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Annual Research Review: A meta-analysis of the worldwide prevalence of

mental disorders in children and adolescents

Article  in  Journal of Child Psychology and Psychiatry · February 2015

DOI: 10.1111/jcpp.12381

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 JCPP

Annual Research Review: A meta-analysis of the worldwide

prevalence of mental disorders in children and adolescents.

Journal: Journal of Child Psychology and Psychiatry

Fo
Manuscript ID: JCPP-2014-00400.R2

Manuscript Type: Annual Research Review

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Date Submitted by the Author: n/a

Complete List of Authors: Polanczyk, Guilherme V.; University of São Paulo Medical School ,
Pe

Psychiatry
Salum, Giovanni; Federal University of Rio Grande do Sul, Post Graduate
Program in Medical Sciences: Psychiatry
Sugaya, Luisa; University of São Paulo Medical School, Psychiatry
er

Caye, Arthur; Federal University of Rio Grande do Sul, Post Graduate

Program in Medical Sciences: Psychiatry
Rohde, Luis; Universidade Federal do Rio Grande do Sul, Departamento de
Psiquiatria; National Institute for Developmental Psychiatry for Children
and Adolescents,
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Key Words: Anxiety, Depression, ADHD, Disruptive behaviour, Prevalence

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Page 1 of 38 JCPP

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3 Annual Research Review: A meta-analysis of the worldwide prevalence of mental
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5 disorders in children and adolescents.
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8 Guilherme V. Polanczyk,1,2,3 Giovanni A. Salum,3,4 Luisa Sugaya,1,2 Arthur Caye,4 Luis A.
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10 Rohde3,4
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13 1
Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.
14 2
15 Research Center on Neurodevelopment and Mental Health, University of São Paulo,
16 São Paulo, Brazil.
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3
18 National Institute of Developmental Psychiatry for Children and Adolescents (INCT-
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20 CNPq), Brazil.
21 4
ADHD Outpatient Program at the Child and Adolescent Psychiatric Division, Hospital de
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23 Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
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26 *Corresponding author: Prof. Guilherme V. Polanczyk. Instituto de Psiquiatria, Hospital
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28 das Clínicas da Faculdade de Medicina, Universidade de São Paulo. Rua Dr. Ovídio
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29 Pires de Campos 785, São Paulo, SP – Brazil. 05403-010. Email: gvp@usp.br

30
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32 Disclosure: GVP has served as a speaker and/or consultant to Shire, developed
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34 educational material for Janssen-Cilag and Shire, receives authorship royalties from
35 Editora Manole. GAS, LS, and AC report no conflict of interest. LAR has been a member
36
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37 of the speakers' bureau/advisory board and/or acted as a consultant for Eli-Lilly,

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39 Janssen-Cilag, Novartis and Shire in the last three years. He receives authorship
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40 royalties from Oxford Press and ArtMed. He has also received travel awards from Shire
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42 for his participation of the 2014 APA meeting. The ADHD and Juvenile Bipolar Disorder
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Outpatient Programs chaired by him received unrestricted educational and research
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45 support from the following pharmaceutical companies in the last three years: Eli-Lilly,
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47 Janssen-Cilag, Novartis, and Shire.
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50 This work was supported by the National Council for Scientific and Technological
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52 Development (CNPq) [Bolsa de Produtividade em Pesquisa to GVP, LAR], and
53 Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS) [Post-
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55 doctoral scholarship to GAS].
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 JCPP Page 2 of 38

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3 Summary
4
5 Background
6
7 The literature on the prevalence of mental disorders affecting children and adolescents
8 has expanded significantly over the last three decades around the world. Despite the
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10 field having matured significantly, there has been no meta-analysis to calculate a
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12
worldwide pooled prevalence and to empirically assess the sources of heterogeneity of
13 estimates.
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15 Methods
16 We conducted a systematic review of the literature searching in PubMed, PsycINFO,
17
18 and EMBASE for prevalence studies of mental disorders investigating probabilistic
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20 community samples of children and adolescents with standardized assessments
21 methods that derive diagnoses according to the DSM or ICD. Meta-analytical techniques
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23 were used to estimate the prevalence rates of any mental disorder and individual
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diagnostic groups. A meta-regression analysis was performed to estimate the effect of
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26 population and sample characteristics, study methods, assessment procedures, and
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28 case definition in determining the heterogeneity of estimates.
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29 Results
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31 We included forty-one studies conducted in 27 countries from every world region. The
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worldwide pooled prevalence of mental disorders was 13.4% (CI 95% 11.3 – 15.9). The
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34 worldwide prevalence of any anxiety disorder was 6.5% (CI 95% 4.7 – 9.1), any
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36 depressive disorder was 2.6% (CI 95% 1.7 – 3.9), attention-deficit hyperactivity disorder
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was 3.4% (CI 95% 2.6 – 4.5), and any disruptive disorder was 5.7% (CI 95% 4.0 – 8.1).
39 Significant heterogeneity was detected for all pooled estimates. The multivariate meta-
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41 regression analyses indicated that sample representativeness, sample frame, and
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diagnostic interview were significant moderators of prevalence estimates. Estimates did
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44 not vary as a function of geographic location of studies and year of data collection. The
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46 multivariate model explained 88,89% of prevalence heterogeneity, but residual
47 heterogeneity was still significant. Additional meta-analysis detected significant pooled
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49 difference in prevalence rates according to requirement of funcional impairment for the
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51
diagnosis of mental disorders.
52 Conclusions
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54 Our findings suggest that mental disorders affect a significant number of children and
55
adolescents worldwide. The pooled prevalence estimates and the identification of
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Page 3 of 38 JCPP

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3 sources of heterogeneity have important implications to service, training, and research
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5 planning around the world.
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8 Key-words/MeSH terms: mental disorders, anxiety disorders, depressive disorders,
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10 ADHD, disruptive behavior disorders, children, prevalence, epidemiology, meta-analysis,
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cross-cultural.
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15 Key-points:
16 - Prevalence estimates of mental disorders in children and adolescents vary
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18 significantly across studies, and there has been no meta-analysis to calculate a
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20 worldwide pooled prevalence and a meta-regression to determine sources of variability.
21 - A meta-analysis of 41 studies conducted between 1985 to 2012 in 27 countries
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23 estimates a worldwide prevalence of any mental disorder of 13.4%; any anxiety disorder,
24
6.5%; any depressive disorder, 2.6%; major depressive disorder, 1.3%; attention-
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26 deficit/hyperactivity disorder, 3.4%; any disruptive disorder, 5.7%; oppositional defiant
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28 disorder, 3.6%; conduct disorder, 2.1%.
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29 - Sample representativeness, sample frame, diagnostic interview, and definition of

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31 functional impairment are associated with significant variability across estimates.
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- Variability of prevalence estimates is not explained by geographic location of studies
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34 and year of data collection.
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36 - Future surveys should be conducted in areas with very restricted or no data on
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prevalence rates and should follow methodological strategies that guaranteee
39 comparability across studies.
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41 - The worldwide pooled prevalence rate contributes to estimating the economic burden
42
of disorders, planning and evaluationg services, and allocation of resources.
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 JCPP Page 4 of 38

1
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3 Introduction
4
5 The number of children and adolescents affected by mental disorders has been the
6
7 focus of significant interest over recent decades (Achenbach, Rescorla, & Ivanova,
8 2012; Insel, 2014; Knudsen, Heckman, Cameron, & Shonkoff, 2006; Whiteford et al.,
9
10 2013). Rates of diagnoses have increased substantially and a growing number of
11
12
children and adolescents now requiring pharmacological and psychotherapeutic
13 treatments, educational interventions, and a variety of special services and
14
15 accommodations has prompted the interest of researchers, clinicians, and the
16 community in general (Atladottir et al., 2014; Egan, 2008; Miller, 2010; Olfson, Blanco,
17
18 Wang, Laje, & Correll, 2014; Sahakian & Morein-Zamir, 2007; Schwarz & Cohen, 2013).
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20 There is evidence to suggest that over-diagnosis and over-treatment exist to some
21 extent (James et al., 2014; Visser et al., 2013). Nevertheless, a large body of evidence
22
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23 indicates that children currently in treatment do not exceed the number of children with
24
mental disorders, and under-diagnosis and under-treatment are major public health
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26 problems around the world (Belfer, 2008; Merikangas, 2013; Morris et al., 2011).
27
28 Accurate prevalence estimates are essential to inform service planning, resource
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29 allocation, training, and research priorities (Costello, Burns, Angold, & Leaf, 1993).
30
31 Moreover, the identification of prevalence estimates variability can contribute to
32
addressing questions about etiology and inform the design of future studies.
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34 Community surveys measuring the frequency of children with emotional and
35
36 behavioral problems have been conducted as early as the first half of the 20th century.
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38
These early surveys used non-standardized methods with sampling strategies and
39 measurement approaches that limited the internal and external validity of results. In the
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41 second half of the 20th century, the development of strong principles and methods in
42
epidemiology reached child psychiatry, an emergent discipline at the time. In parallel, the
43
44 introduction of explicit diagnostic criteria including childhood disorders in the DSM-III
45
46 (1980) allowed the development of standardized psychiatric interviews and stimulated
47 epidemiological research in the field. Community surveys employing sound
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49 epidemiological methods and following standardized diagnostic criteria were published in
50
51
the 1980s and 1990s, providing reliable estimates of rates of mental disorders in children
52 and adolescents in the community (Buka, Monuteaux, & Earls, 2002; Costello, 1989;
53
54 Verhulst & Koot, 1991; 1995).
55
In the past three decades, the increasing number of community surveys provided
56
57 unprecedented estimates in various regions of the world (Breton et al., 1999; Canino et
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Page 5 of 38 JCPP

1
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3 al., 2004; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Ford, Goodman, & Meltzer,
4
5 2003; Goodman, Slobodskaya, & Knyazev, 2005b; Kessler et al., 2012). Systematic and
6
7 narrative reviews have summarized the available literature, providing detailed
8 methodological appraisals of studies. One important shared finding among reviews was
9
10 the non-uniformity of methodological approaches, sampling strategies and case
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12
definitions between original surveys, limiting the comparability of rates in different parts
13 of the world (Bird, 1996; Brandenburg, Friedman, & Silver, 1990; Brauner & Stephens,
14
15 2006; Buka et al., 2002; Costello et al., 1993; Verhulst & Koot, 1995). To date, no
16 international multi-site study using strictly the same methodology and deriving formal
17
18 categorical diagnoses of mental disorders in children and adolescents is found in the
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20 literature. In addition, there is no available meta-analysis calculating a worldwide pooled
21 prevalence estimate and testing the relative impact of each individual study method on
22
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23 the variability of estimates across the studies.
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In this review, we first considered previous narrative and systematic reviews on the
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26 prevalence of mental disorders in children and adolescents in the community. Second,
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28 we addressed sources of prevalence variability identified in the literature. Third, we
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29 reported an original comprehensive systematic review of the literature. Fourth, based on

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31 the studies included in our systematic review, we presented the results of a meta-
32
analysis calculating a worldwide-pooled prevalence of mental disorders in children and
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34 adolescents in the community. Fifth, we reported the results of meta-regression analyses
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36 conducted to test study-level covariates associated with the heterogeneity of prevalence
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estimates. Finally, we discussed and integrated the results and implications.
39
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41 Prevalence estimates
42
A number of literature reviews have summarized community surveys and provided a
43
44 comprehensive picture of the field (Angold & Costello, 1995; Bird, 1996; Brandenburg et
45
46 al., 1990; Brauner & Stephens, 2006; Buka et al., 2002; Costello, Egger, & Angold,
47 2005; Duarte et al., 2003; Merikangas, Nakamura, & Kessler, 2009; Roberts, Attkisson,
48
49 & Rosenblatt, 1998; Verhulst & Koot, 1991; 1995). An important limitation is that most of
50
51
the reviews have not used a systematic methodology to identify relevant studies.
52 Summary estimates have been usually calculated as the median of individual estimates,
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54 and none of them have implemented a meta-analytic approach. Verhulst & Koot
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(Verhulst & Koot, 1991) identified 38 studies published between 1965 and 1990, with a
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57 median prevalence rate of mental disorders of 13%, ranging from 3% to 30%.
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 JCPP Page 6 of 38

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3 Subsequently, 11 other studies were incorporated in the pool, resulting in a median rate
4
5 of 12% (Verhulst & Koot, 1995). Another review identified 52 studies published between
6
7 1963 and 1996 with prevalence estimates ranging from 1% to 51%, and median rates of
8 8% for preschoolers, 12% for preadolescents, and 15% for adolescents (Roberts et al.,
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10 1998).
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12
13 Cross-cultural differences
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15 A large number of studies have used symptom scales such as the Child Behavior
16 Checklist (CBCL) and Strengths and Difficulties Questionnaire (SDQ) to assess
17
18 dimensional psychopathology in children and adolescents in a variety of countries
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20 (Achenbach et al., 2008). By using the same instrument and comparable study methods,
21 differences that are detected across studies and countries can be interpreted as
22
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23 resulting from geographic, social and/or cultural aspects. Culture in general may
24
influence the identification and interpretation of symptoms and the meaning attributed to
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26 them, not only by parents and teachers, but also by health professionals (Bird, 1996;
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28 Egan, 2008; Miller, 2010; Olfson et al., 2014; Sahakian & Morein-Zamir, 2007; Schwarz
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29 & Cohen, 2013). Moreover, culture and related factors that are more proximal to
30
31 childhood development (e.g., parental style) influence the emergence of emotional and
32
behavioral problems (Canino & Alegría, 2008; James et al., 2014; Visser et al., 2013).
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34 Nevertheless, studies assessing community samples around the world (most of them
35
36 non-representative of the populations) with dimensional measures found more
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similarities than differences in terms of the psychopathology and correlates between
39 them, with slight differences in the rate of symptoms (Crijnen, Achenbach, & Verhulst,
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41 1997; Ivanova et al., 2010; Merikangas, 2013; Morris et al., 2011; Rescorla et al., 2011;
42
2012; Verhulst & Achenbach, 1995; Verhulst et al., 2003).
43
44 Literature reviews have focused on surveys that used both diagnostic interviews and
45
46 rating scales to assess prevalence rates of mental disorders in specific countries and
47 regions, such as Germany (Barkmann & Schulte-Markwort, 2012; Costello et al., 1993;
48
49 Duarte et al., 2003; Srinath, Kandasamy, & Golhar, 2010), Latin America (Duarte et al.,
50
51
2003), and India (Srinath et al., 2005). Bird (Bird, 1996) conducted a narrative review of
52 the literature and described studies in various countries employing different
53
54 methodological approaches, but all of them using standardized diagnostic interviews to
55
generate categorical diagnoses. Studies using ICD-9 diagnostic criteria detected rates of
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57 mental disorders of 12.4% in Chartres, France; 25.4% in Dublin, Ireland; and 51.3% in
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Page 7 of 38 JCPP

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3 Mannheim, Germany. Studies following DSM-III or DSM-III-R detected rates of 19.4% in
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5 New York; 17.6% in Dunedin, New Zealand; 26% in Zuid-Hollands, The Netherlands;
6
7 18.1% in Ontario, Canada; 41.3% in Columbia, USA; 22% in Pittsburgh, USA; 49.5% in
8 Puerto Rico; 27.3% in Christchurch, New Zealand. In general, these studies provided a
9
10 heterogeneous picture of prevalence estimates in different countries. Nevertheless,
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12
because variation in cultural aspects cannot be disentangled from variation in study
13 methods in this literature review, no conclusions can be drawn about the independent
14
15 effect of culture and social aspects over prevalence estimates.
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17
18 Methodological approaches
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20 Methods in epidemiology evolved considerably in the second half on the 20th century
21 and reached the field of child and adolescent psychiatry following the 1980s. Study
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23 designs have since become more sophisticated, as well as case definition and methods
24
of ascertainment. New diagnostic interviews have been developed, information from
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26 different sources has been aggregated in a variety of new formats, and functional
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28 impairment has been conceptualized and operationalized differently. Thus, important
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29 variability in diverse aspects of study methods has characterized the surveys conducted
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31 to date (Breton et al., 1999; Buka et al., 2002; Canino et al., 2004; Costello et al., 2003;
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Ford et al., 2003; Goodman, Slobodskaya, & Knyazev, 2005b; Kessler et al., 2012;
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34 Verhulst & Koot, 1991; 1995).
35
36 Variability in study methods introduces noise in the process of estimating a true
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global prevalence and of investigating the impact of social and cultural aspects on the
39 estimates. Therefore, it has been understood as a barrier to the progress of the field
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41 (Brauner & Stephens, 2006; Buka et al., 2002; Merikangas et al., 2009; Verhulst & Koot,
42
1995). Nevertheless, fluctuations in the prevalence rates as a function of methodological
43
44 approaches also contributed to the further refinement of epidemiological methods and
45
46 principles (Bird, 1996; Brandenburg et al., 1990; Brauner & Stephens, 2006; Costello et
47 al., 1993; 2005). Additionally, it prompted the field’s attention to the limitations of current
48
49 nosological schemes in capturing mental disorders and the need to move beyond them
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51
(Angold & Costello, 1995; 2009; Bird, 1996; Brandenburg et al., 1990; Brauner &
52 Stephens, 2006; Buka et al., 2002; Costello et al., 2005; Duarte et al., 2003; Hyman,
53
54 2011; Merikangas et al., 2009; R. E. Roberts et al., 1998; Verhulst & Koot, 1991; 1995).
55
Described below are methodological strategies related to study design, case definition
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 JCPP Page 8 of 38

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3 and ascertainment that are identified in the literature as potentially relevant for variability
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5 on prevalence estimates.
6
7 Sampling strategy
8 Sampling is the process of selecting the specific study subjects. A study sample that
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10 accurately represents the target population is an essential characteristic of a prevalence
11
12
study because it ensures that results are generalizable to all members of the population.
13 To identify a representative sample of the population, a probabilistic sampling strategy
14
15 must be adopted.That is, each eligible member of the population has a known chance to
16 be identified and included in the sample by the principle of randomization. In practice,
17
18 the population is defined through a sampling frame, which is a list of all of the units in the
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20 target population used to draw the sample. Examples of sampling frames include
21 telephone directories, census data, and schools. Different sampling strategies can be
22
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23 adopted to select the units within the frame, such as simple random sampling, stratified
24
random sampling, systematic sampling, and cluster sampling (Fleming & Hsieh, 2002;
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26 Rothman, Greenland, & Lash, 2008; Verhulst & Koot, 1991).
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28 Community surveys of mental disorders in children and adolescents have commonly
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29 used schools as a sampling frame, which are selected within a defined area or randomly
30
31 selected from a register of schools (Angold et al., 2002; Kroes et al., 2001; Leung et al.,
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2008; Verhulst & Koot, 1995). In countries where virtually all children are enrolled in
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34 schools, this is a robust strategy that is likely to have equivalent external validity to
35
36 studies using population census or household frames (Ford et al., 2003; R. E. Roberts et
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al., 1998; Vicente et al., 2012), with practical and logistic advantages.
39 As the sampling frame and the individuals who are eligible for inclusion in the study
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41 are identified, it is possible to recognize those who in fact participated, and those who
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did not. The number of individuals eligible for participation who are included in the study,
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44 or the response rate of a study, is an important paremeter of the success of the sampling
45
46 procedure. If a substantial proportion of the eligible participants does not take part in a
47 survey or if non-participation occurrs non-randomly (i.e, specific characteristics are
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49 associated to non participation), results may not be generalized to the population or may
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51
be biased.
52 Study design
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54 Community surveys using a one-stage design, in which diagnostic interviews are
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used to assess an entire representative sample of the population, provide strong
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57 methodological basis to generate prevalence rates. Nevertheless, these studies are
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Page 9 of 38 JCPP

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3 expensive and time-consuming for families, limiting their feasibility. The Isle of Wight
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5 study was the first to use a two-stage design to maximize resources and minimize
6
7 burden to participants. This study design includes a screening instrument answered by
8 the entire sample; subsequently, only individuals who screen positive (or a random
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10 sample of them) and a proportion of individuals who screen negative are further selected
11
12
for the diagnostic phase. With the rates of diagnosis for both groups of individuals who
13 screen positive and negative, it is possible to calculate the instrument’s diagnostic
14
15 properties and therefore to estimate the prevalence in the initial sample and the
16 population. However, considerable work should be directed to identify the screening
17
18 method, screening informant, and the most appropriate cut-off points. These are
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20 important elements that are frequently inconsistent across studies and may impact the
21 resulting prevalence rates (Achenbach et al., 2008; Gómez-Beneyto, Bonet, Catalá,
22
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23 Puche, & Vila, 1994; Kroes et al., 2001).
24
Diagnostic criteria
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26 The development of classification systems has provided the foundations for reliable
27
28 assessment of mental disorders (Buka et al., 2002). Differences in the diagnostic criteria
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29 for the same disorder between the two most used systems in Psychiatry [the
30
31 International Classification of Diseases – ICD and the Diagnostic and Statistical Manual
32
of Mental Disorders – DSM] result in differences in prevalence rates (Anselmi, Fleitlich-
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34 Bilyk, Menezes, Araujo, & Rohde, 2009). Additionally, as revised versions of ICD and
35
36 DSM were published and criteria of specific mental disorders changed, differences in
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38
prevalence rates are expected. Therefore, diagnostic criteria is a major issue to consider
39 when comparing rates across studies.
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41 Diagnostic assessment
42
Diagnostic assessment is the procedure employed by the investigators to determine
43
44 the presence or absence of mental disorders following specific diagnostic criteria. The
45
46 diagnostic interview is a major component of the assessment, as assessment
47 standardization is a fundamental requirement to guarantee within and between studies
48
49 consistency. Diagnostic interviews differ in regard to the way questions are formulated,
50
51
to the presence of gate/skip questions, and to the emphasis on the respondent’s
52 understanding and interpretation of the questions (respondent-based), or the
53
54 interviewer’s interpretation of the answers given (interviewer-based). The former tend to
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be structured interviews, usually administered by lay-interviewers, and the latter, semi-
56
57 structured interviews usually administered by clinicians (Buka et al., 2002).
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 JCPP Page 10 of 38

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3 Informant
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5 Community surveys commonly use parents as informants, adolescents and less
6
7 frequently teachers. The correlation between different informants is low, which may
8 potentially be explained by the differential expression of symptoms according to the
9
10 environment, and by the emphasis placed on different aspects of behavior by each
11
12
informant (Breton et al., 1999). Thus, as in clinical practice, it is desirable to collect data
13 from different sources. However, the challenge is how to integrate the data. A number of
14
15 strategies have been developed, such as the ‘best estimate procedure’, ‘and rule’, and
16 ‘or rule’. Following the best estimate procedure, data from different sources and
17
18 instruments are integrated by clinicians, who define the presence of a diagnosis based
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19
20 on their understanding of the available information (Leckman, Sholomskas, Thompson,
21 Belanger, & Weissman, 1982). According to the ‘and rule’, a symptom is considered
22
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23 positive if both informants endorsed the symptom. According to the ‘or rule’, a symptom
24
is considered positive if one out of two informants endorsed the symptom. Evidence
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26 indicate that the ‘or rule’ approach results in higher rates than the ‘and rule’ approach
27
28 (Verhulst, Van Der Ende, Ferdinand, & Kasius, 1997). Alternative strategies include the
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29 definition of specific rules for each diagnosis and the identification of optimal informants
30
31 based on conditional agreement between informants (Bird, Gould, & Staghezza, 1992;
32
Kraemer et al., 2003)
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34 Functional impairment
35
36 The definition of functional impairment is an important parameter for case definition,
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38
as a significant number of children present with symptomatic criteria but have optimal
39 functioning (Bird et al., 1988). On the other hand, a number of children do not met
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41 symptomatic criteria, but have functional impairment that justifies access to services
42
(Angold, Costello, Farmer, Burns, & Erkanli, 1999). The presence of both symptomatic
43
44 and impairment criteria is the most robust approach for case definition (Costello et al.,
45
46 2005). Different definitions of functional impairment may be adopted, such as measures
47 of impairment specifically related to the disorder or global measures of impairment (such
48
49 as the Child Global Assessment Scale, CGAS). The former has the advantage to be
50
51
related specifically to the identified disorder, and the latter, although not specifying the
52 source of impairment, is a good predictor of adaptative functioning and need of service
53
54 (Bird et al., 1990). Different studies have reported rates of mental disorders according to
55
different impairment definitions and CGAS score thresholds. As expected, these diverse
56
57 approaches result in variable estimates (Shaffer et al., 1996; Verhulst et al., 1997).
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Page 11 of 38 JCPP

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5 Methods
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7 Literature Search
8 We conducted a systematic review of the literature through electronic search in three
9
10 separate databases and a review of the references of all articles examined for inclusion
11
12
as well as relevant review articles and textbooks. We followed the guidelines for
13 conducting and reporting meta-analyses (Liberati et al., 2009; Stroup et al., 2000).
14
15 We searched PubMed, PsycINFO, and EMBASE using the following entry terms:
16 “mental disorders or psychiatric disorders AND epidemiology or prevalence or survey
17
18 AND child or adolescent”. All abstracts were reviewed independently by two authors (LS
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20 and AC) supervised by the first author (GVP) and selected if they satisfied one of the two
21 criteria: 1) Reviews of the literature on the epidemiology of mental disorders in children
22
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23 and adolescents; 2) Original prevalence studies of mental disorders assessing
24
community samples of children and adolescents with standardized diagnostic
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26 procedures that derive diagnosis following DSM versions III, III-R, or IV, or ICD versions
27
28 9 or 10. Abstracts were independently reviewed by two authors (LS and AC) and
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29 selected for full-text review based on consensus. If there was not enough information to
30
31 determine eligibility, articles were selected for further review.
32
Study inclusion criteria
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33
34 Two authors (LS and AC) reviewed the full-text of selected articles and inclusion was
35
36 discussed with the first author (GVP). Inclusion criteria were: 1) original prevalence
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37
38
studies assessing community samples; 2) probabilistic sampling strategy; 3) use of a
39 standardized assessment procedure deriving diagnosis according to DSM-III, DSM-III-R,
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40
41 DSM-IV, ICD-9, or ICD-10), 4) assessment of a minimum of three diagnostic groups of
42
disorders (e.g., anxiety disorders, mood disorders, disruptive behavior disorder), 5)
43
44 inclusion of children or adolescents up to age 18. Twin samples and the first wave of
45
46 longitudinal studies were eligible for inclusion. Studies without available data to estimate
47 standard errors were excluded. Languages included Portuguese, English, Spanish,
48
49 French and German.
50
51
Data extraction
52 Data were independently extracted by two authors (LS or AC and GVP). For the
53
54 meta-analyses of prevalence estimates and the meta-regression analysis, each study
55
contributed with a single estimate. Therefore, for studies that reported multiple estimates
56
57 according to different case definitions, only one prevalence estimate was selected based
58
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 JCPP Page 12 of 38

1
2
3 on a priority criteria defined a priori. The following information was extracted and levels
4
5 were created for each variable for purposes of analysis. Levels for each variable are
6
7 presented in priority order for selection when multiple estimates were derived by the
8 same study.
9
10 Population characteristics
11
12
- Study location
13 - Year of data collection
14
15 Sample characteristics
16 - Age range, coded in three levels: i) 6 to 18; ii) 6 to 11; iii) 12 to 18.
17
18 Study methods
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19
20 - Representativeness and sampling strategy, coded in four levels: i) country, weighted to
21 represent the population; ii) large city or area, weighted to represent the population; iii)
22
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23 small-medium city or area, probably representative sample, complex sampling
24
considered; iv) small-medium city or area, probably non-representative sample, complex
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25
26 sampling not considered.
27
28 - Sample-frame, coded in five levels: i) schools; ii) households; iii) population census; iv)
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29 birth register; v) multiple frames.

30
31 - Study design, coded in two levels: i) one-stage; ii) two-stage.
32
Assessment procedures and case definition
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33
34 - Time-frame for assessment, coded in six levels: i) 1-month; ii) 3-months; iii) 6-months;
35
36 iv) 12-months; v) current; vi) lifetime;
vi

37
38
- Diagnostic criteria, coded in five levels: i) DSM-IV; ii) DSM-III-R; iii) DSM-III; iv) ICD-10;
39 v) ICD-9.
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40
41 - Diagnostic interview, coded in eight levels: i) K-SADS; ii) CAPA; iii) DISC; iv) CIDI; v)
42
DAWBA; vi) DICA; vii) Isle of Wight interview; viii) clinical interview.
43
44 - Number of diagnostic groups assessed (anxiety, mood, attention-deficit/hyperactivity
45
46 disorders and developmental disorders, disruptive behavioral disorders, substance use
47 disorders, impulse control disorders, elimination disorders, tic disorders, eating disorders,
48
49 psychotic disorders).
50
51
- Informant, coded in five levels: i) parent, child, and teacher; ii) parent and teacher; iii)
52 parent and child; iv) parent; v) child;
53
54 - Diagnostic algorithm to aggregate data from different informants, coded in seven
55
levels: i) best estimate procedure; ii) clinical assessment and decision; iii) and rule; iv) or
56
57 rule; v) parent only; vi) child only; vii) different for each disorder.
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Page 13 of 38 JCPP

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2
3 - Requirement of functional impairment for the diagnosis: coded in two levels: i) yes; ii)
4
5 no.
6
7 - Definition of functional impairment, coded in five levels: i) CGAS score below 69-71; ii)
8 CGAS score below 59-61; iii) disorder-specific impairment, as defined by the diagnostic
9
10 interview; iv) disorder-specific impairment, as defined by the diagnostic interview and
11
12
CGAS score below 71; v) clinical judgment.
13 Data Analysis
14
15 Initially, outlier and influential case diagnostics were performed using the externally
16 standardized residuals, DFFITS values, Cook’s distances, covariance ratios, leave-one-
17
18 out estimates of the amount of heterogeneity, leave-one-out heterogeneity test statistics,
Fo
19
20 and hat values and weights (Viechtbauer & Cheung, 2010). Studies identified as outliers
21 were excluded from analysis.
22
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23 The first set of analyses involved random effects meta-analysis of prevalence
24
estimates of any mental disorders. It also included meta-analysis to estimate pooled
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25
26 prevalence rates of individual diagnostic groups that were commonly reported by the
27
28 studies, i.e., Any Anxiety Disorder, Any Depressive Disorder, Major Depressive Disorder,
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29 Attention-Deficit Hyperactivity Disorder, Any Disruptive Disorder, Oppositional Defiant

30
31 Disorder, and Conduct Disorder. The second set of analysis included meta-regression
32
analysis, performed using linear mixed-effects models including study-level covariates
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33
34 identified in the literature as potentially implicated in heterogeneity (Raudenbush, 2009).
35
36 Only studies that contributed to information on all covariates were included. Otherwise,
vi

37
38
results related to different covariates would not be comparable between them. For 12
39 studies, ‘years of data collection’ was not presented. Therefore, we performed data
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40
41 imputation from publication year using a linear regression model (Adjusted R2=0.89;
42
F(1,34)=280.9, p<0.001). For 5 studies, requirement of impairment for the diagnosis was
43
44 not informed, and only 5 other studies reported estimates according to no requirement of
45
46 impairment, which would constrain variability for the analysis. Therefore, the effect of this
47 covariate was not investigated in the context of meta-regression. Time-frame for
48
49 assessment was not reported by 19 studies, and its effect was not evaluated in the
50
51
meta-regression analysis. The following covariates were tested in univariate models
52 using the Maximum Likelihood estimator: geographic location, year of data collection,
53
54 sample age range, sample representativeness, sample frame, study design, diagnostic
55
criteria, diagnostic interview, number of diagnostic groups assessed, informants,
56
57 diagnostic algorithm. The ‘Variance Accounted For (VAF)’, a pseudo-R2 statistic, is
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 JCPP Page 14 of 38

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3 given for each univariate model and indicates the proportion of the total heterogeneity in
4
5 the true effects that is accounted for by each one of the covariates individually.
6
7 Covariates associated with heterogeneity at a p-value < 0.2 were subsequently included
8 in a multivariate model. The third set of analyses included random effects meta-analysis
9
10 to estimate pooled difference in prevalence rates according to requirement of funcional
11
12
impairment for the diagnosis. This strategy provides a strong test of the effect of different
13 case definitions, as other methodological variables were held constant within studies. All
14
15 analyses were conducted with R using the ‘metafor’ package (Viechtbauer, 2010).
16
17
18 Results
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19
20 Systematic review
21 The systematic review identified 23,191 abstracts, and 198 studies were selected for
22
r
23 full-text review. Figure 1 presents the detailed results of the review. Forty-eight original
24
studies met inclusion criteria and are described in detail in Table 1.
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26 Studies meeting inclusion criteria were published from 1985 to 2012, and conducted
27
28 in 27 countries distributed in North America (k=14) (Angold et al., 2002; Benjet, Borges,
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29 Medina-Mora, Zambrano, & Aguilar-Gaxiola, 2009; Breton et al., 1999; Canino et al.,
30
31 2004; Carter et al., 2010; Costello et al., 1996; Kashani et al., 1987; Kessler et al., 2012;
32
Merikangas et al., 2010; Offord et al., 1987; R. E. Roberts, Roberts, & Xing, 2007;
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33
34 Romano, Tremblay, Vitaro, Zoccolillo, & Pagani, 2001; Shaffer et al., 1996; Velez,
35
36 Johnson, & Cohen, 1989), Europe (k=14) (Almqvist et al., 1999; Fombonne, 1994; Ford
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38
et al., 2003; Frigerio et al., 2009; Gómez-Beneyto et al., 1994; Heiervang et al., 2007;
39 Kroes et al., 2001; Lynch, Mills, Daly, & Fitzpatrick, 2006; McArdle, Prosser, & Kolvin,
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40
41 2004; Petersen, Bilenberg, Hoerder, & Gillberg, 2006; Puura et al., 1998; Steinhausen,
42
Metzke, Meier, & Kannenberg, 1998; Verhulst et al., 1997; Verhulst, Berden, & Sanders-
43
44 Woudstra, 1985), Asia (k=8) (Alyahri & Goodman, 2007; Goodman, Slobodskaya, &
45
46 Knyazev, 2005b; R. Hackett, Hackett, Bhakta, & Gowers, 1999; Leung et al., 2008;
47 Malhotra, Kohli, & Arun, 2002; Mullick & Goodman, 2005; Pillai et al., 2008; Srinath et al.,
48
49 2005), Africa (k=2) (Ashenafi, Kebede, Desta, & Alem, 2001; Robertson, Ensink, Parry,
50
51
& Chalton, 1999), South America and the Caribbean (k=5) (Anselmi et al., 2009; Bird et
52 al., 1988; Fleitlich-Bilyk & Goodman, 2004; Goodman, Neves dos Santos, Robatto
53
54 Nunes, Pereira de Miranda, et al., 2005a; Vicente et al., 2012), Middle East (k=2)
55
(Eapen, Jakka, & Abou-Saleh, 2003; Farbstein et al., 2009), and Oceania (k=3)
56
57 (Anderson, Williams, McGee, & Silva, 1987; Fergusson, Horwood, & Lynskey, 1993;
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Page 15 of 38 JCPP

1
2
3 Sawyer et al., 2001). One study was identified as an influential outlier and was excluded
4
5 from the analysis (Supplementary Figure). Six studies did not report information on one
6
7 or more relevant covariates (informants, algorithm for aggregating information from
8 different sources). Forty-one studies reported data for all covariates and were therefore
9
10 included in the meta-analyses and meta-regression analysis.
11
12
Worldwide prevalence of mental disorders
13 Meta-analysis estimated a worldwide prevalence of mental disorders in children and
14
15 adolescents of 13.4% (CI 95% 11.3 – 15.9; k=41; pooled sample size 87,742).
16 Heterogeneity was found to be substantial, I2>99%, Q(df=40)=5036747.2, p-
17
18 value<0.0001. Random effects meta-analysis was also performed for every individual
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19
20 group of mental disorders. Prevalence rates were estimated as follow: Any Anxiety
21 Disorder, 6.5% (CI 95% 4.7 – 9.1); Any Depressive Disorder, 2.6% (CI 95% 1.7 – 3.9);
22
r
23 Major Depressive Disorder, 1.3% (CI 95% 0.7 – 2.3); Attention-Deficit Hyperactivity
24
Disorder, 3.4% (CI 95% 2.6 – 4.5); Any Disruptive Disorder, 5.7% (CI 95% 4.0 – 8.1);
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26 Oppositional Defiant Disorder, 3.6% (CI 95% 2.8 – 4.7); Conduct Disorder, 2.1% (CI 1.6
27
28 – 2.9). Heterogeneity was found to be substantial for each individual outcome (I2>99%).
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29 Results are presented in Figure 2.

30
31 Sources of variability on prevalence estimates
32
The meta-regression analysis was performed to study the sources of heterogeneity
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33
34 of any mental disorder’s pooled prevalence estimate and results are presented in Table
35
36 2. Given the reduced number of studies reporting prevalence estimates for each specific
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37
38
group of disorders in relation to the combination of disorders, the meta-regression was
39 not performed for heterogeneity of specific outcomes. Initially, the proportion of the total
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40
41 heterogeneity in the true effects accounted for by each one of the covariates individually
42
was investigated in univariate models. Also, a single test was performed for each
43
44 specific covariate to estimate the prevalence difference (represented in percentage) and
45
46 its significance between all levels and the contrast level. Covariates associated with
47 heterogeneity at a p-value < 0.2 were subsequently included in a multivariate model.
48
49 The following covariates were associated with estimates of heterogeneity at a p-value <
50
51
0.2 and were therefore included in the multivariate model: geographic location (p-
52 value=0.1638; VAF=22.62%), sample age range (p-value=0.0521; VAF=14.94%),
53
54 sample representativeness (p-value=0.1152; VAF=14.78%), sample frame (p-
55
value=0.0121; VAF=29.53%), diagnostic interview (p-value<0.0001; VAF=68.61%), and
56
57 diagnostic algorithm (p-value=0.0519; VAF=26.66%).
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3 The final multivariate model identified sample representativeness, sample frame, and
4
5 diagnostic interview as significant moderators of prevalence estimates. Study
6
7 geographic location and sample age range were not significant moderators. Studies
8 conducted in single cities assessing probably representative samples generated a
9
10 prevalence estimate of 11,46% (CI 95% -1,22 - 21,71) lower than studies assessing
11
12
national representative samples. Studies that used schools as the sampling frame
13 generated an estimate of 11,2% (CI 95% 2,17 – 20,23) higher than studies that used
14
15 households as sampling frames. In regard to diagnostic interview, using studies that
16 adopted K-SADS as the contrast, studies that adopted CIDI generated estimates
17
18 25,12% (CI 95% 6,59 – 43,64) higher, and studies that adopted Isle of Wight, DICA and
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19
20 clinical interview generated estimates 22,91% (CI 95% -2,08 – 43,74), 13,17% (CI 95% -
21 0,96 – 25,38), and 31,58% (CI 95% -10,98 – 52,18) lower. The multivariate model
22
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23 explained 88,89% of prevalence estimates variability, but residual heterogeneity was still
24
significant at a p-value < 0.001. Results are presented in Table 2.
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26 The effect of functional impairment on prevalence variability
27
28 Random effects meta-analysis estimated pooled difference in prevalence rates
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29 according to diferent requirement and definitions of funcional impairment for the

30
31 diagnosis as presented by the same studies. Eleven studies reported prevalence rates
32
following no requirement of impairment (pooled prevalence: 27.1%, CI95% 20.2-34.0;
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34 I2=99%) and disorder-specific impairment defined by the diagnostic interview (pooled
35
36 prevalence: 14.0%, CI95% 11.1-16.9; I2=97.3%). Four studies reported prevalence rates
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38
following no requirement of impairment (pooled prevalence: 28.1%, CI95% 14.1-42.1;
39 I2=98.8%) and impairment defined as a CGAS score below 59-61 (pooled prevalence:
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40
41 9.7%, CI95% 4.5-14.8; I2=98.1). Seven studies reported prevalence rates following no
42
requirement of impairment (pooled prevalence: 20.2%, CI95% 16.1-24.3; I2=97.2%) and
43
44 impairment defined as a CGAS score below 69-71 (pooled prevalence: 9.6%, CI95%
45
46 6.7-12.4; I2=97.2%). The pooled difference in prevalence rates following the possible
47 comparisons within studies are presented in Table 3.
48
49
50
51
Discussion
52 We conducted a comprehensive systematic review and meta-analysis of prevalence
53
54 studies of mental disorders in children and adolescents that identified 41 studies in 27
55
countries and in every region of the world, yielding a pooled estimate of 13.4% (CI 95%
56
57 11.3 – 15.9). Significant heterogeneity was detected and explained by sample
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Page 17 of 38 JCPP

1
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3 representativeness, sample frame, and diagnostic interview. Although these variables
4
5 explained approximately 89% of the variance, heterogeneity remained significant.
6
7 Additional meta-analysis revealed that estimates with no requirement of impairment
8 were identified to be consistently higher than estimates with different definitions of
9
10 impairment.
11
12
The worldwide-pooled prevalence of 13.4% for any mental disorders estimated by
13 our meta-analysis is very similar to the median prevalence rates of 13% (Verhulst & Koot,
14
15 1991),12% (Verhulst & Koot, 1995), and 12% to 15% (R. E. Roberts et al., 1998)
16 previously reported in the literature. The consistency of the estimate is a striking result
17
18 considering that significant inter-study heterogeneity exists. In 2014, the US Census
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19
20 Bureau estimated a population of approximately 1.8 billions youth from 5 to 19 years
21 around the world. Our estimates indicate that approximately 241 million youths around
22
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23 the world are affected by a mental disorder. The most common group of mental
24
disorders are anxiety disorders, affecting 117 million; disruptive behavior disorder,
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26 affecting 113 million; ADHD, affecting 63 million; and depressive disorders, affecting 47
27
28 million. Considering the prevalence of other childhood chronic health conditions, such as
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29 obesity (16,8%) (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010) and asthma (8,5%)
30
31 (Moorman et al., 2007), the high frequency of mental disorders and their associated
32
negative consequences, render them major health priorities (Halfon, Houtrow, Larson, &
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34 Newacheck, 2012; Whiteford et al., 2013).
35
36 Pooled prevalence estimates, however, are heterogeneous and influenced by study
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37
38
methods, following results of meta-regression analyses for childhood ADHD (Polanczyk,
39 Willcutt, Salum, Kieling, & Rohde, 2014; Polanczyk, de Lima, Horta, Biederman, &
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41 Rohde, 2007) and for common mental disorders in adults (Steel et al., 2014). Our study
42
identified sample representativeness, sample frame, and diagnostic interview as
43
44 significant moderators of prevalence variability. Additionally, as several studies reported
45
46 more than one prevalence rate according to different definitions of impairment, we could
47 test its effect within studies, while other factors remain constant. This is a preferable
48
49 approach to test the influence of study methods on estimates because unmeasured
50
51
factors are also constant within studies. In this sense, requirement of functional
52 impairment for the diagnosis, and definition of impairment were identified as major
53
54 issues on prevalence estimates variability, as already documented in previous studies
55
specifically addressing this issue (Bird et al., 1990; Leung et al., 2008; McArdle et al.,
56
57 2004; Romano et al., 2001).
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 JCPP Page 18 of 38

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3 On the other hand, variability of prevalence estimates is not explained by geographic
4
5 location of studies and year of data collection. This was tested by studies conducted in
6
7 27 countries and in every region of the world from 1985 to 2012, representing important
8 differences with regard to socio-economic characteristics, language, religion, and also
9
10 attributions about mental disorders and the health system. The result is consistent with
11
12
comparisons across multiple countries of self (Verhulst et al., 2003) and parental
13 (Crijnen et al., 1997) ratings of dimensional measures that identified limited cross-
14
15 cultural differences. In regard to assessment of time-trends, there are limited studies
16 with directly comparable methods that repeatedly assessed succeeding generations
17
18 (Maughan, Iervolino, & Collishaw, 2005). Thus, methodological variability between
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19
20 individual studies has been a major limitation to determining the effect of time over
21 estimates. By controlling for the effect of study methods, the meta-regression analysis
22
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23 conducted in our study did not detect a significant effect of time on rates of any mental
24
disorders, for a period of approximately 30 years. It is important to highlight that the data
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26 included precluded the investigation of time-trends on individual rates of autism
27
28 spectrum disorder, suicide, substance use, and eating disorders. Nevertheless, our
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29 results are important pieces of evidence supporting cross-cultural and temporal stability
30
31 of prevalence rates of mental disorders.
32
Our results have important implications for the administrative and the scientific fields.
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33
34 In terms of administrative implications, a worldwide pooled prevalence rate contributes to
35
36 estimating the economic burden of disoders, planning services and the allocation of
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37
38
resources. Also, it is a relevant parameter to evaluate the health care coverage within a
39 given area. It is important to emphasize that the resulting prevalence rate of 13,4% was
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40
41 calculated by preferentially selecting estimates associated with the presence of
42
functional impairment as defined by a CGAS score below 69-71. Therefore, these are
43
44 youths who are most likely to be in need of treatment. In comparison to prevalence rates
45
46 following the impairment criteria defined as CGAS scores below 69-71 and 59-61,
47 prevalence rates following no requirement of impairment are 10,7% and 17,4% higher,
48
49 respectively. Resulting prevalence rates of mental disorders with no impairment are
50
51
10.7% (in comparison to a CGAS score below 69-71) and 17,4% (in comparison to a
52 CGAS score below 59-61) higher. In this sense, services should be prepared to assess
53
54 up to 30% of children and adolescents from the community who present with a diagnosis
55
and may be clinically impaired. Furthermore, it is important to consider that the number
56
57 of youths with subthreshold symptoms and funcional impairment who need to be
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Page 19 of 38 JCPP

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3 observed or even treated is considerable, and has not been included in these estimates
4
5 (Angold et al., 1999). Youth with subthreshold symptoms are understudied and there are
6
7 limited estimates of their numbers in representative samples of the population. A large
8 European study assessing approximately 12,000 adolescents from 11 countries
9
10 estimated the prevalence of anxiety disorder in 5.8% of youths, subthreshold anxiety in
11
12
32%, depression in 10.5%, and subthreshold depression in 29.2%. Rates of comorbidity
13 were approximately 50% and subthreshold symptoms were significant predictors of
14
15 functional impairment and suicidality (Balázs et al., 2013). Therefore, it is possible to
16 anticipate that an additional substantial number of children and adolescents from the
17
18 community present with subthreshold symptoms and may need to be monitored or even
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19
20 treated. These figures indicate the significance of mental disorders for the health of
21 populations, and the urgent need for consistent policies for mental healthcare globally
22
r
23 (Belfer, 2007)
24
In terms of scientific implications, our results contribute to the process of designing
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26 future community surveys. Study methods, assessment procedures and case definition
27
28 are essential elements in a prevalence study affecting significantly its estimates. Studies
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29 that differ in these elements provide results that are not directly comparable and
30
31 therefore broad conclusions about distribution of the disorder and risk factors can not be
32
drawn. It is urgent that researchers in the field aim for consistency between surveys,
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34 otherwise they will impair the informative potential of the future generation of studies.
35
36 Our results also contribute by showing no evidence of cross-cultural and temporal
vi

37
38
variability of the prevalence of mental disorders in children and adolescents. This is
39 relevant for etiological research, which should not expect risk factors with large
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40
41 magnitude of effect varying across cultures and time. Nevertheless, results suggest that
42
consistency of methods is a major requirement to test the effect of culture and time on
43
44 rates of disorders. Multi-country studies assessing proximal cultural aspects with
45
46 identical methodological approaches and repeated studies over time in the sampe
47 population with consistent methodologies are necessary to establish solid conclusions.
48
49 Results should be interpreted in the context of limitations. First, results are limited by
50
51
the studies included, which were constrained by the inclusion criteria imposed, such as
52 probabilistic samples, use of standardized diagnostic criteria, and assessment of at least
53
54 three diagnostic groups. These criteria were established to identify surveys with sound
55
methodology. The fact that these are well-designed studies might have indirect effects
56
57 over the covariates, or may be related to other methodological aspects not measured.
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3 For example, these studies may have included more trained interviewers, may have had
4
5 a lower number of missing variables and less errors in data registration, and more
6
7 consistent strategies of data analysis may have been used. Also, by including studies
8 with a sound methodological design, we have likely restricted the variability of other
9
10 ascertainment variables and case definitions variables. All these aspects may have
11
12
restricted the impact of methodology on the results of meta-regression analysis. A
13 number of available studies have used non-probabilistic strategies in selecting the
14
15 sample frame or the units for the sample, or presented other important caveats in the
16 sampling strategies. These limitations do not guarantee a random sample of the
17
18 population, and consequently their representativeness. We therefore chose to exclude
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19
20 these studies. By including the studies with the best designs, we aimed to estimate a
21 pooled prevalence of mental disorders that might be as representative as possible of the
22
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23 worldwide population of children and adolescents.
24
Second, results are also limited by the the information provided by original studies for
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25
26 the covariates. There were reduced studies in various levels of different covariates, and
27
28 poor reporting for others. For example, for geographic location, a small number of
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29 surveys were conducted in Africa (k=2), the Middle East (k=2), and Oceania (k=3).
30
31 Although national representative studies were conducted in the Middle East (Farbstein et
32
al., 2009) and Oceania (Sawyer et al., 2001), studies identified in Africa assessed
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34 samples that were likely not representative of the population (Ashenafi et al., 2001;
35
36 Robertson et al., 1999). As identified by the 2010 Global Burden of Disease Study,
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37
38
nationally representative studies estimating prevalence of mental disorders and other
39 epidemiological parameters are absent in most parts of the world (Baxter, Patton, Scott,
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40
41 Degenhardt, & Whiteford, 2013). For diagnostic algorithm as a covariate, no study using
42
the ‘and rule’ was included in the analysis. For variables such as response rate and
43
44 time-frame, reports were poor for several studies, which precluded the investigation of its
45
46 effect. This is significant as it has been demonstrated that these methodological
47 characteristics are important sources of variability. Nevertheless, we chose to adopt a
48
49 conservative approach by including in the analysis only studies that were informative for
50
51
all covariates of interest to ensure that results for different covariates are comparable.
52 This resulted in the exclusion of six studies, and would have resulted in the exclusion of
53
54 a number of other studies if we had decided to include additional covariates in the model.
55
Also, it precluded the test of functional impairment for diagnosis in the context of
56
57 multivariate meta-regression analysis.
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Page 21 of 38 JCPP

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3 Third, by including only studies that assessed multiple diagnoses we have restricted
4
5 the number of prevalence estimates included for specific disorders and the resulting
6
7 pooled estimate. For example, the estimate of 3.4% (CI 95% 2.6 – 4.5) for ADHD
8 prevalence based on 33 studies is significantly lower than a previous pooled estimate of
9
10 5.29% (95% CI 5.01–5.56) based on 102 studies that investigated only this disorder
11
12
(Polanczyk et al., 2007).
13 Finally, most of the studies did not report prevalence estimates for less frequent
14
15 disorders, such as eating disorders, obsessive-compulsive disorder, psychotic disorders,
16 and autistim spectrum disorders. Studies were inconsistent in the assessment of
17
18 substance use disorders in adolescents. Although meta-regression analysis did not
Fo
19
20 identify the number of diagnostic groups assessed in the individual studies as significant
21 moderators of variability - which is consistent with a previous meta-regression (Steel et
22
r
23 al., 2014) - the pooled prevalence estimate is likely to be an underestimate.
24
To the best of our knowledge, this is the first meta-analysis to estimate the
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26 worldwide-pooled prevalence of mental disorders in children and adolescents. Results
27
28 indicate that mental disorders are frequent across 27 countries in all continents, and that
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29 variability of estimates is largely explained by study methods, assessment procedures,

30
31 and case definition. These results are essential to service, training, and research
32
planning around the world.
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36
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39
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42
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47
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52
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 JCPP Page 30 of 38

1
2
3
4
5 Table 2 – Univariate and Multivariate Meta-regression Models for the diagnosis of any mental disorder
6 Univariate Meta-Regression Models (k=41) Multiple Meta-regression Model (k=41)
7 Estimated Moderator Analysis F(df1 = 27, df2 = 13), p-value < ,0001, R2=88,99%
8 Estimated Prev. Diff
Prev. se t-value p-value lower upper Estimated
9 (%) p-
(%) F VAF Prev. Diff se t-value p-value lower upper
value
10 (%)

Fo
11 F(df1 = 6, df2 22,6
0,1638
Geographic location = 34) = 1,6497 2%
12North America [index] 19,9110 - - - - - - - - - - - -
13Europe 11,9664 -7,9446 3,2392 -2.4526 0,0195 -14,5275 -1,3618 -2,88 4,18 -0,6895 0,5026 -11,91 6,15

rP
14Asia 11,8599 -8,0511 3,5786 -2,2498 0,0310 -15,3237 -0,7785 5,38 4,63 1,1613 0,2664 -4,63 15,39
15Africa 8,3423 -11,5687 5,7208 -2,0222 0,0511 -23,1947 0,0573 3,72 5,55 0,6695 0,5149 -8,28 15,72
16South America and 14,2938 -5,6172 4,0278 -1,3946 0,1722 -13,8028 2,5684
17Caribbean 7,11 4,63 1,5351 0,1487 -2,89 17,11
18Middle East
Oceania
19Year of data
12,7758
16,2802
-7,1352
-3,6308
6,1406
5,7115
-1,1620
-0,6357
0,2533
0,5292
ee
-19,6144
-15,2380
5,3440
7,9764
F(df1 = 1, df2 0,12
-1,78
6,67
5,0
5,74
-0,3567
1,1622
0,7271
0,266
-12,59
-5,73
9,02
19,07

rR
20collection 0,8609
= 39) = 0,0311 %
211995 [mean] 14,8431 - - - - - -
22 0,0353 0,2002 0,1764 0,8609 -0,3696 0,4402
23 F(df1 = 2, df2 14,9

ev
0,0521
Age range = 38) = 3,1957 4%
24
6 to 11 [index] 12,3580 - - - - - - - - - - - -
2512 to 18 20,8717 8,5137 3,5526 2,3965 0,0216 1,3219 15,7054 -3,79 4,52 -0,8397 0,4162 -13,56 5,97

iew
266 to 18 13,9663 1,6083 2,8056 0,5732 0,5699 -4,0714 7,2880 -5,72 3,42 -1,6753 0,1177 -13,10 1,66
27 F(df1 = 3, df2 14,7
0,1152
28Representativeness = 37) = 2,1126 8%
29Country [index] 16,6255 - - - - - - - - - - - -
2,8552 3,6031 0,7924 0,4332 -4,4454 10,1557
30Large area 19,4807 4,11 4,09 1,0058 0,3329 -4,72 12,95
City, probably 11,9750 -4,6505 3,2642 -1,4247 0,1626 -11,2644 1,9633
31representative -11,46 4,74 -2,4182 0,031 -21,71 -1,22
32City, probably not 12,7782 -3,8473 3,6574 -1,0519 0,2997 -11,2578 3,5632
33representative -1,36 4,5 -0,3034 0,7664 -11,08 8,35
34 F(df1 = 4, df2 29,5
0,0121
Sample frame = 36) = 3,7372 3%
35 - - - - - -
Household [index] 14,3885 - - - - - -
36Schools 13,2739 -1,1146 2,7040 -0,4122 0,6826 -6,5987 4,3694 11,2 4,18 2,6792 0,0189 2,17 20,23
37Census register 14,0586 -0,3299 2,9312 -0,1126 0,9110 -6,2747 5,6149 3,81 3,68 1,0342 0,3199 -4,15 11,77
38Birth register 19,5060 5,1175 5,4171 0,9447 0,3511 -5,8688 16,1039 8,91 4,95 1,8006 0,095 -1,78 19,61
39Household and 40,30 25,9115 7,2383 3,5798 0,0010 11,2315 40,5915
40school -8,01 8,86 -0,9037 0,3826 -27,14 11,13
F(df1 = 1, df2 0,2194
41Study design
42
43
44
45
46
30
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48
Page 31 of 38 JCPP

1
2
3
4
5 = 39) = 1,5579 3,84
%
6 One-stage [index] 16,2199 - - - - - -
7 Two-stage 13,0877 -3,1322 2,5094 -1,2482 0,2194 -8,2080 1,9436
8
F(df1 = 4, df2
9 = 36) = 0,5812
0,6782 6,00
10Diagnostic criteria %
15,6747 - - - - - -
11DSM-IV [index]
DSM-III-R
12DSM-III
13ICD-10
14,8978
18,0192
10,2405
-0,7769
2,3445
-5,4342
2,9851
5,1763
4,0682 Fo
-0,2603
0,4529
-1,3358
0,7961
0,6533
0,1900
-6,8309
-8,1536
-13,6849
5,2771
12,8425
2,8164

rP
14ICD-9 12,40 -3,2747 8,6823 -0,3772 0,7083 -20,8831 14,3338
15Diagnostic F(df1 = 7, df2 68,6
<,0001
16interview = 33) = 9,4518 1%
17K-SADS [index] 15,3211 - - - - - - - - - - - -
18CAPA
19
DISC
CIDI
17,5401
15,1797
39,8405
2,2190
-0,1414
24,5194
4,5372
3,6598
4,9117
0,4891
-0,0386
4,9920
0,6280
0,9694
<,0001 ee
-7,0120
-7,5874
14,5263
11,4501
7,3046
34,5124
-9,56
-8,97
25,12
6,27
5,58
8,57
-1,5233
-1,6079
2,9295
0,1516
0,1319
0,0117
-23,12
-21,02
6,59
4,0
3,08
43,64

rR
20DAWBA 11,2495 -4,0716 3,8129 -1,0678 0,2933 -11,8290 3,6859 -8,43 4,84 -1,7434 0,1049 -18,89 2,02
21Isle of Wight 10,6645 -4,6566 5,0700 -0,9185 0,3650 -14,9716 5,6583 -22,91 9,64 -2,3763 0,0335 -43,74 -2,08
22DICA 7,5534 -7,7677 4,6067 -1,6862 0,1012 -17,1400 1,6046 -13,17 5,65 -2,3309 0,0365 -25,38 -0,96
23Clinical Interview -9,0211 6,3318 -1,4247 0,1636 -21,9033 3,8611

ev
6,30 -31,58 9,53 -3,3123 0,0056 -52,18 -10,98
24 F(df1 = 1, df2 1,50
0,4190
25N diagnostic groups = 39) = 0,6671 %
5 [mean] 14,5793 - - - - - -

iew
26 0,7024 0,8599 0,8168 0,4190 -1,0370 2,4417
27 F(df1 = 4, df2 13,7
28Informant 0,2685
= 36) = 1,3558 4%
29Parent [index] 12,2141 - - - - - -
30Child 20,7549 8,5408 5,0957 1,6761 0,1024 -1,7939 18,8754
31Parent and child 16,7838 4,5697 3,0808 1,4833 0,1467 -1,6784 10,8179
12,3463 0,1322 4,2886 0,0308 0,9756 -8,5654 8,8298
32Parent and teacher
Parent, child, and 11,1036 -1,1105 4,6613 -0,2382 0,8130 -10,5641 8,3430
33teacher
34Diagnostic F(df1 = 5, df2 26,6
0,0519
35algorithm = 35) = 2,4606 6%
36Best estimate [index] 12,3165 - - - - - - - - - - - -
9,40 -2,9165 7,3936 -0,3945 0,6956 -17,9264 12,0934
37Clinical decision 15,87 9,5 1,6708 0,1186 -4,65 36,4
20,7179 8,4014 2,9207 2,8765 0,0068 2,4720 14,3308
38Or rule 4,46 4,16 1,0703 0,3039 -4,54 13,45
Different for each -1,0165 7,4167 -0,1371 0,8918 -16,0732 14,0402
39disorder 11,30
-0,34 8,97 -0,038 0,9703 -19,71 19,03
40Parent only 12,4980 0,1815 3,0262 0,0600 0,9525 -5,9621 6,3250 0,37 3,83 0,0963 0,9248 -7,90 8,63
41
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 JCPP Page 32 of 38

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3
4
5 Child only 22,2778 9,9613 5,3676 1,8558 0,0719 -0,9354 20,8581 -8,57 6,85 -1,2507 0,2331 -23,36 6,23
Abbreviations: Prevalence; Diff, Difference; VAF, Variance Accounted For. Note: For these analysis we used the crude prevalence rates (instead of prevalence transformed logits);
6
7
8
9
10

Fo
11
12
13

rP
14
15
16
17
18
19 ee
rR
20
21
22
23
24
25
ev
iew
26
27
28
29
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Page 33 of 38 JCPP

1
2
3
4 Table 3. Pooled difference on prevalence rates according to diferent requirements and definitions of funcional
5
impairment for the diagnosis presented within studies.
6
7 Estimated 95% Confidence
8 Requirement and definition of k prevalence Interval Heterogeneity
9 funcional impairment contrast difference (%) Lower Upper Q Test p-value I2
10
11
No impairment vs CGAS < 69-71 7 10,7 6,8 14,5 Q(6) = 57,2 <0,001 91,15
12
13 No impairment vs CGAS < 59-61 4 17,4 1,2 33,6 Q(3) = 60,7 <0,001 95,50
14 No impairment vs Disorder-specific
11 12,8 5,2 20,4 Q(10) = 572,6 <0,001 98,42
15 impairment
16
17
18
Fo
19
20
21
22
r
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24
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 JCPP Page 34 of 38

1 Table 1. Description of studies identified by the systematic review

2
3 sample size -
screening
response rate
screening screening
screening
method for sample size response rate requirement of definition of
number of
diagnostic
Years data time- sample size informant (if sample size diagnostic diagnostic diagnostic diagnostic grous
4 Author, year Country
collection
Representativeness frame
frame
Age range % boys sample (if 2-
step
sample (if 2-
step
evaluated
instrument if 2-
step procedure)
2-step
procedure)
screening
selection
- diagnostic
sample
diagnostic
sample
evaluated instrument informants algorithm criteria
functional
impairment
functional
impairment
considered
for any
procedure) procedure)
5 disorder

6 Almqvist, 1999 Finland

1989 National population 3-month 8-9 50,6 6017 96,6 5813 RA2. CDI. RB2 P. C. T 435 435
Isle of Wight
Interview
P DSM-III-R yes clinical

7 Alyahri, 2008 Yemen

City of Mukalla or the rural area of
8 2002-3
Tuban.
school 7-14 90 465 DAWBA P.T clinical DSM-IV yes interview items 4

9 Anderson, 1987 New Zealand

1983-84
All children born in Dunedin, NZ
in 1971-2
birth registers 12-month 11 52,52 925 85,6 792 DISC-C.
C, supplem ented
by teacher and
best-
estimate
DSM-III no 4
parent
10 Angold, 2002 United States
following

Fo
Catchment area in North
11 Carolina. USA
schools 3-month 9 - 17 52,7 3941 91,7 3613 CBCL P screen
distribution
1302 70,7 920 CAPA C. P or rule DSM-IV yes interview items 6

12 Anselmi, 2010 Brazil

2004-2006 City of Pelotas population 11 - 12 49,8 5249 87,5 4452 SDQ P. C or rule 280 94,64 265 DAWBA P.C
clinical
rating
DSM-
IV/ICD-10
yes specific 5

13 Ashenafi, 2001 Ethiopia

rP
14 1998 District of Butajira household 5 to 15 50,6 99,8 1477 DICA P DSM-III-R 6

Benjet, 2009 Mexico

15 2005
Representative sample of Mexico
city
household 12-month 12 - 17 49,9 70,1 3005 WMH-CIDI-A C DSM-IV yes specific 6

16 Bird, 1988 Puerto Rico National. Multistage probability

sample of 2036 households
17 best-

ee
1985-1986 distributed across Puerto Rico in household 6-month 4-16 50.4 843 92,7 777 CBCL P. T or rule 440 87,7 386 DISC P, C DSM-III yes/no CGAS < 61 6
estimate
210 clusters, weighted to complex
sampling procedures
18 Breton,1999 Canada
Representative sample of C. P. specific
1992 household 6-month 6 - 14 51,6 2400 83,5 DISC-2.25 C. P DSM-III-R yes/no 4
19 Quebec Combined questions

rR
Canino, 2004 Puerto Rico specific
20 1999-2000
National, weighted to represent
household 12-month 4 - 17 53,1 90,1 1897 DISC-IV C. P or rule DSM-IV yes/no
impairment,
CGAS < 69,
5
the general populatio specific
21 impairment +
CGAS < 69

22 Carter, 2010 United States

2000-2004
Children born in New Haven–
Meriden Standard Metropolitan
birth registers 12-month 5 to 6 53,4 1468 73,4 1078
ITSEA. CBCL.
P. T or rule 567 78 541 DISC-IV P DSM-IV yes/no
DISC
Impairment 5
Statistical Area from July 1995 to TRF. CDI
23 algorithm

ev
September 1997
Costello, 1996 United States
All children from the southern
24 Appalachian mountain region of
North Carolina
household 3-month 9. 11 and 13 4067 95,7 3896 CBCL P 1346 75,4 1015 CAPA P, C or rule DSM-III-R yes specific 10

25 Eapen, 2003 United Arab

Emirates
District of Al Ai, random sample household 6 - 18 50,15 385 86 329 K-SADS C. P
best-
DSM-IV yes/no CGAS < 60 5

iew
estimate
26 Farbstein, 2010 Israel
population best-
27 2004-2005 National
register
14 - 17 51,2 68,2 957 DAWBA C. P
estimate
DSM-IV 4

28 Fergusson, 1993 New Zealand

1992
Children born in the Christchurch
birth register current 15 1265 78 986 C. P DSM-III-R no 5
urban region during mid- 1977
29 Fleitlich-Bilyk, Brazil
2004 City of Taubate, weighted to best-
30 2000-2001
represent city
schools 7 - 14 53 1504 83 1251 DAWBA C. P. T
estimate
DSM-IV yes 4

31 Fombonne, 1994 France

1987
City of Chartres and the semi
school 3-month 8 - 11 2441 88,4 2158 CBCL. RB2 P. T or rule 347 62,5 217
Isle of Wight
P ICD-9 yes
clinical, clinical
4
rural county of Auneau Interview + CGAS < 61
32 Ford, 2003 United
Kingdom population clinical
33 1999 National
register
current 5 - 15 49,9 12529 83 10438 DAWBA C. P. T
rating
DSM-IV yes clincal 7

34 Frigerio, 2009 Italy

Random sample of schools in 7
urban areas, random sample of schools 10 - 14 46 5627 60,74 3418 CBCL P
following
screen 972 64,9 631 DAWBA P. C
clinical
DSM-IV yes clinical 5
rating
students distribution
35 Gomez-Beneyto, Spain best-
1994 following estimate
36 City of Valencia population 8. 11. 15 51,56 1200 93,91 1127 CBCL P screen
distribution
325 98,46 320 K-SADS-E P. C. clinical procedure
(excluded if
DSM-III-R yes/no
no, CGAS <
60, GAF < 70
6

37 Goodman, 2001 Brazil

low IQ)

computer clinical
38 2001 Ilha de Maré population 7 to 14 50 519 100 SDQ P. T. C
algorithm
100 100 100 DAWBA C. P. T
rating
DSM-IV yes specific 4

Goodman, 2005 Russia

39 City of Novosibirsk school 7 - 14 48,3 541 83 448 SDQ P. T. C
computer
algorithm
193 89,1 172 DAWBA C. P. T
clinical
rating
ICD-10 yes specific 4

40 Hackett, 1999 India

Random sample of 2 local
Isle of Wight
1992 districts outside of Calicut, Kerala household 8 - 12 59 100 1403 RA2. RB2 P. T or 426 100 426 P clinical ICD-10 no 5
41 State
Interview

Heiervang, 2007 Norway

42 2002-2003
All children in the city of Bergen,
Norway, attending primary school schools 7-9 59,7 9430 66,7 6297
SDQ + specific to
disorders
P. T or rule 2180 46,32 1011 DAWBA
P, T
(questionnaire)
ratings by
clinicians
DSM-
IV/ICD-10
yes specific 9
grades 2 to 4 in the fall of 2002
43 Kashani USA
7% students in public schools in Best-
school 14 to 16 50 150 72,4 115 DICA P, C DSM-III yes clinical 8
44 Columbia estimate

45
46
47
48
Page 35 of 38 JCPP

1 sample size -
screening
response rate
screening screening
screening
method for sample size response rate requirement of definition of
number of
diagnostic
Years data time- sample size informant (if sample size diagnostic diagnostic diagnostic diagnostic grous
2 Author, year Country
collection
Representativeness frame
frame
Age range % boys sample (if 2-
step
procedure)
sample (if 2-
step
procedure)
evaluated
instrument if 2-
step procedure)
2-step
procedure)
screening
selection
- diagnostic
sample
diagnostic
sample
evaluated instrument informants algorithm criteria
functional
impairment
functional
impairment
considered
for any
disorder
3 Kessler, 2012 United States
household 1-month, Specific
2001-2004 National 13-18 51,3 10123 82.9 10123 CIDI C. P or rule DSM-IV yes 6
4 and school 12-month impairment

Kroes, 2011 Netherlands All children in the second grade of

5 normal kindergardens in the
south of the provicen of Limburg,
school 6 to 8 57,8 2290 57,5 1317 CBCL P
following
screen
distribution
89 403 DICA P P DSM-III-R yes/no
clinical defined
as in need of
help
5
weighted for the whole sample
6 Author, year Country
sample size - response rate
number of
screening diagnostic
7 Years data
collection
Representativeness frame
time-
frame
Age range % boys
screening
sample (IF 2-
step
screening
sample (if 2-
step
sample size
evaluated
screening
instrument if 2-
step procedure)
informant (if
2-step
method for
screening
selection
sample size
- diagnostic
sample
response rate
diagnostic
sample
sample size
evaluated
diagnostic
instrument
diagnostic
informants
diagnostic
algorithm
diagnostic
criteria
requirem ent of
functional
impairment
definition of
functional
impairment
grous
considered
procedure) for any
8 Leung, 2008 China Grades 7, 8
procedure) procedure)
disorder

9 Random sample of schools from

Hong Kong
schools 12-month
and 9 (mean
age: 13.8 48.2 541 DISC-IV P, C or rule DSM-IV yes/no specific 5
years;
10 Lynch, 2006 Ireland
SD=1.2).

Fo
CDI. SDQ. C. one or
11 Catchment area in Dublin schools
current
and past
12-15 47 1412 51,2 723 suicidal ideation
question
C other
instrument
314 62,1 195 K-SADS-PL
best-estimated
procedure (C. P)
best-
estimate
DSM-IV 6

12 Malhotra, 2002 India

1991-1994 City of Chandigarh 4 to 11 48,4 963
Rutter B scale,
CPMS (indian
P, T or rule (P, T) 228 97.3
semistructured
P, C
best-
estimated ICD-10
adaptation of standard history
13 McArdle, 2004 England
CBCL)
Rutter B
procedure

rP
14 1993 - 1994 City of Newcastle-upon-Tyne schools current 7-8 1051 99.3 1044
(teacher).
sociometric
indices.YGRT.
C. child-
peers. T
or rule (C. C
peers. T)
277
sample
replacement
277 CAPA P P DSM-III-R yes/no
CGAS < 61,
CGAS < 71,
4

15 Merikangas, US
TRF
C (anxiety).
2010 P (ADHD. Specific
16 2001-2004 National population 12-month 8-15 49 - - - - - -
79.2% to
92.3%
3024 DISC-IV C. P CD). C or P
(eating.
DSM-IV yes/no impairment for
each disorders
5

17

ee
mood)
Merikangas, US C. C or P
2010a household (mood. Specific
18 2001-2004 National
and school
lifetime 13-18 51.3 - - - - - - 82.9 10123 CIDI 3.0 C. P
ODD. CD.
ADHD)
DSM-IV yes/no
impairment
4

19 Mullick, 2005 Bangladesh Community samples of 5- to 10-

year-olds in each of the three
areas (rural area, a moderately

rR
20 2004 prosperous urban area, and an
urban slum) were obtained by
population 5 to 10 75 922 SDQ P, T 208 DAWBA P, T ICD-10 yes specific 4

random sampling from the

21 Offord, 1987 Canada
electoral registers
Representative sample of
22 1983 province Ontario, weighted to
represent the population
household 6-month 4 to 16 49,7 91,1 2674 clinical P, T, C
best-
estimate
DSM-III yes clinical

23 Petersen, 2006 Denmark

ev
1999 - 2001 County of Funen schools current 8-9 751 49.7 373 CBCL P P 208 90 188 K-SADS-PL C. P DSM-IV yes C-GAS =<70 6

24 Pillai, 2008 India

best-
25 2002-2003 Urban and rural catchment areas population 12-16 50.3 2684 76,3 2048 DAWBA C. P
estimate
DSM-IV yes 4

iew
26 Puura, 1998 Finland
1989 National population 12-month 8-9 58.6 3558 90.1 3206
Rutter A2
(parents). Rutter P. C. T
or rule (C. P.
278 98,2 273
DISC, Isle of
C. P
best
DSM-III-R yes
clinical
4
T) Wight interview estimate assessment
27 Roberts, 2007 US
Random sample weighted to
B2 (teacher). CDI

CGAS <70,
28 2000 represent metropolitan area of
Houston
household 12-month 11 - 17 51.14 66 4175 DISC-IV C DSM-IV yes/no DISC
impairment
6

29 Robertson, 1999 South Africa

Settlem ent area in Cape Town household 6-month 6-16 45.5 500 98 500 DISC 2.3 C. P DSM-III-R yes/no 6

30 Romano, 2001 Canada

City of Quebec, weighthed to C. P. or Specific
31 1995-1997
represent the population
community 6-month 14-17 2000 60,1 1201 DISC 2.25 C. P
rule
DSM-III-R yes/no
impairment
4

32 Sawyer, 2001 Australia

National household 12-month 6 to 17 49,8 86 3597 DISC-IV P DSM-IV no 3

33 Shaffer, 1996 US
Representative sample of 4 areas
C. P. or
34 1992 in the country chosen by
convenien
community 6-month 9-17 53 1523 84,4 1285 DISC 2.3 C. P
rule
DSM-III-R yes/no CGAS=<70 6

35 Srinath, 2005 India

1995-2000
Sample from Bangalore, selected
by stratified random sampling
from urban middle-class, urban
household 4 to 16 49,3 CBCL 1578 DISC P, T
best
estimate
ICD-10 yes/no CGAS < 71 6

36 Steinhausen, Switzerland
slum and rural areas

1998
37 1994 Canton of Zurich school 6-month 7-16 51,6 2780 70,6 1964 CBCL. YSR P. C or rule (C. P) 705 56 399 DISC-P 2.3 P DSM-III-R 6

38 Velez, 1989 USA

1983
Random sample of children from
2 counties in NY State
household
9 to 12, 13 to
18
50 79,5 320 DISC P, T or rule DSM-III-R no 4

39 Verhulst, 1985 Netherlands

National representative sample of
municipal best-
40 1982-1984 Dutch children from the general
population, not weighted
registers
8, 11 CBCL, TRF P, T 153 76 116 clinical interview P, C
estimate
DSM-III yes clinical 10

41 Verhulst, 1997 Netherlands

1993 National community 6-month 13 - 18 50 2916 82,2 2227
CBCL. TRF.
YSRF
P. C. T combined 312 88 DISC 2.3 C. P
C. P. or
rule. and DSM-III-R yes/no CGAS =< 71 8
rule
42 Vicente, 2012 Chile
C. P. or
2007-2009 National household 12-month 4-11 50.9 82.4 1558 DISC-IV C. P DSM-IV yes 7
43 rule

P, Parent; C, Child; T, Teacher.

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 JCPP Page 36 of 38

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Page 37 of 38 JCPP

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5 Figure 2. Worldwide pooled prevalence estimates of any mental disorders and specific groups of disorders in children and
6 adolescents.
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8 Outcome N studies Sample size
9
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Fo
11 Any Anxiety Disorder 41 63130
12
13 Any Depressive Disorder 23 59492

rP
14
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MDD 22 68382
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ADHD 33

ee
77297

rR
20 Any Disruptive Behavior Disorder 19 38324
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22 ODD 28 69799
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CD 28 73679
ev
iew
26 Any Mental Disorder 41 87742
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33 Note: MDD, Major Depressive Disorder; ADHD, Attention Deficit/Hyperactivity Disorder; ODD, Oppositional Defiant Disorder; CD, Conduct Disorder.
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 JCPP Page 38 of 38

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5 Supplemental Figure – Plot of the externally standardized residuals, DFFITS values, Cook’s distances, covariance ratios, estimates
6 of τ2 and test statistics for (residual) heterogeneity when each study is removed in turn, hat values, and weights.
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