metropolitan, medium metropolitan, and small metropolitan areas; rural includes
nonmetropolitan counties. YRBS: MDR (formerly Market Data Retrieval) propriety information, determined by an MDR formula based on the National Center for Education Statistics Locale Code
classification and zip code. The urban category includes the urban, suburban, and town groups, and the rural category includes the rural/nonmetropolitan group.

MMWR / February 25, 2022 / Vol. 71 / No. 2 19

did not differ. NSCH data indicated that children from TABLE 7. Weighted prevalence estimates of anxiety problems among
rural areas had a higher prevalence of diagnosed depression children and adolescents aged 3–17 years, by sociodemographic
characteristics — National Survey of Children’s Health, United States,
than those from other areas. Depression indicators from the 2016–2019
2018–2019 NSDUH and the 2019 YRBS data indicated no Ever had Current
differences by geographic classification. anxiety problems anxiety problems
Characteristic % (95% CI) % (95% CI)
Age group (yrs) 3–17 3–17
Anxiety Sample size (no.) 114,476 114,476
Anxiety disorders are characterized by excessive fears and Total 9.4 (9.0–9.7) 7.8 (7.5–8.1)
worries that are developmentally inappropriate, persist for Age group (yrs)
3–5 2.0 (1.7–2.4) 1.6 (1.4–2.0)
>6 months, are severe, and interfere with daily functioning 6–11 8.6 (8.1–9.2) 7.1 (6.6–7.6)
(1). Anxiety symptoms in childhood and adolescence might 12–17 13.7 (13.1–14.3) 11.4 (10.9–12.0)
include clear fear or worry but can also include irritability, Sex
anger, and trouble sleeping, as well as physical symptoms Male 9.1 (8.6–9.6) 7.5 (7.1–7.9)
Female 9.7 (9.2–10.2) 8.1 (7.6–8.5)
such as fatigue, headaches, or stomachaches (1). In addition Race/Ethnicity*
to generalized anxiety, anxiety can also manifest as separation Hispanic 8.0 (7.1–9.0) 6.1 (5.3–6.9)
anxiety, panic disorder, or phobias. Children with anxiety Black, non-Hispanic 6.4 (5.6–7.3) 5.3 (4.6–6.1)
White, non-Hispanic 11.4 (11.0–11.8) 9.7 (9.4–10.1)
disorders are at risk for other mental disorders and physical Asian, non-Hispanic 3.0 (2.3–3.8) 2.2 (1.7–2.9)
health conditions, as well as school problems and negative FPL†
effects on family relationships (17,34,42). Only NSCH asked ≤100% FPL 9.7 (8.8–10.6) 8.0 (7.2–8.8)
>100% to ≤ 200% FPL 9.4 (8.6–10.3) 7.5 (6.9–8.3)
parents whether a health care provider had ever told them that >200% FPL 9.3 (8.9–9.7) 7.8 (7.4–8.2)
their child had anxiety problems, followed by a question on Highest level of parent education§
whether the child currently had anxiety. Less than high school 8.9 (7.3–10.8) 6.3 (5.1–7.6)
Results of the 2016–2019 survey years of NSCH showed High school graduate 9.1 (8.3–10.0) 7.4 (6.7–8.2)
More than high school 9.6 (9.2–9.9) 8.1 (7.8–8.5)
that 9.4% of children and adolescents aged 3–17 years had ever Health insurance¶
received a diagnosis of anxiety problems, and 7.8% had anxiety Yes
problems at the time of the survey (Table 7). State prevalence Any public 11.3 (10.6–12.1) 9.4 (8.8–10.0)
Any private 9.2 (8.8–9.6) 7.6 (7.3–8.0)
estimates of ever having had anxiety problems among children No insurance 6.9 (5.6–8.6) 5.6 (4.5–6.9)
and adolescents aged 3–17 years ranged from 5.1% in Hawaii to Geographic classification**
17.3% in Maine; estimates of current anxiety ranged from 3.8% Urban/Suburban 9.0 (8.6–9.5) 7.4 (7.1–7.8)
Rural 10.2 (9.4–11.1) 8.7 (7.9–9.4)
in Hawaii to 14.7% in Maine (Supplementary Tables 1 and 2;
https://stacks.cdc.gov/view/cdc/113924). Abbreviations: FPL = federal poverty level; NSCH = National Survey of Children’s Health.
* Estimates exclude other race and ethnicity groups that did not have a large
The prevalence of ever having had anxiety problems increased enough sample size to produce stable estimates.
† FPL is based on family income and family size using the Census Bureau’s
with age, from 2.0% among children aged 3–5 years to 8.6% for
poverty thresholds for the previous calendar year. Imputed income files were
those aged 6–11 years and 13.7% for those aged 12–17 years. used to impute family income when it was not provided and family size was
Estimates of anxiety for boys and girls were similar. The imputed using other information about the household when the number of
family members was not provided (https://www.census.gov/topics/income-
highest prevalence estimates among children and adolescents poverty/poverty/guidance/poverty-measures.html)
aged 3–17 years were observed among White children and § The highest level of parent education is based on the highest education level

adolescents, and the lowest were observed among Asian children among up to two adults who were identified as primary caregivers in the survey.
¶ Private included any insurance from an employer or union, directly purchased,
and adolescents. Although no differences in the prevalence of TRICARE or other military health care, or the Affordable Care Act; coverage
ever having anxiety problems were found by parent education from any government assistance plan was considered public, including
Medicaid or other state-sponsored health plans including the Children’s
level, prevalence estimates of current anxiety among children and Health Insurance Program. Respondents who indicated both public and
adolescents aged 3–17 years were higher among children and private insurance coverage were represented in both subcategories.
** Method for determining geographic classification for NSCH was based on
adolescents of parents with more than a high school education the 2010 Office of Management and Budget metropolitan and micropolitan
than among those with less than a high school education. statistical areas standards (https://www.govinfo.gov/content/pkg/FR-2010-
06-28/pdf/2010-15605.pdf ). Urban/suburban includes metropolitan
Prevalence estimates were highest for children and adolescents statistical areas associated with at least one urbanized area of at least 50,000
aged 3–17 years with public health insurance and lowest for population; rural was defined as counties that were not part of a metropolitan
those with no health insurance. No differences were found by statistical area.

poverty level. Prevalence estimates of anxiety among children

20 MMWR / February 25, 2022 / Vol. 71 / No. 2

and adolescents aged 3–17 years were slightly higher for children children. Other ASD estimates for children and adolescents
and adolescents living in rural areas than in urban areas. aged 3–17 years from NSCH and NHIS data showed no
differences among racial and ethnic groups. Regarding
Autism Spectrum Disorder socioeconomic factors, NSCH data showed that children with
public health insurance had the highest prevalence of ASD, and
ASD is a developmental disability that can cause significant social, children and adolescents aged 3–17 years in families with the
communication, and behavioral challenges. Symptoms include highest income level (>200% FPL) had the lowest prevalence
difficulties with communication, social interactions, restricted and of ASD; these differences were not observed in NHIS data.
repetitive behaviors, and adapting to change. Intellectual ability can Parent education level and geographic classification were not
range from gifted to severely challenged (1). A diagnosis of ASD associated with significantly different prevalences of ASD in
now encompasses several conditions that were previously diagnosed NSCH or NHIS data.
separately: autistic disorder, pervasive developmental disorder
not otherwise specified, and Asperger syndrome. The DSM-5,
published in 2013, collectively described these conditions as ASD Tourette Syndrome
(1). Children with ASD often experience significant functional Tourette syndrome is a tic disorder characterized by the
impairment and are at risk for having other mental disorders presence of both multiple motor tics and at least one vocal tic,
and medical conditions, including respiratory, gastrointestinal, with tics occurring for at least 1 year to meet diagnostic criteria.
dermatologic, and neurologic conditions that require treatment Other tic disorders include persistent motor tic disorder, with
(81). NSCH and NHIS surveys both asked parents if a health care motor tics present for at least 1 year, and persistent vocal tic
provider had ever told them that their child had ASD, followed disorder, with vocal tics present for at least 1 year. Provisional
by a question asking whether the child currently had ASD. The tic disorder is used when any tics have been present for
ADDM Network uses a records review to cumulatively assess ASD <1 year (1). Tics often begin in children aged 4–8 years, and
diagnoses and symptoms through age 8 years. approximately 80% have another co-occurring mental disorder,
Estimates of the overall prevalence of ASD among children and including ADHD, obsessive-compulsive disorder, anxiety, or
adolescents aged 3–17 years using 2016–2019 NSCH data were depression (1,82). Tourette syndrome is the only tic disorder
3.1% and 2.9% for ever having had a diagnosis of ASD and having included in national surveillance systems and is only included
a current diagnosis of ASD, respectively (Table 8). Estimates of in the NSCH questionnaire, which asks parents whether a
ASD among children and adolescents aged 3–17 years from 2017– health care provider has ever told them that their child had
2018 NHIS data were lower, at 2.4% and 2.0%, respectively. State Tourette syndrome, followed by a question on whether the
prevalence estimates of ever ASD among children and adolescents child currently has Tourette syndrome.
aged 3–17 years ranged from 1.5% in North Dakota to 4.5% in Data from the 2016–2019 survey years of NSCH indicate
Delaware. Estimates of current ASD ranged from 1.3% in North that 0.3% of children and adolescents aged 3–17 had ever
Dakota to 4.1% in Delaware (Supplementary Tables 1 and 2; received a diagnosis of Tourette syndrome, and 0.2% of
https://stacks.cdc.gov/view/cdc/113924). children and adolescents aged 3–17 years had a current Tourette
Prevalence estimates of ASD from 2016–2019 NSCH syndrome diagnosis (Table 9). A Tourette syndrome diagnosis
data increased from ages 3–5 years to ≥6 years. Although was more common in boys than girls; prevalence estimates were
differences showed similar patterns in 2017–2018 NHIS data similar among various age groups, races/ethnicities (Hispanic
(a survey with a smaller sample size), the differences were not and White), parent education levels, types of health insurance,
significant. The 1.9% estimate from 2016 ADDM Network household poverty level, and geographic classification.
data among children aged 8 years was lower than the 3.0% Because of the relatively small sample size of children and
estimate of current ASD from NSCH data among children adolescents aged 3–17 years with Tourette syndrome, state
aged 6–11 years but similar to the 2.0% estimate from NHIS prevalence estimates are not presented, and estimates for certain
data among children aged 6–11 years. Across all data sources, sociodemographic characteristics were suppressed because
ASD was more common in boys. Prevalence estimates among of cell sizes of <20 (children aged 3–5 years, Black children,
different racial and ethnic groups varied among the surveys. Asian children, children of parents with less than a high school
Whereas the ADDM data showed that Hispanic children education, and children with no health insurance).
aged 8 years had a lower prevalence of ASD than White or
Black children aged 8 years, estimates of current ASD among Substance Use Disorders
children and adolescents aged 3–17 years based on NSCH data
were lower among Asian children compared with Hispanic Substance use is typically initiated during adolescence
(83). Familial, social, and individual risk factors might lead

MMWR / February 25, 2022 / Vol. 71 / No. 2 21

TABLE 8. Weighted prevalence estimates of autism spectrum disorder among children and adolescents aged 3–17 years, by sociodemographic
characteristics — three surveillance systems, United States, 2016–2019
Met ASD surveillance case
Ever had ASD Current ASD definition*
NSCH 2016–2019 NHIS 2017–2018 NSCH 2016–2019 NHIS 2017–2018 ADDM Network 2016
Characteristic % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Age group (yrs) 3–17 3–17 3–17 3–17 8
Sample size (no.) 114,476 14,316 114,476 14,292 275,419
Total 3.1 (2.8–3.3) 2.4 (2.1–2.7) 2.9 (2.6–3.1) 2.0 (1.8–2.4) 1.9 (1.8–1.9)

Age group (yrs)

3–5 2.1 (1.7–2.5) 1.8 (1.3–2.6) 1.9 (1.6–2.2) 1.6 (1.1–2.3) NA
6–11 3.2 (2.8–3.6) 2.3 (1.8–3.0) 3.0 (2.6–3.4) 2.0 (1.5–2.5) 1.9 (1.8–1.9)†
12–17 3.5 (3.1–3.9) 2.7 (2.2–3.2) 3.3 (2.9–3.7) 2.3 (1.9–2.8) NA
Sex
Male 4.8 (4.3–5.2) 3.6 (3.1–4.2) 4.4 (4.0–4.9) 3.1 (2.7–3.7) 3.0 (2.9–3.1)
Female 1.3 (1.1–1.5) 1.1 (0.8–1.5) 1.2 (1.0–1.5) 0.9 (0.7–1.3) 0.7 (0.7–0.7)
Race/Ethnicity§
Hispanic 3.5 (2.8–4.4) 2.1 (1.6–2.7) 3.4 (2.7–4.3) 1.8 (1.3–2.4) 1.5 (1.4–1.6)
Black, non-Hispanic 3.4 (2.7–4.1) 2.8 (1.7–4.6) 3.1 (2.6–3.8) 2.2 (1.4–3.4) 1.8 (1.7–1.9)
White, non-Hispanic 2.9 (2.7–3.1) 2.5 (2.1–2.9) 2.7 (2.5–2.9) 2.3 (1.9–2.7) 1.9 (1.8–1.9)
Asian, non-Hispanic 2.1 (1.6–2.8) 1.3 (0.7–2.5) 1.9 (1.4–2.6) 0.8 (0.4–1.7) 1.8 (1.6–2.0)
FPL¶
≤100% FPL 4.0 (3.3–4.9) 2.3 (1.6–3.1) 3.9 (3.2–4.8) 2.1 (1.5–3.0) NA
>100% to ≤200% FPL 3.8 (3.2–4.6) 2.8 (2.2–3.5) 3.5 (2.9–4.3) 2.3 (1.8–3.0) NA
>200% FPL 2.4 (2.3–2.6) 2.3 (1.8–2.8) 2.3 (2.1–2.5) 1.9 (1.6–2.3) NA
Highest level of parent education**
Less than high school 3.1 (2.1–4.8) 1.6 (1.0–2.6) 3.1 (2.0–4.7) 1.4 (0.8–2.3) NA
High school graduate 3.6 (3.0–4.4) 2.2 (1.6–2.9) 3.4 (2.7–4.2) 2.0 (1.5–2.8) NA
More than high school 2.9 (2.7–3.2) 2.5 (2.1–3.0) 2.7 (2.5–2.9) 2.1 (1.8–2.5) NA
Health insurance††
Yes
Any public 4.8 (4.3–5.5) 3.1 (2.6–3.7) 4.6 (4.0–5.2) 2.8 (2.3–3.4) NA
Any private 2.6 (2.4–2.9) 2.2 (1.8–2.8) 2.4 (2.2–2.7) 1.8 (1.4–2.3) NA
No insurance 1.8 (1.1–3.0) 2.4 (1.0–5.3) 1.8 (1.1–3.0) 1.7 (0.7–4.2) NA
Geographic classification§§
Urban/Suburban 3.0 (2.7–3.4) 2.3 (2.0–2.7) 2.9 (2.6–3.2) 2.0 (1.7–2.3) NA
Rural 2.8 (2.4–3.2) 2.8 (2.0–3.9) 2.6 (2.2–3.0) 2.7 (1.9–3.8) NA
Abbreviations: ADDM = Autism and Developmental Disabilities Monitoring; ASD = autism spectrum disorder; FPL = federal poverty level; NA = not available;
NHIS = National Health Interview Survey; NSCH = National Survey of Children’s Health.
* Case definition based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria for autism spectrum disorder. Clinicians applied the case definition
through a review of information systematically collected from developmental evaluations completed by medical and educational service providers in the community.
† Estimate is for children aged 8 years only.
§ Estimates exclude other race and ethnicity groups that did not have a large enough sample size to produce stable estimates
¶ FPL is based on family income and family size using the Census Bureau’s poverty thresholds for the previous calendar year. Imputed income files were used to
impute family income when it was not provided, and for NSCH, family size was imputed using other information about the household when the number of family
members was not provided (https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html).
** The highest level of parent education is based on the highest education level among up to two adults who were identified as primary caregivers in the survey.
†† Private included any insurance from an employer or union, directly purchased, TRICARE or other military health care, or the Affordable Care Act; coverage from any
government assistance plan was considered public, including Medicaid or other state-sponsored health plans including the Children’s Health Insurance Program.
Respondents who indicated both public and private insurance coverage were represented in both subcategories.
§§ Method for determining geographic classification differed by survey. NSCH: 2010 Office of Management and Budget metropolitan and micropolitan statistical areas
standards (https://www.govinfo.gov/content/pkg/FR-2010-06-28/pdf/2010-15605.pdf ). Urban/suburban includes metropolitan statistical areas associated with
at least one urbanized area of at least 50,000 population; rural was defined as counties that were not part of a metropolitan statistical area; NHIS: 2013 NCHS urban/
rural classification (https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf ). Urban/suburban includes large metropolitan, medium metropolitan, and small
metropolitan areas, whereas rural includes nonmetropolitan areas with >50,000 population.

to substance use and substance use disorders among youths health issues, disabilities, and failure to meet responsibilities
(84). The use of substances during adolescence has been linked at work, school, or home (85). Substance use disorders during
to motor vehicle deaths, sexually transmitted infections, and the past year were assessed by NSDUH through adolescent
other physical and mental health problems (84). Substance self-report on use of and experiences related to use of alcohol
use disorders are characterized by impairments caused by the and illicit drugs. During 2018–2019, an estimated 1 million
recurrent use of alcohol or illicit drugs (or both), including

22 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 9. Weighted prevalence estimates of Tourette syndrome among adolescents aged 12–17 years met criteria for a past year
children and adolescents aged 3–17 years, by sociodemographic substance use disorder (85) (Table 3).
characteristics — National Survey of Children’s Health, United States,
2016–2019 Data from the 2018 and 2019 NSDUH indicated that
Ever had Current
an estimated 407,000 adolescents aged 12–17 years (1.6%)
Tourette syndrome Tourette syndrome had an alcohol use disorder. Alcohol use disorder among
Characteristic % (95% CI) % (95% CI) adolescents aged 12–17 years varied by state, with prevalence
Age group (yrs) 3–17 3–17 estimates ranging from 0.9% in Delaware to 4.7% in Vermont.
Sample size (no.) 114,476 114,476 Approximately 788,000 (3.2%) adolescents aged 12–17 years
Total 0.3 (0.2–0.4) 0.2 (0.2–0.3)
had an illicit drug use disorder. State prevalence estimates of
Characteristic
an illicit drug disorder among adolescents aged 12–17 years
Age group (yrs)
3–5 —* —* ranged from 1.1% in Louisiana to 6.0% in Vermont. More
6–11 0.3 (0.2–0.5) 0.2 (0.1–0.4) detailed information on substance use disorders by state is
12–17 0.4 (0.3–0.5) 0.3 (0.2–0.4)
available (Supplementary Table 2; https://stacks.cdc.gov/view/
Sex
Male 0.5 (0.3–0.6) 0.4 (0.3–0.5) cdc/113924).
Female 0.1 (0.1–0.2) 0.1 (0.0–0.1) Past year alcohol use was higher among adolescent girls
Race/Ethnicity† aged 12–17 years (2.0%) than among adolescent boys aged
Hispanic 0.3 (0.1–0.6) 0.2 (0.1–0.6)
Black, non-Hispanic —* —*
12–17 years (1.3%) (Table 10). Overall substance use disorder
White, non-Hispanic 0.3 (0.3–0.4) 0.3 (0.2–0.4) (either alcohol or illicit drugs) was lower among Asian
Asian, non-Hispanic —* —* adolescents aged 12–17 years (2.0%) than among White
FPL§ (4.2%) and Hispanic (4.5%) adolescents aged 12–17 years.
≤100% FPL 0.2 (0.2–0.4) 0.2 (0.1–0.3)
>100% to ≤200% FPL 0.2 (0.1–0.3) 0.2 (0.1–0.3) Alcohol use disorder was lower among Asian and Black (both
>200% FPL 0.3 (0.2–0.4) 0.2 (0.2–0.4) 0.5%) adolescents aged 12–17 years than among Hispanic
Highest level of parent education¶ (1.7%) and White (2.0%) adolescents aged 12–17 years;
Less than high school —* —*
High school graduate 0.3 (0.2–0.4) 0.2 (0.1–0.3) estimates among Asian and Hispanic adolescents did not differ.
More than high school 0.3 (0.2–0.4) 0.2 (0.2–0.3) A higher prevalence of illicit drug use disorder was reported
Health insurance** by adolescents aged 12–17 years with public health insurance
Yes
Any public 0.2 (0.2–0.3) 0.2 (0.1–0.3)
(3.6%) compared with those with private health insurance
Any private 0.3 (0.2–0.4) 0.2 (0.2–0.4) (2.8%). The prevalence of substance use disorders was similar
No insurance 0.4 (0.2–0.8) —* across poverty levels and geographic classifications.
Geographic classification††
Urban/Suburban 0.3 (0.2–0.4) 0.2 (0.2–0.3)
Rural 0.4 (0.3–0.6) 0.3 (0.2–0.5) Suicide
Abbreviations: FPL = federal poverty level; NSCH = National Survey of Children’s Health.
* Estimates based on cell sizes <20 have been suppressed due to instability of estimates.
Suicide is defined as a death caused by injuring oneself with
† Estimates exclude other race and ethnicity groups that did not have a large the intent to die. Suicidal behavior is a public health problem
enough sample size to produce stable estimates. (86) that can have lasting effects on persons, families, and
§ FPL is based on family income and family size using the Census Bureau’s
poverty thresholds for the previous calendar year. Imputed income files were communities associated with the decedent (87). Suicide is
used to impute family income when it was not provided and family size was usually the result of a combination of individual, relational,
imputed using other information about the household when the number of
family members was not provided (https://www.census.gov/topics/income- community, and societal factors that interact with one another
poverty/poverty/guidance/poverty-measures.html).
¶ The highest level of parent education is based on the highest education level
over time (87). For example, suicide is associated with violence
among up to two adults who were identified as primary caregivers in the survey. victimization, such as child abuse and neglect, bullying, peer
** Private included any insurance from an employer or union, directly purchased, violence, and dating and sexual violence (88). Suicide does
TRICARE or other military health care, or the Affordable Care Act; coverage
from any government assistance plan was considered public, including
not always result from a mental disorder (78). A study of
Medicaid or other state-sponsored health plans including the Children’s circumstances surrounding suicides documented in NVDRS
Health Insurance Program. Respondents who indicated both public and found that 54% of suicide decedents did not have a known
private insurance coverage were represented in both subcategories.
†† Method for determining geographic classification for NSCH was based on the mental health problem (86). The number of deaths from
2010 Office of Management and Budget metropolitan and micropolitan statistical suicides reflects only a small portion of the overall impact of
areas standards (https://www.govinfo.gov/content/pkg/FR-2010-06-28/
pdf/2010-15605.pdf). Urban/suburban includes metropolitan statistical areas suicidal behavior. Although suicide is a complex problem,
associated with at least one urbanized area of at least 50,000 population; rural it can be prevented by using a public health approach that
was defined as counties that were not part of a metropolitan statistical area.
reduces factors that increase suicide risk and increases factors
that promote resilience (89).

MMWR / February 25, 2022 / Vol. 71 / No. 2 23

TABLE 10. Weighted prevalence estimates of past year substance use disorder, alcohol use disorder, and/or illicit drug use disorder among
adolescents aged 12–17 years, by sociodemographic characteristics — National Survey on Drug Use and Health, United States, 2018–2019
Past year substance use disorder* Past year alcohol use disorder Past year illicit drug use disorder
Characteristic % (95% CI) % (95% CI) % (95% CI)
Age group (yrs) 12–17 12–17 12–17
Sample size (no.) 33,678 33,678 33,678
Total 4.1 (3.8–4.4) 1.6 (1.5–1.8) 3.2 (2.9–3.4)
Characteristic
Sex
Male 3.8 (3.4–4.2) 1.3 (1.1–1.6) 3.1 (2.7–3.4)
Female 4.4 (4.0–4.8) 2.0 (1.7–2.2) 3.3 (2.9–3.6)
Race/Ethnicity†
Hispanic 4.5 (3.8–5.2) 1.7 (1.3–2.2) 3.5 (2.9–4.2)
Black, non-Hispanic 3.3 (2.7–4.0) 0.5 (0.3–0.7) 3.0 (2.4–3.7)
White, non-Hispanic 4.2 (3.9–4.6) 2.0 (1.8–2.3) 3.1 (2.8–3.4)
Asian, non-Hispanic 2.0 (1.1–3.4) 0.5 (0.2–1.6) 1.7 (1.0–3.0)
FPL§
≤100% FPL 3.9 (3.4–4.6) 1.4 (1.1–1.8) 3.2 (2.7–3.8)
>100% to ≤200% FPL 4.3 (3.8–5.0) 1.5 (1.2–1.9) 3.5 (3.0–4.1)
>200% FPL 4.0 (3.7–4.4) 1.8 (1.5–2.0) 3.0 (2.7–3.4)
Health insurance¶
Yes
Any public 4.3 (3.9–4.8) 1.5 (1.2–1.8) 3.6 (3.2–4.1)
Any private 3.9 (3.5–4.3) 1.7 (1.5–2.0) 2.8 (2.5–3.1)
No insurance 4.8 (3.6–6.4) 1.6 (1.0–2.4) 4.1 (3.0–5.6)
Geographic classification**
Urban/Suburban 4.1 (3.8–4.5) 1.6 (1.4–1.8) 3.3 (3.0–3.6)
Rural 3.8 (3.3–4.4) 2.1 (1.7–2.5) 2.5 (2.1–3.0)
Abbreviations: FPL = federal poverty level; NSDUH = National Survey on Drug Use and Health.
* Includes either past year alcohol use disorder or past year illicit drug use disorder.
† Estimates exclude other race and ethnicity groups that did not have a large enough sample size to produce stable estimates.
§ FPL is based on family income and family size using the Census Bureau’s poverty thresholds for the previous calendar year. Imputed income files were used to
impute family income when it was not provided (https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html). NSDUH only imputes
family size when exact counts cannot be determined from the household roster.
¶ Private included any insurance from an employer or union, directly purchased, TRICARE or other military health care, or the Affordable Care Act; coverage from any
government assistance plan was considered public, including Medicaid or other state-sponsored health plans including the Children’s Health Insurance Program.
Respondents who indicated both public and private insurance coverage were represented in both subcategories.
** Geographic classification for NSDUH used Rural-Urban Continuum Codes (https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/). Urban/
suburban includes large metropolitan, medium metropolitan, and small metropolitan areas; rural includes nonmetropolitan counties.

Data on suicide among children and adolescents were persons aged ≥19 years. The number of school-associated
available from NVSS 2018–2019, NVDRS 2014–2018, and suicides among persons aged 10–18 years fluctuated by year,
SAVD-SS 2013–2019; data on suicidal ideation were available ranging from four in the first 6 months of 2019 to 11 in 2013.
from YRBS 2019. Data from YRBS indicated that during the Seven (14.9%) of these suicides involved a known diagnosed
past year among U.S. high school students primarily aged or suspected mental health condition. NVSS data indicate that
14–18 years, 18.8% seriously considered attempting suicide, rates of suicide per 100,000 persons aged 10–19 years were
15.7% made a suicide plan, 8.9% attempted suicide one the lowest in Massachusetts (2.8) and the highest in Alaska
or more times, and 2.5% made a suicide attempt requiring (27.3) (Supplementary Table 2; https://stacks.cdc.gov/view/
medical treatment (Table 11). On the basis of data from NVSS, cdc/113924).
with coverage of the entire United States in 2018 and 2019, a YRBS 2019 data indicate that among high school students
total of 5,744 (6.9 per 100,000) persons aged 10–19 years died primarily aged 14–18 years, the prevalence of suicidal ideation
by suicide; the corresponding number from NVDRS, with data (i.e., seriously considered attempting suicide and made a suicide
from selected states and counties for 2014–2018, was 4,903 plan), attempting suicide, and making a suicide attempt requiring
(7.0 per 100,000) suicides among persons aged 10–19 years. medical treatment were more common among female than male
During January 2013–June 2019, SAVD-SS data included 85 high school students. The prevalence of seriously considering
suicides; of these, 47 (55.3%) occurred among persons aged attempting suicide was higher among AI/AN students primarily
10–18 years, and the remaining 38 suicides (44.7%) involved aged 14–18 years compared with Hispanic, Black, and White

24 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 11. Prevalence estimates* of suicidal ideation and suicide attempts and number and rate of suicides among persons aged 10–19 years,
by sociodemographic characteristics and known circumstances — three surveillance systems, 2014–2019
Current Current
mental mental
Made suicide disorder disorder
Seriously attempt among treatment
considered requiring those who among those
attempting Made suicide Attempted medical died by who died by
suicide† plan† suicide§ treatment¶ Suicide suicide suicide
YRBS 2019 (N = 13,677) NVSS 2018–2019** NVDRS 2014–2018†† NVDRS 2014–2018††
Rate per
100,000 Rate per 100,000
Characteristic % (95% CI) % (95% CI) % (95% CI) % (95% CI) No. (95% CI) No. (95% CI) No. (%)§§ No. (%)§§
Age group (yrs) 14–18¶¶ 14–18¶¶ 14–18¶¶ 14–18¶¶ 10–19 10–19 10–19 10–19 10–19 10–19
Total 18.8 (17.6–20.0) 15.7 (14.6–16.9) 8.9 (7.9–10.0) 2.5 (2.1–3.0) 5,744 6.9 (6.7–7.0) 4,903 7.0 (4.7–9.3) 2,100 (46.9) 1,325 (29.6)
Age group (yrs)***
10–14 18.1 (15.1–21.5) 14.8 (12.4–17.6) 8.4 (7.0–10.0) 1.9 (1.0–3.4) 1,130 2.7 (2.6–2.9) 928 2.7 (1.7–3.7) 359 (8.0) 242 (5.4)
15–19 18.8 (17.7–19.9) 15.7 (14.7–16.8) 8.9 (7.8–10.1) 2.6 (2.1–3.1) 4,614 10.9 (10.6–11.3) 3,975 11.2 (9.1–13.2) 1,741 (38.9) 1,083 (24.2)
Sex
Male 13.3 (12.2–14.5) 11.3 (10.3–12.4) 6.6 (5.5–8.1) 1.7 (1.3–2.3) 4,286 10.0 (9.7–10.3) 3,633 10.1 (8.2–12.1) 1,404 (31.4) 848 (19.0)
Female 24.1 (22.3–26.0) 19.9 (18.4–21.6) 11.0 (9.7–12.5) 3.3 (2.6–4.2) 1,458 3.6 (3.4–3.7) 1,270 3.7 (2.4–4.9) 696 (15.6) 477 (10.7)
Race/Ethnicity†††
Hispanic 17.2 (15.2–19.4) 14.7 (13.0–16.7) 8.9 (7.1–11.1) 3.0 (2.3–3.8) 978 4.7 (4.4–5.0) 555 5.5 (4.7–6.3) 203 (4.5) 111 (2.5)
Black, non-Hispanic 16.9 (15.3–18.7) 15.0 (12.9–17.5) 11.8 (8.7–15.9) 3.3 (2.2–4.9) 632 5.0 (4.6–5.4) 543 4.3 (3.6–5.1) 161 (3.6) 99 (2.2)
White, non-Hispanic 19.1 (17.6–20.8) 15.7 (14.1–17.4) 7.9 (6.9–9.1) 2.1 (1.5–2.8) 3,652 8.1 (7.9–8.4) 3,395 7.8 (5.9–9.7) 1,591 (35.6) 1,020 (22.8)
Asian, non-Hispanic 19.7 (15.8–24.3) 16.1 (13.1–19.7) 7.7 (4.8–12.3) 1.7 (0.6–4.6) 272 5.5 (4.8–6.1) 144 4.5 (4.1–4.9) 45 (1.0) 32 (0.72)
American Indian or Alaska 34.7 (23.8–47.6) 24.2 (13.5–39.6) 25.5 (12.6–44.6) 11.5 (3.7–30.3) 198 24.0 (20.7–27.4) NA 13.4 (13.1–13.8) NA NA
Native, non-Hispanic
Native Hawaiian or other 15.4 (8.2–27.0) 13.5 (6.2–26.8) 8.8 (2.4–27.2) NA NA NA NA NA NA NA
Pacific Islander, non-Hispanic
Geographic classification§§§
Urban/Suburban 19.0 (17.6–20.5) 15.8 (14.5–17.1) 8.9 (7.7–10.2) 2.5 (2.0–3.0) 4,559 6.3 (6.1–6.5) NA NA NA NA
Rural 17.6 (16.0–19.3) 15.0 (13.6–16.6) 9.1 (7.3–11.3) 2.8 (1.9–4.1) 1,185 10.2 (9.6–10.7) NA NA NA NA

Abbreviations: FPL = federal poverty level; NA = not available; NVDRS = National Violent Death Reporting System; NVSS = National Vital Statistics System; YRBS = National Youth Risk Behavior Survey.
* Estimates for YRBS are weighted; numbers, rates, and unweighted percentages are presented for NVSS and NVDRS.
† During the 12 months before the survey.
§ During the 12 months before the survey, actually attempted suicide ≥1 time.
¶ During the 12 months before the survey, made a suicide attempt ≥1 time that resulted in injury, poisoning, or overdose that had to be treated by a physician or nurse.
** Suicides are identified using International Classification of Diseases, 10th Revision underlying cause-of-death codes U03, X60–X84, and Y87.0.
†† States (n = 18) included Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South
Carolina, Utah, Virginia, and Wisconsin.
§§ The overall denominator for percent of suicides associated with a current mental disorder and current mental disorder treatment is 4,471.
¶¶ Survey participants were public and private high school students in grades 9–12 (i.e., primarily aged 14–18 years).
*** For YRBS, only age 14 years is included for the 10–14 years age group, and 15 to ≥18 years is included in 15–19 years age group.
††† Estimates exclude other race and ethnicity groups that did not have a large enough sample size to produce stable estimates.
§§§ Geographic classification for YRBS was determined using MDR (formerly Market Data Retrieval) propriety information, determined by an MDR formula based on the National Center for
Education Statistics Locale Code classification and zip code. The urban category includes the urban, suburban, and town groups, and the rural category includes the rural/nonmetropolitan
group. Geographic classification for NVSS was determined by the decedent’s county of residence and was categorized using the 2013 NCHS Urban–Rural Classification Scheme for
Counties. Counties were classified into six urbanization levels based on metropolitan–nonmetropolitan status, population distribution, and other factors. The four metropolitan categories
(i.e., large central metro, large fringe metro, medium metro, and small metro) were grouped as urban counties. The two nonmetropolitan categories (i.e., micropolitan and noncore) were
grouped as rural counties.

students. Similarly, the estimated percentage of students who and ethnic groups; however, the rates among White and Hispanic
attempted suicide was higher among AI/AN students than children based on NVDRS data did not differ.
among Hispanic, White, and Asian students, and the estimated
percentage of students who made a suicide attempt requiring Mental Health Services
medical treatment was also higher among AI/AN students than
White students, but not significantly different compared with Mental health services include the assessment, diagnosis,
Hispanic, Black, and Asian students. Both NVSS 2018–2019 and treatment of mental disorders. Options to treat mental
and NVDRS 2014–2018 data indicated that suicide rate was disorders among children include psychological treatments
higher among persons aged 15–19 years than among those aged as well as medication (75,90–92). Effective treatments can
10–14 years and higher among boys than among girls, and the vary by age of the child, type of diagnosis and co-occurring
rate per 100,000 children and adolescents aged 10–19 years was conditions, and other circumstances. Psychological treatments
highest for AI/AN students. The rate was also higher among are typically delivered by mental health professionals, including
White children and adolescents than among those in other racial psychologists, psychiatrists, or counselors, but also might
involve training parents and teachers to deliver interventions

MMWR / February 25, 2022 / Vol. 71 / No. 2 25

to children (75,93). Evidence-based psychological treatment about an emotional or behavioral problem of their child. Data
can focus on the parent, child, or family and can be delivered from the 2013–2018 NHANES indicated that 9.8% of parents
individually or in groups (94). Examples of effective of children aged 4–17 years had consulted with a mental
treatment approaches include parent training in behavior health professional during the past 12 months. Data from the
management, which has been documented as effective for 2018–2019 survey years of NSDUH indicate that 25.9% of
ADHD and disruptive behavior disorders, particularly for adolescents aged 12–17 years reported receiving mental health
younger children (94,95); applied behavior analysis for ASD services in the past year.
(93); cognitive-behavioral therapy for disruptive behavior Regarding medication, 2016–2019 NSCH data indicated
disorders, depression, and anxiety (96–98); interpersonal that 7.8% of children and adolescents aged 3–17 years had
psychotherapy for adolescents with depression (99); or taken medication because of difficulties with emotions,
behavior therapy targeted to specific skills, such as cognitive- concentration, or behavior during the past 12 months, and
behavioral intervention for tics (100) or organizational training 2013–2018 NHANES data indicated that 6.6% of children
for children with ADHD (101), among others. However, and adolescents aged 3–17 years had used a psychotropic
the treatment that children receive is often different from medication during the past 30 days (Table 12).
the originally developed and tested programs with proven State prevalence estimates for mental health treatment
effectiveness, and providers might vary in their use of strategies from a health professional among children and adolescents
and degree of fidelity with evidence-based approaches (102). aged 3–17 years based on 2016–2019 NSCH data ranged
Medications might be prescribed by primary care providers from 6.5% in Nevada to 15.6% in Montana (Supplementary
and other licensed mental health providers (103). The Food Table 3; https://stacks.cdc.gov/view/cdc/113924). NSDUH
and Drug Administration (FDA) has approved medications 2018–2019 data indicated that receipt of mental health services
for childhood mental disorders such as ADHD, depression, among adolescents aged 12–17 years ranged from 15.9% in
anxiety, and ASD; however, many medications for mental Tennessee to 35.9% in Colorado. NSCH 2016–2019 data
disorders are prescribed without specific FDA approval for indicated that the prevalence of using medications related to
use in children and without following standard care guidelines mental health in the past year among children and adolescents
(104,105). Medication might be more effective if carefully aged 3–17 years ranged from 3.7% in California and Nevada
titrated and used in combination with behavioral treatment to 12.4% in Louisiana.
(95). Indicators of mental health services were included in Consultations with general health care providers and mental
NHIS, NSCH, NHANES, and NSDUH. NHIS and NSCH health professionals about emotional or behavioral problems,
both included questions about receiving services from a mental as well as use of medications for mental health problems,
health professional during the past 12 months. In addition, increased with age. NHIS data from 2017–2018 for children
NHIS included a question about seeing a general physician and adolescents aged 3–17 years showed that boys were more
because of an emotional or behavioral problem. Both NSCH likely than girls to have seen a mental health professional during
and NHANES included questions about medication; NSCH the past 12 months and that parents of boys were more likely
asked about whether the child had taken any medication because to have spoken with a doctor about a child’s emotional or
of difficulties with emotions, concentration, or behavior during behavioral problem. NSCH 2016–2019 estimates of mental
the past 12 months, whereas NHANES asked about use of health treatment by a professional among boys aged 3–17 years
psychotropic medication during the past 30 days. NSDUH (10.6%) and girls (9.6%) did not differ. However, NSDUH
included questions about receipt of specialty and nonspecialty 2018–2019 data indicated that a higher proportion of adolescent
mental health services. All estimates of mental health services girls aged 12–17 years received mental health services compared
were calculated for the population of children and were not with adolescent boys. Data from both NSCH 2016–2019 and
restricted to children with diagnosed mental disorders. NHANES 2013–2018 showed that boys aged 3–17 years were
Regarding treatment, data from the 2016–2019 survey years more likely than girls to take medications related to mental health
of NSCH indicated that 10.1% of children and adolescents (i.e., for difficulties with emotions, concentration, or behavior
aged 3–17 years, regardless of diagnoses, received any treatment or a psychotropic medication).
or counseling from a mental health professional during the Across surveys (NSCH, NHIS, NSDUH, and NHANES),
past 12 months (Table 12). Data from the 2017–2018 survey for each indicator of mental health services, White children
years of NHIS indicated that 9.6% of parents of children had the highest estimated prevalence, whereas Asian children
and adolescents aged 3–17 years had consulted with a mental had the lowest estimated prevalence. NSCH data from 2016–
health professional about the child’s health during the past 2019 for children and adolescents aged 3–17 years indicated
12 months, and 5.2% had consulted with a general physician that Hispanic children had a lower estimated prevalence of

26 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 12. Weighted prevalence estimates of receipt of mental health treatment, services, and medication among children and adolescents
aged 3–17 years, by sociodemographic characteristics — four surveillance systems, United States, 2013–2019
Mental health
consultation, Past year medication Current medication for
Mental health treatment, general Mental health for mental health mental health
professional* Mental health consultation, professional† physician§ services¶ problems** problems††
NSCH 2016–2019 NHIS 2017–2018 NHANES 2013–2018 NHIS 2017–2018 NSDUH 2018–2019 NSCH 2016–2019 NHANES 2013–2018
Characteristic % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Age group (yrs) 3–17 3–17 4–17 3–17 12–17 3–17 3–17
Sample size (no.) 114,476 14,287 8,071 13,440 33,678 114,476 8,637
Total 10.1 (9.8–10.5) 9.6 (9.0–10.2) 9.8 (8.6–11.2) 5.2 (4.8–5.7) 25.9 (25.3–26.5) 7.8 (7.5–8.1) 6.6 (5.7–7.7)
Characteristic
Age group (yrs)
3–5 2.6 (2.2–3.1) 4.0 (3.1–5.2) 4.7 (3.2–6.5) 3.8 (3.0–4.9) NA 1.0 (0.7–1.4) 1.2 (0.6–2.0)
6–11 9.5 (9.0–10.0) 9.5 (8.6–10.5) 9.8 (8.3–11.4) 5.5 (4.9–6.3) NA 7.2 (6.7–7.6) 7.1 (5.9–8.5)
12–17 14.3 (13.7–15.0) 12.4 (11.5–13.4) 11.5 (9.8–13.5) 5.6 (5.0–6.3) 25.9 (25.3–26.5) 11.6 (11.1–12.2) 8.7 (7.0–10.7)
Sex
Male 10.6 (10.1–11.1) 10.6 (9.8–11.5) 10.9 (9.5–12.5) 6.0 (5.3–6.7) 21.3 (20.5–22.1) 9.5 (9.0–9.9) 8.5 (7.3–9.8)
Female 9.6 (9.1–10.1) 8.6 (7.8–9.4) 8.7 (7.3–10.3) 4.5 (3.9–5.0) 30.6 (29.7–31.5) 6.0 (5.6–6.4) 4.7 (3.6–6.0)
Race/Ethnicity§§
Hispanic 8.7 (7.8–9.6) 6.7 (5.8–7.8) 7.4 (5.6–9.6) 4.2 (3.5–5.1) 24.6 (23.3–26.0) 5.3 (4.6–6.0) 2.9 (1.9–4.1)
Black, non-Hispanic 9.8 (8.8–10.9) 7.6 (6.2–9.2) 8.8 (7.4–10.4) 4.8 (3.7–6.2) 25.6 (24.0–27.2) 8.7 (7.7–9.8) 4.1 (3.0–5.5)
White, non-Hispanic 11.4 (11.0–11.8) 11.9 (11.1–12.8) 11.4 (9.5–13.5) 6.2 (5.6–6.9) 27.1 (26.3–27.9) 9.2 (8.9–9.6) 9.1 (7.6–10.8)
Asian, non-Hispanic 4.3 (3.5–5.4) 3.9 (2.7–5.6) 4.5 (2.8–6.8) 1.9 (1.1–3.3) 18.5 (15.8–21.4) 1.9 (1.4–2.5) 1.3 (0.5–2.8)
FPL¶¶
≤100% FPL 11.0 (10.1–12.1) 9.6 (8.2–11.2) 11.3 (9.3–13.6) 6.3 (5.2–7.7) 26.8 (25.4–28.2) 8.8 (8.0–9.7) 7.2 (5.6–9.2)
>100% to ≤200% FPL 9.8 (9.0–10.7) 9.7 (8.5–11.0) 11.0 (8.9–13.5) 5.8 (4.9–6.8) 25.1 (23.9–26.4) 8.0 (7.3–8.8) 6.3 (4.9–8.1)
>200% FPL 9.9 (9.5–10.3) 9.6 (8.9–10.3) 9.4 (7.8–11.3) 4.7 (4.2–5.3) 25.8 (25.0–26.7) 7.3 (7.0–7.6) 7.0 (6.6–10.0)
Highest level of parent education***
Less than high school 8.7 (7.3–10.4) 6.5 (5.1–8.4) 6.2 (4.5–8.3) 4.6 (3.4–6.1) NA 7.7 (6.2–9.4) 3.4 (1.8–5.8)
High school graduate 9.8 (9.0–10.8) 8.1 (6.8–9.5) 12.5 (9.9–15.6) 4.4 (3.5–5.5) NA 8.6 (7.8–9.4) 8.2 (5.9–11.0)
More than high school 10.4 (10.0–10.7) 10.0 (9.4–10.8) 10.0 (8.5–11.7) 5.3 (4.8–5.9) NA 7.6 (7.3–7.8) 7.0 (5.9–8.3)
Health insurance†††
Yes
Any public 13.1 (12.4–13.9) 11.4 (10.4–12.4) 13.0 (11.2–15.1) 6.6 (5.9–7.5) 27.6 (26.5–28.6) 10.4 (9.8–11.1) 8.6 (7.0–10.4)
Any private 9.4 (9.0–9.7) 8.5 (7.6–9.5) 7.7 (6.2–9.4) 4.5 (3.8–5.3) 25.5 (24.7–26.3) 7.1 (6.8–7.5) 5.6 (4.4–7.1)
No insurance 5.8 (4.7–7.1) 5.5 (3.8–8.0) 4.1 (1.9–7.6)§§§ 3.0 (2.0–4.5) 19.8 (17.1–22.9) 4.9 (3.9–6.3) 0.9 (0.2–2.4)
Geographic classification¶¶¶
Urban/Suburban 9.9 (9.5–10.4) 9.5 (8.9–10.2) NA 5.1 (4.7–5.6) 26.1 (25.4–26.8) 7.4 (7.1–7.8) NA
Rural 10.2 (9.4–11.1) 10.3 (8.9–12.0) NA 6.0 (4.9–7.3) 24.5 (23.2–25.9) 10.3 (9.4–11.1) NA

Abbreviations: FPL = federal poverty level; NA = not available; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSCH = National
Survey of Children’s Health; NSDUH = National Survey on Drug Use and Health.
* “During the past 12 months, has this child received any treatment or counseling from a mental health professional?“
† NHIS: “During the past 12 months, have you seen or talked to...a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker...about child’s
health?“ NHANES: “During the past 12 months, has the child seen or talked to a mental health professional such as a psychologist, psychiatrist, psychiatric nurse or clinical social worker
about their health?“
§ “Did you see or talk to this general doctor because of an emotional or behavioral problem that [child] may have?“
¶ Receipt of specialty and nonspecialty mental health services.
** “During the past 12 months, has this child taken any medication because of difficulties with his or her emotions, concentration, or behavior?“
†† Use of psychotherapeutic agents in past 30 days.
§§ Estimates exclude other race and ethnicity groups that did not have a large enough sample size to produce stable estimates.
¶¶ For NSCH and NHIS, FPL is based on family income and family size using the Census Bureau’s poverty thresholds for the previous calendar year. Imputed income files were used to impute
family income when it was not provided, and for NSCH, family size was imputed using other information about the household when the number of family members was not provided
(https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html). NSDUH only imputes family size when exact counts cannot be determined from the
household roster. NHANES uses the US Department of Health and Human Services poverty guidelines in calculating the FPLs (also known as the family income to poverty ratio) and does
not impute missing incomes.
*** The highest level of parent education is based on the highest education level among up to two adults who were identified as primary caregivers in the survey. For NHANES, education
of household reference person and spouse of household reference person (most often primary caregiver of youth).
††† Private included any insurance from an employer or union, directly purchased, TRICARE or other military health care, or the Affordable Care Act; coverage from any government assistance
plan was considered public, including Medicaid or other state-sponsored health plans including the Children’s Health Insurance Program. Respondents who indicated both public and
private insurance coverage were represented in both subcategories.
§§§ Estimate did not meet all NCHS data presentation standards (CI width >5, relative CI width >130) and should be interpreted with caution.
¶¶¶ Method for determining geographic classification differed by survey. NSCH: 2010 Office of Management and Budget metropolitan and micropolitan statistical areas standards (https://
www.govinfo.gov/content/pkg/FR-2010-06-28/pdf/2010-15605.pdf ). Urban/suburban includes metropolitan statistical areas associated with at least one urbanized area of at least 50,000
population; rural was defined as counties that were not part of a metropolitan statistical area; NHIS: 2013 NCHS urban/rural classification (https://www.cdc.gov/nchs/data/series/sr_02/
sr02_166.pdf ). Urban/suburban includes large metropolitan, medium metropolitan, and small metropolitan areas, whereas rural includes nonmetropolitan areas with >50,000 population;
NSDUH: Rural-Urban Continuum Codes (https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/). Urban/suburban includes large metropolitan, medium metropolitan,
and small metropolitan areas; rural includes nonmetropolitan counties.

MMWR / February 25, 2022 / Vol. 71 / No. 2 27

taking mental health-related medication than White and (4–7,67). For example, positive socioemotional skills such as self-
Black children; a similar pattern was indicated by NHANES regulation and resilience can be enhanced through intervention
2013–2018 data for children and adolescents aged 3–17 years, and predict long-term positive outcomes (26,106).
although the estimates for Black and Hispanic children did not NSCH (2018–2019) assessed six positive indicators of
differ. No consistent patterns were noted for mental health mental health for children aged 6 months–17 years. Parents
service variables by household poverty level. Children and were asked to report how often their child exhibited certain
adolescents aged 3–17 years (NHIS) or 4–17 years (NHANES) behaviors, and responses were categorized as “usually or
of parents with less than a high school education were less likely always” versus “sometimes or never.” Among children aged
to have a mental health consultation with a professional than 6 months–5 years, 97.3% usually or always showed affection
children of parents with more than a high school education; for (i.e., were affectionate and tender), 89.8% usually or always
NHANES, children of parents with a high school education showed resilience (i.e., bounced back quickly when things did
were also less likely to have a mental health consultation not go their way), and 99% usually or always showed positivity
with a professional than children of parents with a high (i.e., smiled and laughed a lot) (Table 13). Among children
school education. NHANES data indicated that children and aged 6 months–17 years, 91.3% usually or always showed
adolescents aged 3–17 years of parents with less than a high curiosity (i.e., interest and curiosity in learning new things).
school education were least likely to have used a psychotropic Among children aged 6–17 years, 84.5% usually or always
medication during the past 30 days; however, NSCH data did showed persistence (i.e., worked to finish tasks after starting),
not reflect this difference, and the prevalence of other mental and 76.8% usually or always showed self-control (i.e., stayed
health service variables did not vary by parent education level. calm and in control when faced with a challenge).
The prevalence of each indicator of mental health services was Among children aged 6 months–5 years in every state, ≥90%
higher for children with public health insurance compared with were reported to show affection, ranging from 91.5% in Arizona to
children with private health insurance, although the prevalence 99.4% in Colorado and North Carolina (Supplementary Table 4;
estimates from NHANES for current medication did not https://stacks.cdc.gov/view/cdc/113924). The estimated prevalence
differ. All prevalence estimates for mental health services were of resilience among children aged 6 months–5 years ranged from
higher for children with health insurance versus with no health 84.0% in Arizona to 96.1% in New Hampshire. Among children
insurance, although the prevalence estimate from NHANES aged 6 months–5 years in every state, ≥96% were reported to show
and NHIS for receiving mental health services among children positivity. The estimated prevalence of curiosity among children
with no health insurance did not differ from children with aged 6 months–17 years ranged from 87.0% in Oregon to 94.5%
private health insurance; the estimate for a mental health in Maryland. Persistence among children aged 6–17 years ranged
consultation with a general physician in NHIS data also did not from 77.2% in Mississippi to 90.5% in New Jersey. Among children
differ for children aged 3–17 years with private health insurance aged 6–17 years, the estimated prevalence of self-control ranged
compared with those with no health insurance. NSCH data from 66.8% in West Virginia to 81.6% in New York.
indicated that use of mental health–related medication among The prevalence of positive indicators of mental health varied
children and adolescents aged 3–17 years was higher among by sociodemographic characteristics. Prevalence of curiosity
children and adolescents living in rural versus urban areas, was higher among children aged 3–5 years and 6–11 years than
whereas prevalence estimates of consulting with a mental health among children aged 12–17 years, whereas the prevalence of
professional or with a general physician about mental health self-control was higher among adolescents aged 12–17 years
problems were similar among children and adolescents living than among children aged 6–11 years. The percentage of girls
in rural and urban areas. who were reported to demonstrate curiosity, persistence, and
self-control was higher than the corresponding percentage
Positive Indicators of Mental Health of boys. No differences by race and ethnicity were found
in the prevalence of affection or positivity for children aged
Positive indicators of mental health are factors that are 6 months–5 years. White children aged 6 months–5 years had
associated with good mental health, including emotional well- a higher prevalence of resilience than Hispanic, Black, and
being, effective regulatory and coping skills, and supportive Asian children; no differences were found between the other
social relationships (67,68). Understanding positive indicators groups. White children aged 6 months–17 years had a higher
of mental health can provide important information about prevalence of curiosity than Hispanic and Black children,
characteristics of children, such as behaviors and skills, that can and White and Asian children had a higher prevalence of
be promoted to improve overall outcomes, including mental persistence than Black children. Among the four groups
health, physical health, social relationships, and education

28 MMWR / February 25, 2022 / Vol. 71 / No. 2

TABLE 13. Weighted prevalence estimates of positive indicators of mental health among children and adolescents aged 6 months–17 years,
by sociodemographic characteristics — National Survey of Children’s Health, United States, 2018–2019
Characteristic Affection* Resilience† Positivity§ Curiosity¶ Persistence** Self-control††
Age group 6 mos–5 yrs 6 mos–5 yrs 6 mos–5 yrs 6 mos–17 yrs 6–17 yrs 6–17 yrs
Sample size (no.) 15,844 15,844 15,844 59,057 43,213 43,213
Total 97.3 (96.7–97.8) 89.8 (88.7–90.8) 99.0 (98.5–99.3) 91.3 (90.8–91.8) 84.5 (83.7–85.2) 76.8 (76.0–77.7)
Age group (yrs)
3–5 97.0 (96.3–97.6) 87.9 (86.2–89.4) 98.7 (97.9–99.1) 93.9 (92.7–93.8) NA NA
6–11 NA NA NA 93.0 (92.2–93.8) 84.2 (83.1–85.3) 73.8 (72.6–75.1)
12–17 NA NA NA 86.5 (85.5–87.5) 84.7 (83.7–85.7) 79.8 (78.6–80.9)
Sex
Male 97.0 (96.2–97.7) 88.6 (86.9–90.1) 98.7 (98.0–99.2) 89.9 (89.2–90.6) 81.2 (80.1–82.3) 74.3 (73.1–75.5)
Female 97.5 (96.6–98.2) 91.1 (89.6–92.4) 99.2 (98.6–99.6) 92.8 (92.0–93.4) 87.8 (86.8–88.8) 79.5 (78.2–80.6)
Race/Ethnicity§§
Hispanic 96.8 (94.8–98.0) 85.5 (82.0–88.4) 98.9 (97.5–99.5) 89.4 (87.8–90.8) 84.3 (82.0–86.3) 76.5 (74.0–78.9)
Black, non-Hispanic 97.7 (96.3–98.6) 85.2 (80.9–88.6) 97.8 (95.2–99.0) 89.9 (88.5–91.2) 80.4 (78.0–82.5) 74.3 (71.8–76.7)
White, non-Hispanic 97.5 (96.8–98.0) 93.7 (92.7–94.6) 99.3 (99.0–99.5) 92.7 (92.3–93.2) 85.5 (84.7–86.2) 77.1 (76.2–77.9)
Asian, non-Hispanic 96.7 (94.2–98.2) 79.3 (73.1–84.3) 99.5 (98.5–99.8) 91.7 (89.3–93.6) 87.8 (84.0–90.9) 85.7 (82.6–88.3)
FPL¶¶
≤100% FPL 95.4 (93.0–97.0) 83.1 (79.3–86.3) 98.6 (97.5–99.2) 86.3 (84.7–87.8) 77.3 (75.0–79.5) 69.4 (66.8–71.9)
>100% to ≤200% FPL 96.4 (94.9–97.5) 88.1 (85.1–90.6) 99.0 (98.3–99.5) 89.5 (88.1–90.8) 81.7 (79.7–83.6) 74.1 (72.0–76.1)
>200% FPL 98.2 (97.8–98.6) 92.7 (91.7–93.6) 99.0 (98.4–99.4) 93.6 (93.1–94.1) 87.7 (86.9–88.4) 80.3 (79.4–81.2)
Highest level of parent education***
Less than high school 97.3 (92.5–99.1) 82.5 (74.5–88.4) 97.4 (92.1–99.2) 84.9 (81.7–87.6) 79.7 (75.6–83.3) 72.9 (68.4–77.1)
High school graduate 95.0 (92.6–96.6) 84.2 (80.0–87.6) 97.7 (95.8–98.7) 87.6 (86.1–89.0) 79.7 (77.6–81.6) 72.7 (70.5–74.8)
More than high school 97.8 (97.3–98.2) 91.9 (90.9–92.7) 99.4 (99.2–99.6) 93.2 (92.7–93.6) 86.4 (85.7–87.1) 78.6 (77.7–79.4)
Health insurance†††
Yes
Any public 95.9 (94.5–96.9) 85.9 (83.5–87.9) 98.7 (97.9–99.2) 87.7 (86.6–88.8) 77.0 (75.3–78.7) 68.6 (66.8–70.4)
Any private 97.8 (97.0–98.4) 92.0 (90.7–93.0) 99.4 (99.0–99.6) 93.6 (93.1–94.1) 87.6 (86.8–88.3) 80.3 (79.4–81.2)
No insurance 96.5 (93.8–98.1) 88.4 (80.5–93.4) 98.1 (95.8–99.2) 87.5 (84.5–89.9) 82.2 (78.5–85.4) 76.3 (72.1–80.1)
Geographic classification§§§
Urban/Suburban 97.5 (96.8–98.1) 89.7 (88.2–91.0) 98.9 (98.4–99.3) 91.5 (90.9–92.1) 84.7 (83.7–85.6) 77.5 (76.4–78.5)
Rural 96.2 (94.3–97.5) 92.1 (89.6–94.1) 99.2 (98.3–99.6) 89.8 (88.6–91.0) 82.5 (80.6–84.2) 73.4 (71.3–75.4)
Abbreviations: FPL = federal poverty level; NA = not available; NSCH = National Survey of Children’s Health.
* “This child is affectionate and tender with you” (usually or always).
† “This child bounces back quickly when things do not go his or her way” (usually or always).
§ “This child smiles and laughs a lot” (usually or always).
¶ “This child shows interest and curiosity in learning new things” (usually or always).
** “This child works to finish tasks he or she starts” (usually or always).
†† “This child stays calm and in control when faced with a challenge” (usually or always).
§§ Estimates exclude other race and ethnicity groups that did not have a large enough sample size to produce stable estimates.
¶¶ FPL is based on family income and family size using the Census Bureau’s poverty thresholds for the previous calendar year. Imputed income files were used to
impute family income when it was not provided and family size was imputed using other information about the household when the number of family members
was not provided (https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html).
*** The highest level of parent education is based on the highest education level among up to two adults who were identified as primary caregivers in the survey.
††† Private included any insurance from an employer or union, directly purchased, TRICARE or other military health care, or the Affordable Care Act; coverage from
any government assistance plan was considered public, including Medicaid or other state-sponsored health plans including the Children’s Health Insurance
Program. Respondents who indicated both public and private insurance coverage were represented in both subcategories.
§§§ Method for determining geographic classification for NSCH was based on the 2010 Office of Management and Budget metropolitan and micropolitan statistical
areas standards (https://www.govinfo.gov/content/pkg/FR-2010-06-28/pdf/2010-15605.pdf ). Urban/suburban includes metropolitan statistical areas associated
with at least one urbanized area of at least 50,000 population; rural was defined as counties that were not part of a metropolitan statistical area.

studied, the highest prevalence of self-control among children had a higher estimated prevalence of each positive mental
aged 6–17 years was among Asian children. health indicator than children with public health insurance,
Children who had a parent with more than a high school except for positivity, which did not differ by health insurance
education had higher parent-reported ratings on each of the status. For each of the other five indicators, children with no
positive mental health indicators than those whose parents had health insurance had prevalence estimates between or similar
lower levels of education, although no difference was found in to those of children with private and public health insurance.
rates of affection and positivity among children whose parents A linear pattern was noted for poverty level; children living in
had more than a high school education compared with those households with the highest income level (>200% FPL) were
whose parents had less. Children with private health insurance most likely to demonstrate each indicator, except for positivity.

MMWR / February 25, 2022 / Vol. 71 / No. 2 29

Among the groups studied, the lowest prevalence of curiosity, and rates of suicide (1,34,38,42,82,86), and girls had higher
persistence, and self-control was among children living in estimated prevalences of depression, suicidal ideation, and
households with the lowest income level (≤100% FPL). Only attempted suicide (1,34). Girls also had a higher estimated
one indicator varied by geographic classification; children living prevalence of curiosity, persistence, and self-control than boys.
in urban areas had a higher estimated prevalence of self-control Although previous studies have shown higher a prevalence of
than those in rural areas. anxiety among females compared with males (1,34), previous
estimates with NSCH data have shown no differences in anxiety
by sex (17,42), similar to the results in this report. Although
Discussion the reported prevalence of substance use and substance use
Surveillance of children’s mental health and mental disorders disorders have tended to be higher in boys than girls (1,34),
is a critical part of defining the overall public health impact, no differences by sex based on 2018–2019 NSDUH data were
increasing awareness about mental health and mental disorders, found for substance use disorder or illicit drug use disorder,
and identifying potential needs for allocation of resources. and girls had a slightly higher estimated prevalence of past year
Overall, no single, comprehensive surveillance system for alcohol use disorders than boys. These findings are similar to
children’s mental health in the United States exists, and no single findings based on 2010 NSDUH data (107). Other studies
indicator can be used either to define what constitutes mental have shown that patterns of drug use by sex also differ by age
health in children or to identify the number of children with group and type of drugs used as well as changing trends in the
a mental disorder. These data confirm the overall finding from use of specific drugs (29,40,108). Data from the 2016–2019
the previous report (8), which is that mental disorders among NSCH and 2017–2018 NHIS indicated that boys were more
children continue to be a substantial public health concern. likely than girls to have had a mental health consultation or
One finding from the surveillance systems that collect data received medication for mental health problems, whereas
on children’s mental health was that mental disorders can NSDUH data indicated that more girls than boys reported
begin in early childhood. Approximately 2% of children aged receiving mental health services.
3–5 years had ever received a diagnosis of ADHD, anxiety, The prevalence of many mental disorders and indicators
or ASD, according to parent-reported data from NHIS differed by race and ethnicity. Black and White children had
2017–2018 and NSCH 2016–2019, and approximately 5% the highest prevalence of ADHD, and Black children also had
had ever received a diagnosis of behavior problems. In contrast, the highest prevalence of behavioral or conduct problems.
NSCH data indicated that most young children were reported Because evidence has shown that racial bias can result in certain
to show affection and positivity. Across data sources, estimates behaviors among Black children being incorrectly interpreted
of mental disorders (i.e., ADHD, depression, anxiety, ASD, as disruptive, this finding might represent overdiagnoses or
and Tourette syndrome) and receipt of mental health services misdiagnoses that are masking other forms of mental distress
generally increased with age, although reports of behavior among Black children (21,22). The findings that Black and
problems decreased among adolescents aged 12–17 years. White children had the highest prevalence of ADHD and that
Suicide (2018–2019 NVSS and 2014–2018 NVDRS) was the estimates for these two groups were similar are different
more common among older adolescents aged 15–19 years than from findings from older studies, which found that White
children and younger adolescents aged 10–14 years. Although children had a higher prevalence of ADHD than children from
the positive indicator of curiosity decreased with age, the other racial and ethnic groups. Recent studies have reported a
prevalence of persistence was similar among children in the higher prevalence of ADHD and of ADHD combined with a
age groups of 6–11 years and 12–17 years, and the prevalence learning disability among Black children than among White
of maintaining self-control was higher among adolescents children, suggesting that this association might be changing
aged 12–17 than among children aged 6–11 years. These data (36,38). Similarly, previous studies based on NSCH data have
show the advantage of surveillance systems that include mental reported a higher prevalence of Tourette syndrome among
health indicators for children of all ages because of their ability White children than among Hispanic and Black children
to detect differences by age. (109), whereas 2016–2019 NSCH data in this report indicated
Mental disorders affect children across the range of a similar estimated prevalence of Tourette syndrome among
sociodemographic characteristics; however, the prevalence White and Hispanic children. Although future years of data can
varies by certain characteristics. Consistent with previous be used to confirm whether these differences between White
studies, boys had a higher prevalence than girls of ADHD, and Black children have persisted, these patterns, combined
behavioral or conduct problems, ASD, Tourette syndrome, with the data on ADHD, suggest that diagnoses of these
disorders might have increased among Black and Hispanic

30 MMWR / February 25, 2022 / Vol. 71 / No. 2

children in recent years, a finding that has also been noted for minorities, such as bullying experiences (117,118). At the
developmental disabilities (110). same time, Hispanic children might be less likely than non-
White children had the highest estimated prevalence of Hispanic children to access mental health care services, which
anxiety, each indicator of mental health services use, and the might result in lower rates of diagnosis (119). Estimates of ASD
positive indicator of resilience. YRBS 2019 data indicated by race and ethnicity varied by data source and time frame
that Hispanic and AI/AN high school students primarily (e.g., current ASD versus ever receiving an ASD diagnosis).
aged 14–18 years had the highest prevalence of feeling sad Although Hispanic children had a higher prevalence of ever
and hopeless, although the NSCH 2016–2019 data indicated having received an ASD diagnosis and currently having ASD
that the prevalence of diagnosed depression among Hispanic than Asian children based on 2016–2019 NSCH data, the
children and adolescents aged 3–17 years was similar to or estimate of ASD was higher for Asian children than Hispanic
lower than the prevalence among White children. Data from children based on 2016 ADDM Network data. Asian children
2018–2019 NSDUH indicated a similar prevalence of MDE had the lowest prevalence of ADHD, behavioral or conduct
among Hispanic and White adolescents aged 12–17 years, with problems, depression (NSCH), anxiety, ASD (except for
both groups having a higher prevalence of MDE than Black ADDM Network data, in which Hispanic children had the
adolescents. Similarly, the NSDUH prevalence estimate of lowest prevalence), and receipt of mental health services and the
alcohol use disorder was higher among White adolescents than highest prevalence of self-control. Previous studies have shown
among Black and Asian adolescents; no significant differences increased risk for poor mental health among Asian children
by race and ethnicity were found for prevalence of illicit drug (120,121), although findings have been mixed (122,123).
use disorder. Other studies have found that for numerous years, Research on Asian children is limited and might be complicated
Black adolescents have reported substantially lower levels of by other factors, including heterogeneity on factors such as
illicit drug use than White and Hispanic adolescents; however, cultural group, immigration status, socioeconomic status, or
the difference has decreased in recent years (111). methodological factors such as sampling, sample size, and
Black adolescents aged 12–17 years had a lower prevalence of recruitment (47,120,121). Data are even more limited for
MDE than White adolescents based on NSDUH 2018–2019 AI/AN and NH/OPI children; only data on suicide (from
data, whereas for other indicators of depression, including 2019 YRBS, 2018–2019 NVSS, and 2014–2018 NVDRS)
diagnosed depression among children and adolescents aged and depression (from 2018–2019 NSDUH and 2019 YRBS)
3–17 years using 2016–2019 NSCH data, the prevalence was were included because the sample sizes for AI/ANs and NH/
similar for Black and White children. Also based on NSCH OPIs were too limited to generate estimates from the other
data, Black children tended to have a lower prevalence of data systems. AI/AN persons have increased risk factors for
anxiety problems than White children, and the prevalence poor mental health, a higher prevalence of mental disorders,
was more similar between Black and Hispanic children. and limited access to behavioral health care (124–126);
Although the prevalence of receipt of mental health services therefore, surveillance that includes a sufficient number of
was consistently lower across data sources (2016–2019 NSCH, AI/AN children would allow for better monitoring of the
2017–2018 NHIS, 2018–2019 NSDUH, and 2013–2018 mental health of this population (124). Additional data and
NHANES) for Black children compared with White children, analyses are needed to better understand differences between
the prevalence was only different for three of the mental health and within racial and ethnic groups, as well as which specific
service indicators: mental health treatment by a professional factors contribute such differences.
(NSCH data), mental health consultation with a professional The findings in this report show an association between
(NHIS data), and current medication for mental health health disparities and a lack of economic resources with
problems (NHANES data). Black children and children in indicators of children’s mental health (2). Children living in
other minority groups are at increased risk for poor mental households with the lowest income level (≤100% FPL) had the
health related to the known impact of structural and individual highest prevalence of ADHD, behavior or conduct problems,
racism on mental health and access to services (20,112). depression (NSCH and NHANES, lowest for NSDUH),
Because a substantial subset of Hispanic children in the and anxiety and tended to have the highest prevalence of use
United States are first- or second-generation immigrants (113), of mental health services (with the exception of the NHIS
increased levels of depression in the Hispanic population question about seeing a mental health professional, which
might be related to migration stressors for first-generation did not vary by poverty level). Conversely, children living in
youths (114), parental citizenship status (115), and cultural households with the highest income level (>200% FPL) tended
differences (116). However, they also might be associated to have a higher prevalence of the various positive mental health
with experiences related to racism and bias against cultural indicators and a lower prevalence of ASD. The prevalence of

MMWR / February 25, 2022 / Vol. 71 / No. 2 31

ADHD and behavior problems was lower among children better assessed by self-report, particularly among adolescents
with parents who had more than a high school education than (132,133). Lack of data on anxiety in other surveys might limit
among those whose parents’ highest level of education was high understanding of this disorder in relation to other indicators
school, whereas anxiety and positive indicators of mental health such as suicidality and other youth risk behaviors.
were highest among children of parents with more than high Second, data from these surveillance systems cannot be used
school education. Children with public health insurance had to provide overall estimates of good or poor mental health.
a higher prevalence of ADHD, behavior problems, diagnosed Data on positive indicators of mental health, which were only
depression, anxiety, ASD, and receipt of mental health services assessed in NSCH, are limited. Furthermore, of the positive
and a lower prevalence of five of the six positive mental health indicators that were included, three were only available for
indicators (all except positivity). children aged ≤5 years, two were available for children aged
Previous studies of the impact of geographic classification 6–17 years, and only one indicator (curiosity) was available
indicated that children living in rural areas have increased risk for children aged 6 months–17 years. Although these items
factors for poor mental health and barriers to accessing mental were developed to describe positive development, data are
health services (37,127). For example, children living in rural limited on whether these capture the intended constructs with
areas are more likely than children living in urban areas to sufficient breadth and depth (67,68). In addition, whether
have poor physical health, exhibit health risk behaviors, and the items favor positive attributes among White children is
live in communities with more adults who have poor mental unknown, nor is whether these positive characteristics are
health (37,128,129). Data in this report show that children more likely to be inherently identified among persons from
living in rural areas were more likely to have a diagnosis of higher socioeconomic groups. Specific factors related to
ADHD, behavior problems, depression, and anxiety and were positive indicators, such as child attachment to the parent
more likely to have used mental health–related medication (68), might require more in-depth assessment (134). Finally,
than children living in urban areas. No differences in use of the only negative indicator of a mental health crisis that
other mental health services were found between children in is routinely captured is suicidality; data on other forms of
urban versus rural areas. These findings are similar to those crises, such as need of emergency care for mental health, are
from previous studies showing that children in rural areas important indicators but are not collected in population-based
are more likely to use medication but might be less likely to surveillance systems (135). This limits the ability to understand
receive behavioral treatment (127), which might be related the full spectrum of mental health and of both diagnosed and
to a shortage of mental health providers in rural areas (130). undiagnosed mental disorders.
Third, even when indicators of mental health and mental
Limitations disorders are available, various factors limit the use of these
data to understand differences in certain populations or
The findings in this report are subject to at least eight to understand the complete context of mental health and
limitations. First, numerous gaps exist in surveillance of mental disorders, including possible health disparities based
mental disorders and mental health among U.S. children, on social determinants of health. In many cases, sample sizes
many of which were described in the 2013 report (8). Existing are inadequate for description by racial and ethnic categories,
surveillance covers a limited number of disorders and does by state, or by other specific indicators. For example, even
not allow for estimates of many specific disorders that occur with 4 years of NSCH data combined, estimates for Tourette
among children, including obsessive-compulsive disorder, syndrome among Black and Asian children and among children
posttraumatic stress disorder, or bipolar disorder. Furthermore, with parents who have lower education levels or children
the majority of surveillance systems rely on parent report of a with no health insurance were not reliable and could not be
previous diagnosis, which is influenced by access to health care included in this report. Furthermore, despite using larger
to receive a diagnosis, the parent’s ability to recall the diagnosis data sets, only four racial and ethnic groups were consistently
and willingness to report the diagnosis, and the accuracy of reported among the different surveys, limiting understanding
the diagnosis itself. Health care providers might differ in how of differences in mental health and mental disorders among
they apply diagnostic criteria and distinguish among different other racial and ethnic groups or among subgroups of racial and
diagnoses. Although anxiety is one of the most common mental ethnic groups, such as comparing persons in minority groups
disorders in children (34,131), only NSCH provides regular who have recently immigrated with those whose ancestors
data on the prevalence of anxiety in U.S. children. Relying have lived in the United States for generations. In addition to
on parent reports of diagnoses can be particularly challenging differences in prevalence by sociodemographic characteristics,
with emotional disorders such as anxiety that might be previous research has shown that mental disorders and poor

32 MMWR / February 25, 2022 / Vol. 71 / No. 2

mental health are more common in certain groups of children, about treatment for anxiety and depression. NHANES has
including those with other disabilities and chronic health data on use of specific psychotropic medications but not on
conditions (136), children affected by racism (20,137) and diagnosis of anxiety or depression, which means that these
other adverse childhood experiences (138), and lesbian, gay, factors cannot be compared. Different systems focus on
bisexual, and transgender (LGBT) children (139). NSCH different ages, use different methods for sampling and data
collects information on disabilities, chronic conditions, and collection, and include different indicators of mental health
some adverse childhood experiences, including perceived racial and mental disorders. In addition, other indicators vary
discrimination, unstable relationships, and exposure to violence across systems, including how geographic classification is
(140); thus, these associations can be explored in the future. defined, the availability of data for different racial and ethnic
Although some data systems (e.g., YRBS) collect information groups, and year of data collection. These differences limit the
about LGBT status, too few systems collect these data to be ability to determine how much of the variability in estimates
included in this report. Collection of more data on health is due to differences in survey methods, sociodemographic
equity indicators, such as structural and individual racism, characteristics, and other unmeasured factors (e.g., clinical
sexual orientation and gender identity, adverse experiences, information and cultural context).
and other sociodemographic characteristics related to social Sixth, the data collected in these systems are cross-sectional,
determinants of health (23), might highlight additional focusing on point estimates of mental health and mental
opportunities to promote health equity (24). disorders, and only allow for estimations of association, not
Fourth, surveillance estimates for mental health at the causation. Much of the data are based on parent or adolescent
population level are not timely enough to monitor immediate self-report, including report of health care provider diagnosis,
changes in mental health of a population before, during, and and are subject to recall error and inaccurate or incomplete
after public health emergencies, such as hurricanes or the diagnoses and disparities in access to health care. Moreover,
COVID-19 pandemic (141). In response to COVID-19, the parent-reported data might be influenced by parent perspective
Household Pulse Survey was implemented quickly and included and other factors, including parent mental health. Cultural
questions on adult mental health that were comparable to the differences might also affect parent reporting; parents might
NHIS questions (142). Other surveys were developed that differ in how they interpret or report on items such as whether
included questions on adult mental health (143,144), whereas a child currently has a condition or behavior. For example,
fewer considered children’s mental health (145,146), and they determining whether racial and ethnic differences in child
lacked baseline data from before the COVID-19 pandemic for resilience, curiosity, and persistence are influenced by cultural
comparison. In an attempt to document changes in mental differences in how the behaviors are interpreted is not possible.
health related to the pandemic, the Coronavirus Health and Stigma related to mental health might also influence parent
Impact Survey asked participants, including parents and and adolescent reporting and the likelihood of seeking care,
children (via self-report for those aged 9–18 years), to report a concern consistent with emerging evidence of potential
on their mental health status before the pandemic (147). negative effects of receiving an ADHD diagnosis on some
Data from the National Syndromic Surveillance Program children (149,150). The data are subject to errors such as
allowed for near real-time estimates of mental health–related sampling and nonsampling errors, including measurement
emergency department visits for both children and adults and errors or nonresponse bias, although survey estimates are
comparisons with estimates before the COVID-19 pandemic. weighted for nonresponse.
However, these data only include problems that resulted in Seventh, the data presented in this report also are limited
a visit to an emergency department and therefore do not in scope and focus; data are collected at a single time point
represent the mental health status of the entire population of and do not represent information on trends in prevalence
children (135,148). In public health emergencies, immediate over time. Previous reports have used data from these systems
actions are needed to protect children’s mental health; thus to document increases in ADHD, ASD, anxiety, MDE, and
ongoing, timely surveillance might provide benchmark data suicidal behaviors (17,38–40,85,151). Monitoring changes
for comparison with data collected during and after an event in prevalence over time is critical to understanding the public
to guide response actions and resource management. health impact related to mental health and mental disorders.
Fifth, each surveillance system is designed for specific All data included in this report were collected before the
purposes and uses different methods, affecting the ability to COVID-19 pandemic and do not reflect the impact of the
compare estimates directly across systems or integrate findings pandemic on children’s mental health.
across systems. For example, NSCH includes questions about Finally, the data are presented to show how specific
diagnosed anxiety and depression but not specific questions sociodemographic characteristics are associated with specific

MMWR / February 25, 2022 / Vol. 71 / No. 2 33

mental disorders; however, the complexity of the relation operational tests, HRSA MCHB has determined that making
between the characteristics and disorders is not adequately direct comparisons to data collected before 2016 is not possible.
described. Specifically, disorders might vary by sex and age HRSA MCHB is committed to the annual assessment of
together, such that estimates of anxiety and depression are the NSCH indicators presented in this report. The annual
typically similar by sex in younger children but in adolescents administration of NSCH presents opportunities to continue
are more common in girls than boys (17,152,153). In addition, testing the framing and wording of these existing items
the presented data do not describe whether children had more through regular cognitive and usability testing, as well as the
than one disorder, which is common and has implications assessment of new content on emergent and persistent mental,
for health care needs and health outcomes (1,34,75). emotional, and behavioral problems among children and
Socioeconomic indicators are likely to be highly correlated. For adolescents (e.g., disordered eating). After 2016, NSCH added
example, because public health insurance is linked to poverty, items to more specifically address positive child development
the protective effect of public health insurance for families in the preschool years using the Healthy and Ready to Learn
with low economic resources might not be apparent unless indicators (155). These indicators include two composites
income is considered. Moreover, because of the significant that are closely associated with mental health, self-regulation
association of poverty and racial and ethnic minority status and social-emotional development, which might provide ways
in the United States, additional research could examine the to identify groups of children who need additional support
extent to which differences in rates of indicators experienced (155,156). Finally, HRSA MCHB is exploring options to
by different racial and ethnic groups persist when access to further investigate the specific challenges presented as a result
resources is considered or whether they are better explained by of the COVID-19 public health crisis through NSCH.
health disparities based on racial bias, by cultural differences, NHIS was redesigned in 2019 to reduce the time required
or by other factors. Similarly, additional research might help of respondents and to make the content more relevant to the
clarify the extent to which rural status represents structural data needs of the U.S. Department of Health and Human
inequities related to disparities in access to services and support Services. To reach these goals, the survey length was reduced by
or to lack of financial resources or is confounded by racial and implementing rotating content with fixed periodicity alongside
ethnic differences and disparities (112,154). These complex annual content. Rotating content on a fixed periodicity
interactions are beyond the scope of this report, which provides schedule allows for more content to be included over the long
a broad perspective on surveillance systems that provide term; for data users, partners, and communities to be able to
information on children’s mental health. plan for data availability; and for a shorter interview for the
respondent. A panel of technical experts in the field of children’s
Current Efforts to Improve Surveillance of health convened, consisting of stakeholders representing federal
government as well as academic and public health researchers,
Children’s Mental Health and identified the enhancement of content related to children’s
Despite the identified challenges in surveillance related mental health as a priority for the redesigned NHIS. As such,
to children’s mental health, numerous efforts have been mental health assessment, specifically the full Strengths and
implemented and are underway to improve the availability of Difficulties Questionnaire and impact questions, and mental
related data. As noted previously, the design and administration health care use, which includes use of medication, receipt of
of NSCH has changed substantially since the 2013 report services, and reduced access to mental health care due to cost,
on this topic. The goals and process of the redesign have will be measured on a rotating basis. In addition, beginning
been described elsewhere (66). Decreasing response rates, in 2019, selected stressful life events and expanded social
an increasing proportion of households without a landline determinants of health were added to the survey, which are
telephone, and the desire to provide more timely data useful measures to assess in conjunction with mental health
prompted HRSA MCHB to transition NSCH from an measures. The Baby Pediatric Symptom Checklist, a 12-item
interviewer-assisted telephone survey conducted quadrennially validated screening tool, was added to NHIS annual core
to a self-administered annual survey using online and paper- to assess social and emotional difficulties among children
based methods. Attempts were made to retain all content aged 0–23 months (157). Also, in 2019, the Washington
necessary to produce important estimates related to child health Group/UNICEF Module on Child Functioning (158–160)
and well-being, including the survey items used for analyses was added to NHIS to measure functional limitations in
presented in this report. However, whereas the questions children aged 2–17 years annually; NHANES has included
remained the same, based on the results from mode effects and some of the questions for children aged 5–17 years since 2019.
(Data for the 2019–2020 cycle were insufficient to generate

34 MMWR / February 25, 2022 / Vol. 71 / No. 2

nationally representative estimates and will only be available public health impact of children’s mental health and mental
for analysis without sample weights. Therefore, nationally disorders since the previous report. The Project to Learn
representative data might not be available for these indicators About Youth Mental Health (PLAY-MH), a community-based
until the 2021–2022 data have been collected and released.) epidemiologic study, examined symptoms of mental disorders
The questions ask about a range of functional limitations, in school-aged children and adolescents in four different U.S.
including the child’s level of difficulty concentrating, ability to school districts during 2014–2018 (131). On the basis of data
accept changes in routine, and ability to make friends, as well collected from teachers and parents on children’s symptoms and
as the frequency of experiencing anxiety and depression among impairments, approximately one in six students met DSM-IV
children aged 5–17 years. The new NHIS design allows for the criteria for having a childhood mental disorder, including
inclusion of emerging public health topics. More information anxiety disorders (7.9%–11.2% across sites), oppositional
on the periodicity of NHIS content is available online (https:// defiant disorder (5.7%–17.3%), and ADHD (5.1%–9.4%)
www.cdc.gov/nchs/data/nhis/Sample-Child-Questionnaire- (131). The PLAY-MH study offers complementary data on
Summary-508.pdf ). both diagnosed and undiagnosed mental disorders among
Future reports from the ADDM Network will use revised school-aged children (i.e., kindergarten through 12th grade)
methods to produce more timely and efficient reporting of in the four participating communities.
ASD prevalence, progress toward early identification, and the To help address the problems inherent in relying on national-
transition of adolescents with ASD to adulthood. ADDM level data to guide state and local decision-making, CDC is
will continue to incorporate chart review; however, ASD examining the constraints and value of applying small-area data
ascertainment will reflect ASD diagnoses or classifications estimation methods to the NSCH items on mental disorders.
from various medical, educational, and service providers in Such methods have been applied to the Behavioral Risk Factor
each participating community. An analysis comparing the Surveillance System (i.e., CDC’s PLACES project; https://
previous and new case definitions showed the two produced www.cdc.gov/places) to provide local estimates for adult data,
similar ASD prevalence estimates, and other indicators were and to other content areas in NSCH (162). In addition, HRSA
essentially unchanged (161). The changes enabled ADDM MCHB and the Census Bureau offer the opportunity for states
sites to incorporate a wider range of data sources (such as to sponsor oversampling of specific populations at the statewide
state Medicaid programs), allowed for expanded tracking of or substate levels to support more targeted assessment, program
early ASD identification among children aged 4 years, and planning and evaluation to aid in state and local decision-
allowed sites to begin reporting on the medical issues, mental making (163). YRBSS allows for state, tribal, territorial, and
health issues, and challenges with the transition to adulthood local school district data. Although CDC conducts a national
among children aged 16 years with ASD. Several ADDM YRBS (with data presented in this report), CDC provides
sites are also piloting an approach to provide rapid statewide these sites with technical assistance on surveys and quality
reporting of ASD prevalence, which could provide basic assurance oversight allowing for site-specific YRBS data for
indicators of disparities in services or regional variations in use by education and health agencies (164). These combined
ASD identification practices. efforts could provide more precise local estimates of children’s
Additional indicators of mental health that address the mental disorders and increase the value of the data obtained
continuum of good to poor mental health are also being added via investments in NSCH.
to surveys. Some states and local education agencies have CDC efforts are focused on the longer-term goal of building
added questions to their YRBS that address protective factors. state and local capacity to collect, analyze, and use surveillance
For example, some YRBS questionnaires include a question data on children’s mental health to monitor population health
about who respondents would talk to if they felt sad, empty, and connect more families with effective mental health services.
hopeless, angry, or anxious; a question about whether they feel Through two cooperative agreements, CDC is developing
safe and secure in their neighborhood; and a question about tools to assist state and local stakeholders in their efforts to
whether they feel connected to their school. NSDUH includes support children’s mental health. A CDC-supported resource
questions that ask adolescents whether they have persons they released in May 2020 by the National Network of Public
can turn to when they have a serious problem. Improving Health Institutes (Data Governance for Children’s Mental
overall well-being, in addition to improving health, has been Health Surveillance: What Is It and Why Does it Matter?)
identified as an overarching objective for Healthy People 2030, detailed the specific data governance challenges in working
the goal for the nation’s health in the United States (46). with children’s mental health data (165). In July 2020, the
In addition to the national surveillance efforts described, Public Health Informatics Institute of the Task Force for Global
other activities have been conducted to understand the Health released a CDC-supported summary of laws related to

MMWR / February 25, 2022 / Vol. 71 / No. 2 35

child mental health data collection, sharing, and use (166). In Conclusion
October 2021, the Public Health Informatics Institute released
a playbook to guide the planning and implementation of a Mental health and well-being are important indicators
child and adolescent mental health surveillance program using for public health and have been identified as an important
existing data sources (167). Tools continue to be developed to component of improving the nation’s health overall and health
assist state and local systems to collect and use data to improve equity (46,168). Although current data sources and measures
children’s mental health. provide some information on specific disorders and indicators
of mental health, the data are not sufficient to provide a
comprehensive description of children’s mental health in the
United States (46). However, the surveillance systems reviewed
Future Directions and Public Health in this report provide useful and actionable information on the
Implications status of several children’s mental health indicators. In addition,
The findings in this report can be used by public health this report highlights the importance of ongoing surveillance
professionals, health care providers, state health officials, of children’s mental health to help identify which resources are
policymakers, and educators to understand the prevalence needed to support children and to evaluate progress associated
of specific mental disorders and other indicators of mental with efforts to improve children’s mental health.
health and the challenges related to mental health surveillance.
Because of the substantial impact of children’s mental health Contributor
on the development, overall health, and well-being of children Leah N. Meyer, Associate Director for Demographic Programs Division,
Census Bureau.
(4,10–12,15,16), surveillance data to monitor children’s mental
health, such as data on differences by sociodemographic
Acknowledgments
characteristics and disability status, issues related to health
Peter Boersma, National Center for Health Statistics, CDC;
equity, changes over time, and the relation to public health
Krishna M. Palipudi, Center for Behavioral Health Statistics and
emergencies, are critical for directing resources to support
Quality, Substance Abuse and Mental Health Services Administration.
children and families, including by identifying mental health
workforce provider shortages. Current data sources provide Conflicts of Interest
information on both diagnosis and treatment but do not
indicate whether children and families are receiving adequate All authors have completed and submitted the International Com-
mittee of Medical Journal Editors form for disclosure of potential
or evidence-based treatment. Improved surveillance can be
conflicts of interest. No potential conflicts of interest were disclosed.
used to move beyond point-in-time prevalence to identify
how well children are doing and when they need support
References
and to cover the entire continuum of children’s mental health
and functioning from birth through adolescence. Improved 1. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders (DSM-5). 5th ed. Arlington, VA: American Psychiatric
surveillance would also go beyond focusing on diagnoses and Association; 2013.
would include measures of healthy development and resilience 2. National Academies of Sciences, Engineering, and Medicine. Fostering
as well as symptoms of mental disorders (67). In addition healthy mental, emotional, and behavioral development in children and
youth: a national agenda. Washington, DC: National Academies Press,
to providing information at the national level, more timely National Academies of Sciences, Engineering, and Medicine; 2019.
surveillance of children’s mental health would provide data 3. American Academy of Pediatrics. Promoting mental health. In: Hagan JFJ,
that are actionable at state and local levels. A comprehensive Shaw JS, Duncan PM, eds. Bright futures guidelines for health supervision
of infants, children, and adolescents. 4th ed. Elk Grove Village,
public health approach to surveillance would assess policies IL: American Academy of Pediatrics; 2017:115–50.
and programs that support mental health before a diagnosis 4. Hoagwood K, Jensen PS, Petti T, Burns BJ. Outcomes of mental health
is needed (2). More comprehensive surveillance could help care for children and adolescents: I. A comprehensive conceptual model.
identify which mental health services, including treatment and J Am Acad Child Adolesc Psychiatry 1996;35:1055–63. PMID:8755803
https://doi.org/10.1097/00004583-199608000-00017
prevention efforts, are needed and would be most effective for 5. Lippman LH, Moore KA, McIntosh H. Positive indicators of child well-
children with varying disorders, risk and protective factors, being: a conceptual framework, measures, and methodological issues.
and circumstances so that public health interventions can be Appl Res Qual Life 2011;6:425–49. https://doi.org/10.1007/
s11482-011-9138-6
tailored to promote all children’s mental health. Identifying 6. World Health Organization. Mental health policy and service guidance
and addressing structural and systemic factors are critical to package: child and adolescent mental health policies and plans. Geneva,
promoting health equity. Switzerland: World Health Organization; 2005.

36 MMWR / February 25, 2022 / Vol. 71 / No. 2

 7. Keyes CL. The mental health continuum: from languishing to flourishing 23. US Department of Health and Human Services. Healthy people 2030:
in life. J Health Soc Behav 2002;43:207–22. PMID:12096700 https:// social determinants of health. Washington, DC: US Department of
doi.org/10.2307/3090197 Health and Human Services; 2021. https://health.gov/healthypeople/
8. Perou R, Bitsko RH, Blumberg SJ, et al. Mental health surveillance objectives-and-data/social-determinants-health
among children—United States, 2005–2011. MMWR Suppl 24. US Department of Health and Human Services. Paving the road to
2013;62(No. Suppl. 2). PMID:23677130 health equity. Atlanta, GA: US Department of Health and Human
9. Payton AR. Mental health, mental illness, and psychological distress: same Services, CDC; 2021. https://www.cdc.gov/minorityhealth/publications/
continuum or distinct phenomena? J Health Soc Behav 2009;50:213–27. health_equity/index.html
PMID:19537461 https://doi.org/10.1177/002214650905000207 25. Moffitt TE, Arseneault L, Belsky D, et al. A gradient of childhood self-
10. Gross TJ, Duncan J, Kim SY, Mason WA, Haggerty KP. Predicting school control predicts health, wealth, and public safety. Proc Natl Acad Sci
suspension risk from eighth through tenth grade using the strengths U S A 2011;108:2693–8. PMID:21262822 https://doi.org/10.1073/
and difficulties questionnaire. Contemp Sch Psychol 2019;23:270–89. pnas.1010076108
PMID:32775014 https://doi.org/10.1007/s40688-018-00215-y 26. Pandey A, Hale D, Das S, Goddings AL, Blakemore SJ, Viner RM.
11. Mousteri V, Daly M, Delaney L, Tynelius P, Rasmussen F. Adolescent Effectiveness of universal self-regulation–based interventions in children
mental health and unemployment over the lifespan: population evidence and adolescents: a systematic review and meta-analysis. JAMA Pediatr
from Sweden. Soc Sci Med 2019;222:305–14. PMID:30677644 https:// 2018;172:566–75. PMID:29710097 https://doi.org/10.1001/
doi.org/10.1016/j.socscimed.2018.12.030 jamapediatrics.2018.0232
12. Kessler RC, Foster CL, Saunders WB, Stang PE. Social consequences of 27. Taylor RD, Oberle E, Durlak JA, Weissberg RP. Promoting positive youth
psychiatric disorders, I: educational attainment. Am J Psychiatry development through school-based social and emotional learning
1995;152:1026–32. PMID:7793438 https://doi.org/10.1176/ interventions: a meta-analysis of follow-up effects. Child Dev
ajp.152.7.1026 2017;88:1156–71. PMID:28685826 https://doi.org/10.1111/cdev.12864
13. Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in older 28. Thacker SB, Qualters JR, Lee LM. Public health surveillance in the
adolescents: prevalence, risk factors, and clinical implications. Clin United States: evolution and challenges. MMWR Suppl 2012;61:3–9.
Psychol Rev 1998;18:765–94. PMID:9827321 https://doi.org/10.1016/ PMID:22832990
S0272-7358(98)00010-5 29. Lyerla R, Stroup DF. Toward a public health surveillance system for
14. Copeland WE, Miller-Johnson S, Keeler G, Angold A, Costello EJ. behavioral health. Public Health Rep 2018;133:360–5. PMID:29746207
Childhood psychiatric disorders and young adult crime: a prospective, https://doi.org/10.1177/0033354918772547
population-based study. Am J Psychiatry 2007;164:1668–75. 30. Reeves WC, Strine TW, Pratt LA, et al. Mental illness surveillance among
PMID:17974931 https://doi.org/10.1176/appi.ajp.2007.06122026 adults in the United States. MMWR Suppl 2011;60:1–29. PMID:21881550
15. Roy-Byrne PP, Davidson KW, Kessler RC, et al. Anxiety disorders and 31. US Department of Health and Human Services. Healthy people 2030: mental
comorbid medical illness. Gen Hosp Psychiatry 2008;30:208–25. health and mental disorders. Washington, DC: US Department of Health
PMID:18433653 https://doi.org/10.1016/j.genhosppsych.2007.12.006 and Human Services; 2021. https://health.gov/healthypeople/objectives-and-
16. Shomaker LB, Tanofsky-Kraff M, Stern EA, et al. Longitudinal study data/browse-objectives/mental-health-and-mental-disorders
of depressive symptoms and progression of insulin resistance in youth 32. National Research Council and Institute of Medicine Committee.
at risk for adult obesity. Diabetes Care 2011;34:2458–63. Preventing mental, emotional, and behavioral disorders among young
PMID:21911779 https://doi.org/10.2337/dc11-1131 people: progress and possibilities. Washington, DC: National Academies
17. Bitsko RH, Holbrook JR, Ghandour RM, et al. Epidemiology and Press; 2009.
impact of health care provider-diagnosed anxiety and depression among 33. Angold A, Erkanli A, Farmer EM, et al. Psychiatric disorder, impairment,
US children. J Dev Behav Pediatr 2018;39:395–403. PMID:29688990 and service use in rural African American and white youth. Arch Gen
https://doi.org/10.1097/DBP.0000000000000571 Psychiatry 2002;59:893–901. PMID:12365876 https://doi.org/10.1001/
18. Patalay P, Fitzsimons E. Correlates of mental illness and wellbeing in archpsyc.59.10.893
children: are they the same? Results from the UK Millennium Cohort 34. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental
Study. J Am Acad Child Adolesc Psychiatry 2016;55:771–83. disorders in U.S. adolescents: results from the National Comorbidity
PMID:27566118 https://doi.org/10.1016/j.jaac.2016.05.019 Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child
19. Substance Abuse and Mental Health Services Administration. Adolesc Psychiatry 2010;49:980–9. PMID:20855043 https://doi.
Key substance use and mental health indicators in the United org/10.1016/j.jaac.2010.05.017
States: results from the 2018 National Survey on Drug Use and 35. Jaffee SR, Harrington H, Cohen P, Moffitt TE. Cumulative prevalence
Health. Rockville, MD: Substance Abuse and Mental Health of psychiatric disorder in youths. J Am Acad Child Adolesc Psychiatry
Services Administration, Center for Behavioral Health Statistics 2005;44:406–7. PMID:15843760 https://doi.org/10.1097/01.
and Quality; 2019. https://www.samhsa.gov/data/sites/default/ chi.0000155317.38265.61
files/cbhsq-reports/NSDUHNationalFindingsReport2018/ 36. Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD,
NSDUHNationalFindingsReport2018.pdf Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and
20. Berry OO, Londoño Tobón A, Njoroge WFM. Social determinants of associated treatment among U.S. children and adolescents, 2016. J Clin
health: the impact of racism on early childhood mental health. Curr Child Adolesc Psychol 2018;47:199–212. PMID:29363986 https://doi.
Psychiatry Rep 2021;23:23. PMID:33712922 https://doi.org/10.1007/ org/10.1080/15374416.2017.1417860
s11920-021-01240-0 37. Robinson LR, Holbrook JR, Bitsko RH, et al. Differences in health care,
21. Meek S, Gilliam WS. Expulsion and suspension in early education as family, and community factors associated with mental, behavioral, and
matters of social justice and health equity. Washington, DC: National developmental disorders among children aged 2–8 years in rural and urban
Academy of Medicine; 2016. https://doi.org/10.31478/201610e areas—United States, 2011–2012. MMWR Surveill Summ 2017;66(No. SS-8).
22. Rafa A. Suspension and expulsion: what is the issue and why does it PMID:28301449 https://doi.org/10.15585/mmwr.ss6608a1
matter? Policy snapshot. Denver, CO: Education Commission of the 38. Zablotsky B, Black LI, Maenner MJ, et al. Prevalence and trends of
States; 2018. https://eric.ed.gov/?id=ED581500 developmental disabilities among children in the US, 2009–2017.
Pediatrics 2019;144:e20190811. PMID:31558576 https://doi.
org/10.1542/peds.2019-0811

MMWR / February 25, 2022 / Vol. 71 / No. 2 37

39. Curtin SC, Heron M. Death rates due to suicide and homicide among 54. Sipe TA, Finnie RK, Knopf JA, et al.; Community Preventive Services
persons aged 10–24: United States, 2000–2017. NCHS Data Brief, Task Force. Effects of mental health benefits legislation: a community
no. 352. Hyattsville, MD: US Department of Health and Human guide systematic review. Am J Prev Med 2015;48:755–66.
Services, CDC, National Center for Health Statistics; 2019. https:// PMID:25998926 https://doi.org/10.1016/j.amepre.2015.01.022
www.cdc.gov/nchs/products/databriefs/db352.htm 55. Costello EJ, Burns BJ, Angold A, Leaf PJ. How can epidemiology
40. Division of Adolescent and School Health. Youth Risk Behavior Survey data improve mental health services for children and adolescents? J Am Acad
summary & trends report 2009–2019. Atlanta, GA: US Department of Health Child Adolesc Psychiatry 1993;32:1106–17. PMID:8282654 https://
and Human Services, CDC; 2020. https://www.cdc.gov/healthyyouth/data/ doi.org/10.1097/00004583-199311000-00002
yrbs/pdf/YRBSDataSummaryTrendsReport2019-508.pdf 56. Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of mental
41. CDC. Web-based Injury Statistics Query and Reporting System disorders in children and adolescents. Dialogues Clin Neurosci
(WISQARS). Atlanta, GA: US Department of Health and Human 2009;11:7–20. PMID:19432384 https://doi.org/10.31887/
Services, CDC. 2021. https://www.cdc.gov/injury/wisqars/index.html DCNS.2009.11.1/krmerikangas
42. Ghandour RM, Sherman LJ, Vladutiu CJ, et al. Prevalence and treatment 57. Broder-Fingert S, Sheldrick CR, Silverstein M. The value of state
of depression, anxiety, and conduct problems in US children. J Pediatr differences in autism when compared to a national prevalence estimate.
2019;206:256–267.e3. PMID:30322701 https://doi.org/10.1016/j. Pediatrics 2018;142:e20182950. PMID:30478239 https://doi.
jpeds.2018.09.021 org/10.1542/peds.2018-2950
43. Visser SN, Danielson ML, Wolraich ML, et al. Vital Signs: national and 58. Ashbaugh JW, Hoff MK, Schneider LC, Goldstrom ID, Manderscheid RW.
state-specific patterns of attention deficit/hyperactivity disorder Conducting state and local health needs assessments. Designs and
treatment among insured children aged 2–5 years—United States, strategies. Eval Health Prof 1983;6:413–34. PMID:10264238 https://
2008–2014. MMWR Morb Mortal Wkly Rep 2016;65:443–50. doi.org/10.1177/016327878300600403
PMID:27149047 https://doi.org/10.15585/mmwr.mm6517e1 59. Zipf G, Chiappa M, Porter KS, Ostchega Y, Lewis BG, Dostal J. National
44. Davis DW, Feygin Y, Creel L, et al. Longitudinal trends in the diagnosis Health and Nutrition Examination Survey: plan and operations,
of attention-deficit/hyperactivity disorder and stimulant use in preschool 1999–2010. Vital Health Stat 2013;2:1–37. https://www.cdc.gov/nchs/
children on Medicaid. J Pediatr 2019;207:185–191.e1. PMID:30545564 data/series/sr_01/sr01_056.pdf
https://doi.org/10.1016/j.jpeds.2018.10.062 60. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report
45. Pennap D, Zito JM, Santosh PJ, Tom SE, Onukwugha E, Magder LS. version of PRIME-MD: the PHQ primary care study. JAMA
Patterns of early mental health diagnosis and medication treatment in 1999;282:1737–44. PMID:10568646 https://doi.org/10.1001/
a Medicaid-insured birth cohort. JAMA Pediatr 2018;172:576–84. jama.282.18.1737
PMID:29710205 https://doi.org/10.1001/jamapediatrics.2018.0240 61. American Psychiatric Association. Diagnostic and statistical manual of
46. Pronk N, Kleinman DV, Goekler SF, Ochiai E, Blakey C, Brewer KH. mental disorders. 4th ed., text revision. Falls Church, VA: American
Promoting health and well-being in healthy people 2030. J Public Health Psychiatric Association; 2000.
Manag Pract 2021;27(Suppl 6):S242–8. PMID:33278186 62. Richardson LP, McCauley E, Grossman DC, et al. Evaluation of the
47. Cabrera NJ; The SRCD Ethnic and Racial Issues Committee. Positive Patient Health Questionnaire-9 Item for detecting major depression
development of minority children. Social Policy Report, vol. 27, no. 2. among adolescents. Pediatrics 2010;126:1117–23. PMID:21041282
Washington, DC: Society for Research in Child Development; 2013. https://doi.org/10.1542/peds.2010-0852
https://eric.ed.gov/?id=ED595620 63. Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH
48. So M, McCord RF, Kaminski JW. Policy levers to promote access to and Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV):
utilization of children’s mental health services: a systematic review. Adm description, differences from previous versions, and reliability of some
Policy Ment Health 2019;46:334–51. PMID:30604005 https://doi. common diagnoses. J Am Acad Child Adolesc Psychiatry 2000;39:28–38.
org/10.1007/s10488-018-00916-9 PMID:10638065 https://doi.org/10.1097/00004583-200001000-00014
49. Tyler ET, Hulkower RL, Kaminski JW. Behavioral health integration in 64. Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz DS.
pediatric primary care: considerations and opportunities for Prevalence and treatment of mental disorders among US children in the
policymakers, planners, and providers. New York, NY: Milbank 2001–2004 NHANES. Pediatrics 2010;125:75–81. PMID:20008426
Memorial Fund; 2017. https://www.milbank.org/publications/ https://doi.org/10.1542/peds.2008-2598
behavioral-health-integration-in-pediatric-primary-care-considerations- 65. National Center for Health Statistics. National Health and Nutrition
and-opportunities-for-policymakers-planners-and-providers Examination Survey: 2017–2018 data documentation, codebook, and
50. Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical- frequencies: prescription medications (RXQ_RX_J). Washington DC:
behavioral care compared with usual primary care for child and US Department of Health and Human Services, CDC, National Center
adolescent behavioral health: a meta-analysis. JAMA Pediatr for Health Statistics; 2020. https://wwwn.cdc.gov/Nchs/
2015;169:929–37. PMID:26259143 https://doi.org/10.1001/ Nhanes/2017-2018/RXQ_RX_J.htm
jamapediatrics.2015.1141 66. Ghandour RM, Jones JR, Lebrun-Harris LA, et al. The design and
51. National Academies of Sciences, Engineering, and Medicine. implementation of the 2016 National Survey of Children’s Health.
Opportunities to promote children’s behavioral health: health care reform Matern Child Health J 2018;22:1093–102. PMID:29744710 https://
and beyond. Washington, DC: National Academies Press; 2016. https:// doi.org/10.1007/s10995-018-2526-x
doi.org/10.17226/21795 67. Bethell CD, Gombojav N, Whitaker RC. Family resilience and
52. Barry CL, Busch SH. Do state parity laws reduce the financial burden connection promote flourishing among US children, even amid adversity.
on families of children with mental health care needs? Health Serv Res Health Aff (Millwood) 2019;38:729–37. PMID:31059374 https://doi.
2007;42(3p1):1061–84. PMID:17489904 https://doi. org/10.1377/hlthaff.2018.05425
org/10.1111/j.1475-6773.2006.00650.x 68. Moore KA, Bethell CD, Murphey D, Martin MC, Beltz M. Child Trends,
53. Barry CL, Huskamp HA. Moving beyond parity—mental health and research brief. Flourishing from the start: what is it and how can it be
addiction care under the ACA. N Engl J Med 2011;365:973–5. measured? Bethesda, MD; 2017. https://www.childtrends.org/
PMID:21848453 https://doi.org/10.1056/NEJMp1108649 wp-content/uploads/2017/03/2017-16FlourishingFromTheStart-1.pdf

38 MMWR / February 25, 2022 / Vol. 71 / No. 2

69. Substance Abuse and Mental Health Services Administration. 2018 84. Whitesell M, Bachand A, Peel J, Brown M. Familial, social, and individual
National Survey on Drug Use and Health: methodological summary factors contributing to risk for adolescent substance use. J Addict
and definitions. Rockville, MD: Center for Behavioral Health Statistics 2013;2013:579310. PMID:24826363 https://doi.
and Quality, Substance Abuse and Mental Health Services Administration; org/10.1155/2013/579310
2019. http://www.samhsa.gov/data 85. Substance Abuse and Mental Health Services Administration. Key
70. Center for Behavioral Health Statistics and Quality. 2019 National substance use and mental health indicators in the United States: results
Survey on Drug Use and Health: methodological summary and from the 2019 National Survey on Drug Use and Health. Rockville,
definitions. Rockville, MD: Substance Abuse and Mental Health Services MD: Center for Behavioral Health Statistics and Quality, Substance
Administration; 2020. http://www.samhsa.gov/data Abuse and Mental Health Services Administration; 2020. https://www.
71. Jordan BK, Karg RS, Batts KR, Epstein JF, Wiesen C. A clinical validation samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFF
of the National Survey on Drug Use and Health assessment of substance RPDFWHTML/2019NSDUHFFR090120.htm
use disorders. Addict Behav 2008;33:782–98. PMID:18262368 https:// 86. Stone DM, Simon TR, Fowler KA, et al. Vital Signs: trends in state suicide
doi.org/10.1016/j.addbeh.2007.12.007 rates—United States, 1999–2016 and circumstances contributing to
72. Substance Abuse and Mental Health Services Administration. Reliability suicide—27 states, 2015. MMWR Morb Mortal Wkly Rep 2018;67:617–24.
of key measures in the National Survey on Drug Use and Health. Rockville, PMID:29879094 https://doi.org/10.15585/mmwr.mm6722a1
MD: Health and Human Services, Office of Applied Studies; 2010. 87. Office of the Surgeon General, National Action Alliance for Suicide
73. World Health Organization. WHO Global Consultation on Violence Prevention. 2012 national strategy for suicide prevention: goals and
and Health. Violence: a public health priority. Geneva, World Health objectives for action. Washington, DC: US Department of Health and
Organization. Geneva, Switzerland: World Health Organization; 1996. Human Services, Office of the Surgeon General; 2012. https://www.
74. Petrosky E, Ertl A, Sheats KJ, Wilson R, Betz CJ, Blair JM. Surveillance ncbi.nlm.nih.gov/books/NBK109917/
for violent deaths—National Violent Death Reporting System, 34 states, 88. CDC. Preventing multiple forms of violence: a strategic vision for
four California counties, the District of Columbia, and Puerto Rico, connecting the dots. Atlanta, GA: US Department of Health and Human
2017. MMWR Surveill Summ 2020;69(No. SS-8). PMID:33270620 Services, CDC; 2016. https://www.cdc.gov/violenceprevention/pdf/
https://doi.org/10.15585/mmwr.ss6908a1 strategic_vision.pdf
75. Wolraich ML, Hagan JF Jr, Allan C, et al.; Subcommittee on Children 89. Stone DM, Holland KM, Bartholow BN, Crosby AE, Davis SP, Wilkins
and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical N. Preventing suicide: a technical package of policy, programs, and
practice guideline for the diagnosis, evaluation, and treatment of practice. Atlanta, GA: US Department of Health and Human Services,
attention-deficit/hyperactivity disorder in children and adolescents. CDC; 2017. https://www.cdc.gov/violenceprevention/pdf/
Pediatrics 2019;144:e20192528. PMID:31570648 https://doi. suicidetechnicalpackage.pdf
org/10.1542/peds.2019-2528 90. Birmaher B, Brent D, Bernet W, et al.; AACAP Work Group on Quality
76. Holbrook JR, Cuffe SP, Cai B, et al. Persistence of parent-reported Issues. Practice parameter for the assessment and treatment of children
ADHD symptoms from childhood through adolescence in a community and adolescents with depressive disorders. J Am Acad Child Adolesc
sample. J Atten Disord 2016;20:11–20. PMID:24994874 https://doi. Psychiatry 2007;46:1503–26. PMID:18049300 https://doi.org/10.1097/
org/10.1177/1087054714539997 chi.0b013e318145ae1c
77. Erskine HE, Norman RE, Ferrari AJ, et al. Long-term outcomes of 91. Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice
attention-deficit/hyperactivity disorder and conduct disorder: a parameter for the assessment and treatment of children and adolescents
systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry with anxiety disorders. J Am Acad Child Adolesc Psychiatry
2016;55:841–50. PMID:27663939 https://doi.org/10.1016/j. 2007;46:267–83. PMID:17242630 https://doi.org/10.1097/01.
jaac.2016.06.016 chi.0000246070.23695.06
78. Faraone SV, Asherson P, Banaschewski T, et al. Attention-deficit/ 92. Pringsheim T, Okun MS, Müller-Vahl K, et al. Practice guideline
hyperactivity disorder. Nat Rev Dis Primers 2015;1:15020. recommendations summary: treatment of tics in people with Tourette
PMID:27189265 https://doi.org/10.1038/nrdp.2015.20 syndrome and chronic tic disorders. Neurology 2019;92:896–906.
79. Sun S, Kuja-Halkola R, Faraone SV, et al. Association of psychiatric PMID:31061208 https://doi.org/10.1212/WNL.0000000000007466
comorbidity with the risk of premature death among children and adults
93. Smith T, Iadarola S. Evidence base update for autism spectrum disorder.
with attention-deficit/hyperactivity disorder. JAMA Psychiatry
2019;76:1141–9. PMID:31389973 https://doi.org/10.1001/ J Clin Child Adolesc Psychol 2015;44:897–922. PMID:26430947
jamapsychiatry.2019.1944 https://doi.org/10.1080/15374416.2015.1077448
80. Scott JG, Giørtz Pedersen M, Erskine HE, et al. Mortality in individuals 94. Kaminski JW, Claussen AH. Evidence base update for psychosocial
with disruptive behavior disorders diagnosed by specialist services—a treatments for disruptive behaviors in children. J Clin Child Adolesc
nationwide cohort study. Psychiatry Res 2017;251:255–60. Psychol 2017;46:477–99. PMID:28459280 https://doi.org/10.1080
PMID:28219025 https://doi.org/10.1016/j.psychres.2017.02.029 /15374416.2017.1310044
81. Schieve LA, Gonzalez V, Boulet SL, et al. Concurrent medical conditions 95. Wolraich ML, Hagan JF Jr, Allan C, et al.; Subcommittee on Children
and health care use and needs among children with learning and and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical
behavioral developmental disabilities, National Health Interview Survey, practice guideline for the diagnosis, evaluation, and treatment of
2006–2010. Res Dev Disabil 2012;33:467–76. PMID:22119694
attention-deficit/hyperactivity disorder in children and adolescents.
https://doi.org/10.1016/j.ridd.2011.10.008
82. Murphy TK, Lewin AB, Storch EA, Stock S; American Academy of Child Pediatrics 2019;144:e20192528. PMID:31570648 https://doi.
and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). org/10.1542/peds.2019-2528
Practice parameter for the assessment and treatment of children and adolescents 96. Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF.
with tic disorders. J Am Acad Child Adolesc Psychiatry 2013;52:1341–59. Evidence base update: 50 years of research on treatment for child and
PMID:24290467 https://doi.org/10.1016/j.jaac.2013.09.015 adolescent anxiety. J Clin Child Adolesc Psychol 2016;45:91–113.
83. Gray KM, Squeglia LM. Research Review: what have we learned about PMID:26087438 https://doi.org/10.1080/15374416.2015.1046177
adolescent substance use? J Child Psychol Psychiatry 2018;59:618–27.
PMID:28714184 https://doi.org/10.1111/jcpp.12783

MMWR / February 25, 2022 / Vol. 71 / No. 2 39

 97. Hogue A, Henderson CE, Becker SJ, Knight DK. Evidence base on 111. Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE,
outpatient behavioral treatments for adolescent substance use, Patrick ME. Monitoring the Future national survey results on drug
2014–2017: outcomes, treatment delivery, and promising horizons. J use, 1975–2019. Ann Arbor, MI: Institute for Social Research,
Clin Child Adolesc Psychol 2018;47:499–526. PMID:29893607 University of Michigan; 2020. https://eric.ed.gov/?id=ED594190
https://doi.org/10.1080/15374416.2018.1466307 112. Shonkoff JP, Slopen N, Williams DR. Early childhood adversity, toxic
98. Community Preventive Services Task Force. The guide to community stress, and the impacts of racism on the foundations of health. Annu
preventive services: mental health: targeted school-based cognitive Rev Public Health 2021;42:115–34. PMID:33497247 https://doi.
behavioral therapy programs to reduce depression and anxiety org/10.1146/annurev-publhealth-090419-101940
symptoms. Atlanta, GA: Community Preventive Services Task Force; 113. Flores A. 2015, Hispanic population in the United States: statistical
2 0 1 9 . h t t p s : / / w w w. t h e c o m m u n i t y g u i d e . o r g / f i n d i n g s / portrait of Hispanics in the United States. Washington, DC: Pew
mental-health-targeted-school-based-cognitive-behavioral-therapy- Re s e a rc h C e n t e r ; 2 0 1 5 . h t t p s : / / w w w. p e w re s e a rc h . o r g /
programs-reduce-depression-anxiety-symptoms hispanic/2017/09/18/2015-statistical-information-on-hispanics-in-
99. Spence SH, O’Shea G, Donovan CL. Improvements in interpersonal united-states
functioning following interpersonal psychotherapy (IPT) with 114. Potochnick SR, Perreira KM. Depression and anxiety among first-
adolescents and their association with change in depression. Behav generation immigrant Latino youth: key correlates and implications
Cogn Psychother 2016;44:257–72. PMID:26292976 https://doi. for future research. J Nerv Ment Dis 2010;198:470–7. PMID:20611049
org/10.1017/S1352465815000442 https://doi.org/10.1097/NMD.0b013e3181e4ce24
100. Pringsheim T, Holler-Managan Y, Okun MS, et al. Comprehensive 115. Bey A, Norton M. The role of parental citizenship status on depression
systematic review summary: treatment of tics in people with Tourette of U.S. citizen children. J Prev Interv Community 2021;49:282–91.
syndrome and chronic tic disorders. Neurology 2019;92:907–15. PMID:31469050 https://doi.org/10.1080/10852352.2019.1654258
PMID:31061209 https://doi.org/10.1212/WNL.0000000000007467 116. Céspedes YM, Huey SJJ Jr. Depression in Latino adolescents:
101. Gallagher R, Abikoff HB, Spira EG. Organizational skills training for a cultural discrepancy perspective. Cultur Divers Ethnic Minor
children with ADHD: an empirically supported treatment. New York, Psychol 2008;14:168–72. PMID:18426290 https://doi.
NY: The Guilford Press; 2014. org/10.1037/1099-9809.14.2.168
102. Cho E, Wood PK, Taylor EK, Hausman EM, Andrews JH, Hawley KM. 117. Lutrick K, Clark R, Nuño VL, Bauman S, Carvajal S. Latinx
Evidence-based treatment strategies in youth mental health services: bullying and depression in children and youth: a systematic review.
results from a national survey of providers. Adm Policy Ment Health Syst Rev 2020;9:126. PMID:32493493 https://doi.org/10.1186/
2019;46:71–81. PMID:30209703 https://doi.org/10.1007/ s13643-020-01383-w
s10488-018-0896-4 118. Lopez WD, LeBrón AM, Graham LF, Grogan-Kaylor A. Discrimination
103. Pidano AE, Honigfeld L. Pediatric psychopharmacology: context, model and depressive symptoms among Latina/o adolescents of immigrant
programs, and considerations for care. Psychiatr Serv 2012;63:929–34. parents. Int Q Community Health Educ 2016;36:131–40.
PMID:22810116 https://doi.org/10.1176/appi.ps.201100318 PMID:26861795 https://doi.org/10.1177/0272684X16628723
104. Hirsch GS. Dosing and monitoring: children and adolescents. 119. Caballero TM, DeCamp LR, Platt RE, et al. Addressing the mental
Psychopharmacol Bull 2018;48:34–92. PMID:29713099 health needs of Latino children in immigrant families. Clin Pediatr
105. Cuddy E, Currie J. Treatment of mental illness in American adolescents (Phila) 2017;56:648–58. PMID:27879297 https://doi.
varies widely within and across areas. Proc Natl Acad Sci U S A org/10.1177/0009922816679509
2020;117:24039–46. PMID:32958646 https://doi.org/10.1073/ 120. Song SJ, Ziegler R, Arsenault L, Fried LE, Hacker K. Asian
pnas.2007484117 student depression in American high schools: differences in risk
106. Blair C, Raver CC. Poverty, stress, and brain development: new directions factors. J Sch Nurs 2011;27:455–62. PMID:21844218 https://doi.
for prevention and intervention. Acad Pediatr 2016;16(Suppl):S30–6. org/10.1177/1059840511418670
PMID:27044699 https://doi.org/10.1016/j.acap.2016.01.010 121. Cokley K, Hall-Clark B, Hicks D. Ethnic minority-majority status and
107. Merikangas KR, McClair VL. Epidemiology of substance use disorders. mental health: the mediating role of perceived discrimination. J Ment
Hum Genet 2012;131:779–89. PMID:22543841 https://doi. Health Couns 2011;33:243–63. https://doi.org/10.17744/
org/10.1007/s00439-012-1168-0 mehc.33.3.u1n011t020783086
108. Peiper NC, Ridenour TA, Hochwalt B, Coyne-Beasley T. Overview 122. Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN.
on prevalence and recent trends in adolescent substance use and abuse. Prevalence of and risk factors for depressive symptoms among young
Child Adolesc Psychiatr Clin N Am 2016;25:349–65. PMID:27338960 adolescents. Arch Pediatr Adolesc Med 2004;158:760–5.
https://doi.org/10.1016/j.chc.2016.03.005 PMID:15289248 https://doi.org/10.1001/archpedi.158.8.760
109. Bitsko RH, Holbrook JR, Visser SN, et al. A national profile of Tourette 123. Bostwick WB, Meyer I, Aranda F, et al. Mental health and suicidality
syndrome, 2011–2012. J Dev Behav Pediatr 2014;35:317–22. among racially/ethnically diverse sexual minority youths. Am J Public
PMID:24906033 https://doi.org/10.1097/DBP.0000000000000065 Health 2014;104:1129–36. PMID:24825217 https://doi.org/10.2105/
110. Zablotsky B, Alford JM. Racial and ethnic differences in the prevalence AJPH.2013.301749
of attention-deficit/hyperactivity disorder and learning disabilities 124. Bagalman E, Heisler EJ. Behavioral health among American Indian
among U.S. children aged 3–17 years. NCHS Data Brief, no. 358. and Alaska Natives: an overview. Washington, DC: Congressional
Hyattsville, MD: US Department of Health and Human Services, Research Service; 2016. https://sgp.fas.org/crs/misc/R44634.pdf
CDC, National Center for Health Statistics; 2020. https://www.cdc. 125. Kenney MK, Singh GK. Adverse childhood experiences among
gov/nchs/products/databriefs/db358.htm American Indian/Alaska Native children: the 2011–2012 National
Survey of Children’s Health. Scientifica (Cairo) 2016;2016:7424239.
PMID:27529052 https://doi.org/10.1155/2016/7424239

40 MMWR / February 25, 2022 / Vol. 71 / No. 2

126. Dickerson DL, Johnson CL. Mental health and substance abuse 139. Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender
characteristics among a clinical sample of urban American Indian/ (LGBT) youth. Annu Rev Clin Psychol 2016;12:465–87. PMID:26772206
Alaska native youths in a large California metropolitan area: a https://doi.org/10.1146/annurev-clinpsy-021815-093153
descriptive study. Community Ment Health J 2012;48:56–62. 140. Census Bureau. National Survey of Children’s Health (NSCH) technical
PMID:21161379 https://doi.org/10.1007/s10597-010-9368-3 documentation. Washington, DC: US Department of Commerce,
127. Anderson NJ, Neuwirth SJ, Lenardson JD, Hartley D. Patterns of care Census Bureau. https://www.census.gov/programs-surveys/nsch/
for rural and urban children with mental health problems. Portland, ME: technical-documentation/complete-technical-documentation.html
Maine Rural Health Research Center; 2013. http://muskie.usm.maine. 141. Schwartz RM, Sison C, Kerath SM, et al. The impact of Hurricane
edu/Publications/MRHRC/WP49-Rural-Children-Mental-Health.pdf Sandy on the mental health of New York area residents. Am J Disaster
128. Meit M, Knudson A, Gilbert T, et al. The 2014 update of the rural- Med 2015;10:339–46. PMID:27149315 https://doi.org/10.5055/
urban chartbook. Grand Forks, ND: NORC at the University of ajdm.2015.0216
Chicago, Rural Health Reform Policy Research Center; 2014. https:// 142. Vahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of anxiety
www.norc.org/Research/Projects/Pages/2014-update-of-the-rural- or depressive disorder and use of mental health care among adults
urban-chartbook.aspx during the COVID-19 pandemic—United States, August 2020–
129. Gamm L, Stone S, Pittman S. Mental health and mental disorders—a February 2021. MMWR Morb Mortal Wkly Rep 2021;70:490–4.
rural challenge: a literature review. Rural Healthy People 2010: a PMID:33793459 https://doi.org/10.15585/mmwr.mm7013e2
companion document to Healthy People 2010, vol. 2. College Station, 143. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use,
TX: Texas A&M University System Health Sciences Center; 2010. and suicidal ideation during the COVID-19 pandemic—United States,
https://www.researchgate.net/publication/255683562_Mental_health_ June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–57.
and_mental_disorders-a_rural_challenge_A_literature_review PMID:32790653 https://doi.org/10.15585/mmwr.mm6932a1
130. Andrilla CHA, Patterson DG, Garberson LA, Coulthard C, Larson 144. Wozniak A, Willey J, Benz J, Hart N. COVID impact survey. Washington,
EH. Geographic variation in the supply of selected behavioral health DC: Data Foundation; 2021. https://www.covid-impact.org
providers. Am J Prev Med 2018;54(Suppl 3):S199–207. 145. Patrick SW, Henkhaus LE, Zickafoose JS, et al. Well-being of parents
PMID:29779543 https://doi.org/10.1016/j.amepre.2018.01.004 and children during the COVID-19 pandemic: a national survey.
131. Danielson ML, Bitsko RH, Holbrook JR, et al. Community-based Pediatrics 2020;146:e2020016824. PMID:32709738 https://doi.
prevalence of externalizing and internalizing disorders among school-aged org/10.1542/peds.2020-016824
children and adolescents in four geographically dispersed school districts 146. Verlenden JV, Pampati S, Rasberry CN, et al. Association of children’s
in the United States. Child Psychiatry Hum Dev 2021;52:500–14. mode of school instruction with child and parent experiences and
PMID:32734339 https://doi.org/10.1007/s10578-020-01027-z well-being during the COVID-19 pandemic—COVID Experiences
132. Wren FJ, Bridge JA, Birmaher B. Screening for childhood anxiety Survey, United States, October 8–November 13, 2020. MMWR Morb
symptoms in primary care: integrating child and parent reports. J Am Mortal Wkly Rep 2021;70:369–76. PMID:33735164 https://doi.
Acad Child Adolesc Psychiatry 2004;43:1364–71. PMID:15502595 org/10.15585/mmwr.mm7011a1
https://doi.org/10.1097/01.chi.0000138350.60487.d3 147. Nikolaidis A, Paksarian D, Alexander L, et al. The Coronavirus Health
133. Cantwell DP, Lewinsohn PM, Rohde P, Seeley JR. Correspondence between and Impact Survey (CRISIS) reveals reproducible correlates of
adolescent report and parent report of psychiatric diagnostic data. J Am pandemic-related mood states across the Atlantic. Sci Rep 2021;11:8139.
Acad Child Adolesc Psychiatry 1997;36:610–9. PMID:9136495 https:// PMID:33854103 https://doi.org/10.1038/s41598-021-87270-3
doi.org/10.1097/00004583-199705000-00011 148. Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US
134. Wittkowski A, Vatter S, Muhinyi A, Garrett C, Henderson M. emergency department visits for mental health, overdose, and violence
Measuring bonding or attachment in the parent-infant-relationship: a outcomes before and during the COVID-19 pandemic. JAMA
systematic review of parent-report assessment measures, their Psychiatry 2021;78:372–9. PMID:33533876 https://doi.org/10.1001/
psychometric properties and clinical utility. Clin Psychol Rev jamapsychiatry.2020.4402
2020;82:101906. PMID:32977111 https://doi.org/10.1016/j. 149. Metzger AN, Hamilton LT. The stigma of ADHD: teacher ratings of
cpr.2020.101906 labeled students. Sociol Perspect 2021;64:258–79. https://doi.
135. Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. org/10.1177/0731121420937739
Mental health-related emergency department visits among children aged 150. Owens J. Relationships between an ADHD diagnosis and future school
<18 years during the COVID-19 pandemic—United States, January 1– behaviors among children with mild behavioral problems. Sociol Educ
October 17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1675–80. 2020;93:191–214. https://doi.org/10.1177/0038040720909296
PMID:33180751 https://doi.org/10.15585/mmwr.mm6945a3 151. Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report
136. Cadman D, Boyle M, Szatmari P, Offord DR. Chronic illness, disability, of health care provider-diagnosed and medicated attention-deficit/
and mental and social well-being: findings of the Ontario Child Health hyperactivity disorder: United States, 2003–2011. J Am Acad Child
Study. Pediatrics 1987;79:805–13. PMID:2952939 https://doi. Adolesc Psychiatry 2014;53:34–46.e2. PMID:24342384 https://doi.
org/10.1542/peds.79.5.805 org/10.1016/j.jaac.2013.09.001
137. Pachter LM, Coll CG. Racism and child health: a review of the literature 152. Mojtabai R, Olfson M, Han B. National trends in the prevalence and
and future directions. J Dev Behav Pediatr 2009;30:255–63. treatment of depression in adolescents and young adults. Pediatrics
PMID:19525720 https://doi.org/10.1097/DBP.0b013e3181a7ed5a 2016;138:e20161878. PMID:27940701 https://doi.org/10.1542/
138. Kerker BD, Zhang J, Nadeem E, et al. Adverse childhood experiences peds.2016-1878
and mental health, chronic medical conditions, and development in 153. Beesdo-Baum K, Knappe S. Developmental epidemiology of anxiety
young children. Acad Pediatr 2015;15:510–7. PMID:26183001 disorders. Child Adolesc Psychiatr Clin N Am 2012;21:457–78.
https://doi.org/10.1016/j.acap.2015.05.005 PMID:22800989 https://doi.org/10.1016/j.chc.2012.05.001

MMWR / February 25, 2022 / Vol. 71 / No. 2 41

154. Howell E, McFeeters J. Children’s mental health care: differences by 162. Kramer MR, Raskind IG, Van Dyke ME, Matthews SA, Cook-Smith JN.
race/ethnicity in urban/rural areas. J Health Care Poor Underserved Geography of adolescent obesity in the U.S., 2007–2011. Am J Prev
2008;19:237–47. PMID:18263999 https://doi.org/10.1353/ Med 2016;51:898–909. PMID:27554364 https://doi.org/10.1016/j.
hpu.2008.0008 amepre.2016.06.016
155. Ghandour RM, Hirai AH, Moore KA, et al. Healthy and ready to 163. Census Bureau. State oversampling in the National Survey of Children’s
learn: prevalence and correlates of school readiness among US Health: feasibility, cost, and FAQs. Washington, DC: US Department
preschoolers. Acad Pediatr 2021;21:818–29. PMID:33667721 https:// of Commerce, Census Bureau. https://www.census.gov/content/dam/
doi.org/10.1016/j.acap.2021.02.019 Census/programs-surveys/nsch/NSCH_State_Oversample_Summary_
156. Claussen AH, Robinson LR, Kaminski JW, et al. Factors associated Document.pdf
with self-regulation in a nationally representative sample of children 164. CDC. Youth Risk Behavior Surveillance System: 2019 YRBS results
ages 3–5 years: United States, 2016. Matern Child Health J and data available now. Atlanta, GA: US Department of Health and
2021;25:27–37. PMID:33219911 https://doi.org/10.1007/ Human Services, CDC; 2020. https://www.cdc.gov/healthyyouth/data/
s10995-020-03039-6 yrbs/index.htm
157. Sheldrick RC, Henson BS, Neger EN, Merchant S, Murphy JM, 165. National Network of Public Health Institutes. Data governance for
Perrin EC. The baby pediatric symptom checklist: development and children’s mental health surveillance: what is it and why does it matter?
initial validation of a new social/emotional screening instrument for Washington, DC: National Network of Public Health Institutes; 2020.
very young children. Acad Pediatr 2013;13:72–80. PMID:23092547 https://nnphi.org/wp-content/uploads/2020/05/NNPHI-Data-
https://doi.org/10.1016/j.acap.2012.08.003 Governance-Report-final-508.pdf
158. Loeb M, Mont D, Cappa C, De Palma E, Madans J, Crialesi R. The 166. Public Health Informatics Institute. Summary of laws related to child
development and testing of a module on child functioning for and adolescent mental health. Decatur, GA: Public Health Informatics
identifying children with disabilities on surveys. I: background. Disabil Institute; 2020. https://phii.org/sites/default/files/resource/pdfs/
Health J 2018;11:495–501. PMID:30054226 https://doi. Summary%20of%20Laws%20Related%20to%20CAMH.pdf
org/10.1016/j.dhjo.2018.06.005 167. Public Health Informatics Institute. Using data to improve child and
159. Massey M. The development and testing of a module on child functioning adolescent mental health (CAMH): the opening playbook. Decatur,
for identifying children with disabilities on surveys. II: question GA: Public Health Informatics Institute; 2021. https://phii.org/course/
development and pretesting. Disabil Health J 2018;11:502–9. using-data-to-improve-child-and-adolescent-mental-health-camh-the-
PMID:30049637 https://doi.org/10.1016/j.dhjo.2018.06.006 opening-playbook/
160. Cappa C, Mont D, Loeb M, et al. The development and testing of a 168. Evans AC, Bufka LF. The critical need for a population health approach:
module on child functioning for identifying children with disabilities addressing the nation’s behavioral health during the COVID-19
on surveys. III: field testing. Disabil Health J 2018;11:510–8. pandemic and beyond. Prev Chronic Dis 2020;17:E79. PMID:32762806
PMID:30049638 https://doi.org/10.1016/j.dhjo.2018.06.004 https://doi.org/10.5888/pcd17.200261
161. Maenner MJ, Graves SJ, Peacock G, Honein MA, Boyle CA, Dietz PM.
Comparison of 2 case definitions for ascertaining prevalence of autism spectrum
disorder among 8-year-old children. Am J Epidemiol 2021;190:2198–207.
PMID:33847734 https://doi.org/10.1093/aje/kwab106

42 MMWR / February 25, 2022 / Vol. 71 / No. 2

The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free
of charge in electronic format. To receive an electronic copy each week, visit MMWR at https://www.cdc.gov/mmwr/index.html.
Readers who have difficulty accessing this PDF file may access the HTML file at https://www.cdc.gov/mmwr/index2022.html. Address all inquiries about
the MMWR Series to Editor-in-Chief, MMWR Series, Mailstop V25-5, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30329-4027 or to [email protected].
All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.
MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations
or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses
listed in MMWR were current as of the date of publication.

ISSN: 2380-8950 (Print)