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Received: 5 October 2023
-
Accepted: 15 March 2024
DOI: 10.1002/jcv2.12239
ORIGINAL ARTICLE
The diminishing association between adolescent mental
disorders and educational performance from 2006–2019
Magnus Nordmo
1,2
|Thomas H. Kleppestø
3
|Bjørn‐Atle Reme
2
|
Hans Fredrik Sunde
2
|Tilmann von Soest
4
|Fartein Ask Torvik
2,4
1
Department of Educational Science,
University of South‐Eastern Norway,
Notodden, Norway
2
Centre for Fertility and Health, Norwegian
Institute of Public Health, Oslo, Norway
3
Department of Psychology, Norwegian
University of Science and Technology,
Trondheim, Norway
4
Department of Psychology, PROMENTA
Research Center, University of Oslo, Oslo,
Norway
Correspondence
Magnus Nordmo.
Email: magnus.nordmo@fhi.no
Funding information
Research Council of Norway, Grant/Award
Numbers: 262700, 300816
Abstract
Background: A rising prevalence of adolescent mental disorders in the Western
world has been widely reported, raising concerns for adolescent development and
well‐being. Mental disorders are known to negatively impact educational perfor-
mance. Yet it remains uncertain whether the relationship between mental disorders
and educational outcomes has also changed over time and if the change is more
pronounced among high compared to low performing students. The aims of this
paper are to (1) describe the change over time in the prevalence of common mental
disorders in adolescence; (2) determine whether the change in prevalence of
common mental disorders differs between high and low performing students; and
(3) assess whether the associations between mental health disorders and educa-
tional performance have changed over time.
Methods: To address these issues, this study examines potential shifts in the as-
sociations between diagnoses of ADHD and internalizing disorders and educational
performance among 843,692 Norwegian students graduating from lower secondary
education between 2006 and 2019. We utilize population‐wide register data on
ADHD and internalizing disorders from primary and specialist care combined with
educational outcomes.
Results: Our analysis revealed a marked rise in ADHD prevalence, from 1.0% in
2006 to 2.6% in 2019. Concurrently, diagnoses of internalizing disorders also
increased from 1.9% to 4.2%. This increasing trend in diagnoses spanned across all
high school grade point average (GPA) categories, thereby not supporting the
notion that the rise is predominantly observed among high‐performing adolescents.
Importantly, the strength of the associations of internalizing disorders and ADHD
with GPA diminished significantly over time. For instance, the difference between
the average GPA standardized score for boys with and without an ADHD diagnosis
shrunk from 1.0 in 2006 to 0.73 in 2019.
Conclusions: We discuss various potential explanations for this observation and
suggest that changes in diagnostic thresholds is a contributing factor.
KEYWORDS
ADHD, adolescent mental health, educational performance, internalizing disorders
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, pro-
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© 2024 The Authors. JCPP Advances published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.
JCPP Advances. 2024;4:e12239. wileyonlinelibrary.com/journal/jcv2
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https://doi.org/10.1002/jcv2.12239
INTRODUCTION
Adolescence is an important transitional period with identity forma-
tion, psychological change, and rapid physical growth. Most mental
disorders have their first onset in these years (Solmi et al., 2022) and
can have a host of adverse influences on adolescent development and
school performance. For example, common mental disorders such as
anxiety, depression, and ADHD have detrimental effects on attention,
learning, and cognition (James et al., 2021; Loeffler et al., 2019;
McTeague et al., 2016) and are associated with poor school perfor-
mance, school absenteeism, and school dropout (Finning et al., 2019).
As a result, mental disorders are negatively associated with educa-
tional performance, resulting in a large educational burden of disease
(Nordmo et al., 2022). Because educational performance is linked to a
wide range of important life outcomes, the potential negative effects
of adolescent mental health problems could be far reaching (Davies
et al., 2018; Gubbels et al., 2019).
There are many reports of increasing mental disorders and self‐
reported mental problems during the last 2 decades from adolescents
in the Western world (Collishaw, 2015; Cybulski et al., 2021; Keyes
et al., 2019; Mojtabai et al., 2016; Patalay & Gage, 2019), including
Norway (Potrebny et al., 2024). Reports show a particularly strong
increase in internalizing disorders such as anxiety and depression
among girls, whereas boys show a stronger increase in externalizing
disorders such as ADHD (Collishaw, 2015; Cybulski et al., 2021).
Some have suggested that the driver behind the increasing preva-
lences of anxiety and depression are high‐performing students, as
recent birth cohorts of high‐performing students are reported to be
more perfectionistic and under more pressure to excel in school
(Flett et al., 2022; Luthar, Kumar, & Zillmer, 2020). According to
Luthar, Kumar, and Zillmer (2020), mental health problems in
adolescence can be attributed to the pressure of being extraordi-
narily talented in school. In a Norwegian context, Petersen and
Madsen (2023) discuss how ambitious children from an upper‐middle
class struggle to reach ambitious goals and suffer as a consequence,
while Eriksen (2021) describes how pressure to be the best at school
is a source of stress and anxiety. Further, some have argued that this
particularly affects girls due to their average higher academic ambi-
tions (Haugan et al., 2021; Högberg & Horn, 2022). Similarly, ADHD
is most prevalent in boys and has been shown to be a strong pre-
dictor of poor school performance (Sunde et al., 2022) and sensitive
to academic pressure (Owens, 2021). To summarize, research has
consistently shown increasing rates of self‐reported mental health
problems among teenagers in Western countries. Many have sug-
gested that this rise is due to young people, particularly girls, with
above average school performance who are pushing themselves
harder to achieve more. However, there is a lack of studies that
investigate trends in adolescent mental health while also considering
school performance.
One perspective on the reports of rising prevalence rates is that
they reflect a genuine increase in mental disorders. This viewpoint
suggests that recent birth cohorts, born after 1990, are more
exposed to risk factors negatively affecting mental health, such as the
widespread adoption of social media in a vulnerable age (Potrebny
et al., 2024; Twenge, 2020), contributing to an increase of internal-
izing disorders. There are also speculations that rising rates of ADHD
is caused by an increasing exposure to environmental chemicals
(Moore et al., 2022). An alternative view on rising rates of mental
problems sees the phenomenon as an artifact of changing concep-
tualizations and perceptions of disease (Brinkmann, 2016; Jackson &
Haslam, 2022; Paris, 2020). This shift could manifest in a declining
threshold for what is considered pathological. To what extent
increasing rates of internalizing disorders and ADHD reflect a
genuine increase or a change in threshold is difficult to explore
empirically. However, it is valuable to ascertain whether the negative
impact of a mental disorder has also changed in parallel with
increasing prevalences. We propose educational performance as a
particularly important outcome to assess, given the influence of
common mental disorders on cognition, sleep, and energy, all of
which affect learning and educational performance. Should the as-
sociation between educational performance and mental disorder
weaken over time, this would have significant ramifications for how
researchers and policy workers respond to the increasing prevalence
of mental disorders. A change in this association could be caused by
multiple processes such as increased implementation of effective
treatment or positive educational reforms. Another possibility is that
there has been a shift in diagnostic thresholds. Unfortunately, studies
examining the stability of associations between mental disorders and
correlated outcomes across time are sparse. To our knowledge, there
are only two studies with cohorts born later than 1990, originating in
the Avon Longitudinal Study of Parents and Children (ALSPAC) and
the Millennium Cohort Study (MCS). Gage and Patalay (2021) found
an increase in the association between self‐reported mental health at
age 14 and health‐related behaviors – such as smoking, BMI, sub-
stance abuse – when comparing UK cohorts born in 1991/92 and
Key points
What’s Known:
�The prevalence of adolescent mental disorders, including
ADHD and internalizing disorders, has been increasing in
the Western world.
�Mental disorders negatively impact educational perfor-
mance, affecting attention, learning, and cognition.
What’s New:
�This study demonstrates a significant rise in ADHD and
internalizing disorders among Norwegian adolescents.
�The increases in diagnoses are observed across all grade
point average performance brackets, with the highest
absolute increase among students with the lowest aca-
demic performance.
�The strength of the association between these mental
disorders and educational performance has diminished
over time.
What’s Relevant:
�Our results highlight the need for careful diagnostic
practices to ensure accurate identification and treatment
of mental disorders, avoiding overdiagnosis.
�We encourage further research on the changing dy-
namics between mental health and life outcomes.
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2000/02. Sellers et al. (2019) compared the same cohorts with
respect to parent‐rated adolescent mental health and educational
attainment at age 16 and found an increased association in the recent
cohorts. Both studies reported increased mental health problems for
the recent birth cohorts.
In sum, while many investigations show an increase in adolescent
mental disorder and complaints, it is unknown to what extent this
trend reflects a genuine increase in pathology or a lowered threshold
for what constitutes a diagnosis or complaint. A strategy for inves-
tigating this issue is to examine change or stability in how outcomes
are associated to mental disorder diagnoses across time. Currently,
no temporally informed study relates common mental disorders as
measured by primary care diagnoses to educational outcomes.
Building on this, we first investigate whether diagnoses of internal-
izing disorders and ADHD have become more common, as current
trends suggest. Second, we will assess whether the associations be-
tween diagnoses and school performance have changed over time.
This is a crucial step in understanding how mental health diagnoses
may affect academic performance and the potential shifting dynamics
of this relationship. Third, we will examine time trends in the prev-
alence of diagnoses in relation to school performance. Specifically, we
aim to discern whether high‐performing students in particular have
become more prone to develop internalizing disorders, as some
suspect. This final point of inquiry will allow us to analyze the
intersection of mental health and academic achievement, offering
insight into whether the most successful students are paying a high
price for their accomplishments.
METHODS
Sample
We used administrative register data comprising all individuals born
in Norway between 1990 and 2003 and who graduated from primary
education the year they turned sixteen (2006–2019; N=843,692).
Among adolescents who did not emigrate and who were not diseased
before the age of sixteen, we find that nearly all (96%) graduated
from primary education the year they turn sixteen. We grouped all
individuals in their respective birth cohorts, that is, the year they
were born. To ascertain diagnoses of mental disorders we used the
national register for reimbursement of primary care physicians
(Norwegian Control and Payment of Health Reimbursements Data-
base, KUHR). We selected this timespan to include all years of
available diagnostic data. We also utilized data from specialist‐care
services from the Norwegian Patient Register (NPR). This included
data from both regional outpatient clinics and subsidized contract
specialists. We had access to specialists‐care data in the period
2008–2019. The total number of included patients in these analyses
was N=752,565. Note that the time frame of our investigation does
not overlap with the COVID‐19 pandemic, as the first case was
registered in Norway in February 2020. Data on school performance
was retrieved from the National Educational Database (NUDB). This
work is part of the REMENTA project and was supported by the
Research Council of Norway (#300668). This work was partly sup-
ported by the Research Council of Norway through its Centres of
Excellence funding scheme, project number #262700. Tilmann von
Soest's work with this article was supported by a grant from the
Research Council of Norway (grant # 300816).
School performance
Norwegian students are evaluated at the end of 10 years of
compulsory education in a range of school subjects. All numeric
grades have marks from 1 to 6, where six is best. The GPA is
calculated as the average of all final‐year teacher evaluated grades
and externally graded exams and is later used for ranking students
applying for admission to upper secondary education. It is not
possible to fail the compulsory education in Norway and there is no
grade retention. All received grades are included in the GPA score,
including those that would be considered a failing grade at a higher
level of education. Consequently, nearly all students have a valid
GPA. We standardized the Grade Point Average (GPA) score
(mean =0, SD =1) for each graduation yearly cohort. This was done
to avoid grade inflation confounding the comparisons across cohorts.
Data from Statistics Norway (2023) shows that Norwegian GPA have
gradually increased from 3.95 in 2009 to 4.24 in 2023. To explore the
change in prevalence of mental disorders with respect to GPA, we
divided the GPA into quintiles.
Diagnoses of mental disorders
Primary care diagnostic information is coded according to the In-
ternational Classification of Primary Care, 2nd edition, (ICPC‐2:
WONCA, 2005), by general practitioners treating the patients. Nor-
wegian primary care services are free of charge for children and
adolescents under sixteen. Due to economic incentives, it is unlikely
that visits to general practitioners and subsequent diagnosis are not
reported. Our goal was to include relatively common adolescent
mental disorders that are known to have a negative association with
educational performance which left us with internalizing disorders
and ADHD. We combined three diagnoses to encompass internalizing
disorders: P74 Anxiety Disorder, P76 Depression, and P79 Phobic
Disorder. We used P81 Hyperkinetic Disorder to define ADHD.
Specialist care diagnostic information was coded using the same
scheme but with diagnoses from the International statistical Classi-
fication of Diseases and related health problems 10 (ICD 10: World
Health Organization, 2004). We defined internalizing diagnoses as
F321, F331, F320, F330, F341, F401, F412, F410, F411, F419, and
F431 and ADHD as F90.0 and F90.1. We use the colloquial term
common mental disorders to describe internalizing disorders and
ADHD. We dummy‐coded diagnosis as present (1) if there was a
registered diagnosis the year of graduation, or not present (0) if no
diagnosis was registered the year of graduation. There are substan-
tial overlaps between diagnoses from primary and specialist care as
diagnoses are carried over from specialist care into primary care. In
the case of ADHD, primary care general practitioners refer to
specialist care for a diagnostic assessment. If the patient qualifies for
the diagnosis, then he or she is referred back to the general practi-
tioner for treatment and follow‐up. This procedure entails that most
specialist care diagnoses carry over to primary care but not vice
versa.
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Statistical analyses
To capture the relationship between mental disorders and educa-
tional performance over time, we regressed GPA scores on each
mental disorder, the yearly cohort, gender, and interaction terms
between mental disorder and cohort. Specifically, we estimated the
following multivariate regression model:
GPAi¼β0þβ1ðDiÞ þ β2ðCiÞ þ β3ðGiÞ þ β4ðDi�CiÞ þ εi
D:Dummy coded Disorder Status ðInternalizing &ADHDÞ;C
:Cohort;G:Gender ð0 Male;1 FemaleÞ
We coded cohort (birth year) as zero for the adolescents born in
1990, 1 for 1991, 2 for 1992 et cetera. Similarly, we started the
specialist care analyses by coding cohort 1992 as zero. Both disorder
status and gender were dummy coded into dichotomous variables.
The outcome from this model represents GPA conditioned on dis-
order, cohort, gender and the interaction for disorder �cohort, as
shown in Figure 3. A significant interaction term between cohort and
disorder indicates a significant change in the association between
mental disorders and school performance across time. To assess the
potential for a non‐linear change over time, we estimated and plotted
bivariate associations between GPA and mental disorders separately
for each year. All confidence intervals are specified at the 95% level.
We did not consider comorbidity between internalizing and
ADHD in our analyses. Given the relatively low prevalences and
gendered structure, where boys are more likely to receive ADHD and
girls internalizing disorders, there was limited comorbidity. Of the boys
with either an internalizing or ADHD diagnosis, or both (n=16,992),
only 414 (0.02%) received both. Similarly, girls who received either
diagnosis or both (n=17,587), only 454 (0.03%) received both.
We calculated the prevalence of each disorder in each gradua-
tion year for boys and girls separately. To assess change in preva-
lence of disorders according to academic achievement, we
categorized students into GPA quintiles, ranging from the first
quintile (lowest grades) to the fifth quintile (highest grades), and
stratified by gender. Subsequently, we merged the second, third, and
fourth quintiles, resulting in the formation of three distinct groups:
the bottom 20%, the middle 60%, and the top 20% of students.
RESULTS
Prevalence changes
Our analysis revealed a substantial increase of diagnoses of inter-
nalizing disorders and ADHD in primary care, with prevalence rates
more than doubling between 2006 and 2019, as depicted in Figure 1.
For girls the rate of internalizing diagnoses increased from 1.9% to
4.2%, whereas rates of ADHD diagnoses increased from 0.7% to
1.8%. For boys, the rate of internalizing diagnoses increased from
0.7% to 1.9%, whereas rates of ADHD diagnoses increased from 1.5%
to 3.5%. Supplemental Figure S1 and Supplemental Table S1
demonstrate that using the data obtained from specialized care give
similar results, albeit with a lower total number of cases.
Mental disorder and school performance
As illustrated in Figure 2, the increase in cases of internalizing dis-
orders and ADHD roughly corresponds to the total number of cases
seen in each GPA category. This means that categories with fewer
FIGURE 1 Annual primary care diagnosis prevalence at age 16. The figure shows the proportion of adolescents receiving a primary care
diagnosis at age 16, as a function of gender and cohort. Two different line types distinguish between internalizing disorders (dotted) and
ADHD (solid). The color of the line represents the gender. The bottom Xaxis label shows the birth year and the top Xaxis label shows the
corresponding graduation year of the cohort.
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initial cases experience a smaller absolute increase but a similar
relative proportion increase, compared to categories with a larger
initial number of cases, which show a larger absolute but comparable
relative increase. However, several patterns are worth noticing. First,
the absolute prevalence and prevalence increases were higher within
the lowest quintile of school performance. For example, the lowest
GPA quintile showed an increasing rate of internalizing diagnoses
among girls from 3.8% to 8.5%, while rates in the highest quintile
increased from 0.9% to 1.7%. Second, the relative increases were
similar across the different GPA groups. For example, girls inter-
nalizing in the bottom quintile more than doubled, while girls in the
top quintile nearly doubled from approximately 1% to 2%. Third,
while the strongest increase in ADHD prevalence was observed for
birth cohorts between 1990 and 1995, internalizing disorders
increased particularly strongly in birth cohorts from 1995 and
onwards.
Changing associations over time
The results from our regression model indicate that the GPA differ-
ence between those with and without ADHD decreased during the
observation period with 0.013 z‐scores for each year (p<0.001).
Over the 13‐year study period, this adds up to a decrease in the
difference between those with and without an ADHD diagnosis of
0.17 z‐scores.
1
To put this figure into context – across both girls and
boys – the model implied negative effect of ADHD on GPA in the
2003 cohort was 16% less severe compared with the 1990 cohort.
2
FIGURE 2 Prevalence by gender, disorder, and GPA group. The figure shows the proportion of adolescents receiving a primary care
diagnosis at age 16, as a function of cohort, GPA performance, diagnosis and gender. GPA performance is divided into three groups
representing low, average, and high school performance.
ADOLESCENT MENTAL DISORDERS AND EDUCATIONAL PERFORMANCE FROM 2006–2019
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We further found that the difference between those with and
without an internalizing disorder shrank with 0.012 z‐scores for each
year (p<0.001). This adds up to a difference of 0.16 z‐scores in the
13‐year study period. This entails a model implied reduction of 27%
in the difference between those with and without an internalizing
diagnosis from 1990 to 2003.
3
The main results are shown in Table 1.
See Figure 3for plot of all bivariate associations. Similar effects
were found when utilizing specialist care diagnoses as shown in
Supplemental Figure S1. See Supplemental Figure S2 in the appendix
for descriptive plots of average GPA values in both standardized and
unstandardized form.
DISCUSSION
Our study is consistent with an expanding body of research that
demonstrates a rise in adolescent diagnoses of internalizing disorders
and ADHD. In absolute terms, the increasing prevalence in
internalizing and ADHD diagnoses was particularly pronounced
among the low‐achieving students, although in relative terms, the
increase within each achievement group was similar. Concurrently,
we observed an overall decrease in the association between these
disorders and educational performance. This was the case for both
primary and specialized care diagnoses.
Adolescent mental health across time
While many studies show alarming increases in mental health prob-
lems in adolescents, there is undoubtably heterogeneity across
studies. The referenced research on adolescent mental health is
categorized into three types: the majority using surveys by parents or
adolescents (Collishaw, 2015; Keyes et al., 2019; Mojtabai
et al., 2016; Patalay & Gage, 2019; Potrebny et al., 2024), a second
group, including our study, employing diagnostic register data
(Cybulski et al., 2021), and a third utilizing clinical diagnostic
TABLE 1Primary care regression models.
ADHD Internalizing
Coefficient Standard error Coefficient Standard error
Intercept −0.699 *** (0.004) Intercept −0.742 *** (0.004)
ADHD −1.043 *** (0.015) Internalizing −0.597 *** (0.015)
Cohort 0.006 *** (0.000) Cohort 0.005 *** (0.000)
Gender 0.483 *** (0.002) Gender 0.507 *** (0.002)
ADHD �Cohort 0.013 *** (0.002) Internalizing �Cohort 0.012 *** (0.002)
N843692 N843692
R
2
0.084 R
2
0.071
***p<0.001.
FIGURE 3 Bivariate associations between mental disorder and GPA across yearly cohorts.
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interviews (Polanczyk et al., 2014; Sawyer et al., 2018). Studies in the
first two groups consistently report an increase in mental health
problems or disorders, but those in the third group do not. This
contrasting evidence is compatible with the hypothesis that adoles-
cents are more attentive to their mental health and that increasing
availability of treatment might lead to an apparent increase in mental
health problems. This change in self‐evaluation might not be present
when assessed in standardized clinical interviews. It should also be
noted that it is reasonable to assume different prevalence changes in
studies originating in different countries using different time spans.
More access to treatment has been shown to increase rates of
diagnoses and lead to subjectively worse health, known as the
paradox of health (Barsky, 1988; Madsen, 2021; Ormel & Emmel-
kamp, 2023; Ormel et al., 2022). In recent times, Norway has placed
great emphasis on upscaling Norway's treatment capacity for
adolescent mental disorders (Research Council of Norway, 2009).
According to Statistics Norway, there has been a gradual increase in
clinical psychologists employed in state owned hospitals from 2008
(0.7 per 1000 citizens) to 2019 (1.13 per 1000 citizens). Similarly, the
Increased Access to Psychological Healthcare Initiative has improved
treatment availability (Lervik et al., 2020) in the same timeframe.
Following a recent expansion of the Finnish adolescent psychiatry
services, Holttinen et al. (2022) tentatively concluded that the
perceived need for treatment was reconceptualized with increased
access to treatment so that adolescents classified themselves as
mentally ill in situations which in earlier decades were interpreted in
some other way. This is also consistent with data from US cohorts
where Johnson (2021) assessed a wide range of birth cohorts across
the period 1997–2017. While the average self‐reported distress was
similar across the birth cohorts, the treatment‐seeking was much
greater for recent cohorts. Similarly, a recent study of U.S. adoles-
cents with no treatment history for mental disorders found that the
youngest cohorts, those born 2000–2002, reported the highest need
for treatment, compared to older cohorts (Askari et al., 2022). Ac-
cording to a recent Swedish qualitative investigation, feeling unwell is
the “new normal” (Hermann et al., 2022). These empirical findings are
parallel to the theoretical work of Brinkmann (2016) who posits that
modern adolescents themselves advocate for the pathologizing of
mental distress, as they predominantly interpret suffering through a
medicalized lens. This perspective contrasts alternative perspectives,
such as those offered by religious doctrines or class‐struggle ideol-
ogies, where suffering is regarded as a normative, inevitable part of
existence.
The association between mental disorder and
educational performance
Our finding of an approximately linear decrease in the association
between mental disorders and educational performance are in
contrast with three UK studies (Gage & Patalay, 2021; Sellers
et al., 2019; Thompson et al., 2021) who reported increased clus-
tering of mental health symptoms with low educational achievement,
adverse health outcomes, and substance abuse in recent cohorts. A
plausible reason for this disconnect is that we used primary care
diagnosis, while the UK studies utilized self‐or parent‐reports of
mental health symptoms. As reported above, the literature suggests a
divergence between ratings of subjective experience and a diagnostic
assessment based on a structured interview with a healthcare
professional.
The diminishing association between common mental disorders
and educational performance in adolescence may be attributed to
many distinct but overlapping processes. For example, the threshold
for attaining a mental disorder diagnosis in Norwegian primary and
specialist care may have decreased during the study period, in par-
allel with the expansion of adolescent mental health services. This
argument is based on the observation that admittance to subsidized
treatment is prioritized based on severity. Given this scenario, each
successive yearly cohort has a reduced threshold for diagnoses, as
more adolescents are treated year by year. Consequently, individuals
with less severe symptoms are increasingly likely to be diagnosed
with an internalizing disorder or ADHD. This possibility is consistent
with the considerable increase in the prevalence of diagnoses and the
continuous nature of mental disorders (Conway et al., 2021). Starting
from the hypothesis that the threshold for treatment has decreased,
the diminishing associations could be attributed to two distinct
consequences. Firstly, the increase in diagnoses and treatment
coverage could cause educational benefits, both by psychothera-
peutic and educational interventions. Specifically, the detrimental
impact of ADHD could be lessened by increased use of medication
which has seen a gradual increase between 2000 and 2013 (Lille-
moen et al., 2012; Raman et al., 2018). However, is seems somewhat
unlikely that treatment of internalizing disorders has resulted in large
positive educational gains, given the discouraging research literature
on the subject (Baker et al., 2021; Cuijpers et al., 2023). Secondly, a
lowered diagnosis threshold can cause a decreasing association be-
tween disorder and educational performance directly. If the less se-
vere end of the healthy‐to‐disorder distribution is diagnosed – and
given a link between the severity of the disease and a detrimental
educational effect – then it follows that lowering the threshold would
result in a decreasing association between disorder and GPA. Other
potential processes may as well explain the reduction in associations.
For example, the increasing prevalence could lower stigma around
mental disorders which could serve as a relief, lessening the negative
impact of mental health problems on educational attainment.
In parallel with increased prevalences of adolescent internalizing,
many countries observe an increase in indicators of social in-
equalities, such as the distribution of wealth and income. This is
followed by a rise in social inequality in the Norwegian education
system (Sandsør et al., 2023), whereby the difference in performance
between children form advantaged and disadvantaged backgrounds
have increased over time. Concurrently, we found increased differ-
ences in mental health between children with low versus high GPA.
This could indicate that society is becoming more heterogenous in
terms of not only economy but also mental health.
School achievement and mental disorders
Contrary to some (Flett et al., 2022; Luthar, Kumar, & Zillmer, 2020;
Stentiford et al., 2021), we did not find that the increase in common
mental disorders were attributable to high‐achieving students or
high‐achieving female students in particular. Instead, we found that
the bottom quintile of the GPA distributions had the highest
ADOLESCENT MENTAL DISORDERS AND EDUCATIONAL PERFORMANCE FROM 2006–2019
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prevalence and largest absolute increase in both internalizing disor-
ders and ADHD. This is consistent with well‐established findings that
more low‐performing students have mental disorders (Nordmo
et al., 2022). In terms of relative increases, all GPA groups saw similar
levels of increasing prevalence rates. For example, while boys' ADHD
in the bottom quintile saw a doubling from 4% to 8%, girls ADHD in
the top quintile GPA group saw a doubling from 0.1% to 0.2%. The
finding that most of the internalizing disorders are found in low‐
performing students go against the notion that perfectionism or ac-
ademic expectations among high performing students are the main
driver of increased mental disorders (Eriksen, 2021; Flett et al., 2022;
Luthar, Kumar, & Zillmer, 2020). Increasing academic pressure to
excel might improve school performance while potentially harming
mental health (Högberg et al., 2020). This may be particularly detri-
mental for students who perform poorly despite high expectations.
High‐performing students may experience increased pressure, but
this can be offset by the advantages of high performance. Nonethe-
less, it's important for teachers and healthcare professionals to
recognize that mental health issues are more prevalent among stu-
dents with lower academic performance.
Strengths and limitations
This study has several strengths. It uses data from the entire popu-
lation of Norwegian adolescents, with only a small minority of about
4% excluded due to reasons such as death, emigration, immigration,
or severe intellectual disability. Further, we accessed diagnostic data
from both primary and specialist care. Although dichotomous, di-
agnoses represent mental disorders as defined by professional
healthcare workers with specialized training and often formal pro-
cedures. The fact that we see the same pattern in diagnoses from
both primary and specialist care indicates that the diminishing as-
sociation with educational performance is not attributable to a
greater transfer of healthcare responsibilities from specialist to pri-
mary care settings. By utilizing register‐data, we include individuals
who are underrepresented in traditional recruitment‐based cohort
studies (Brayne & Moffitt, 2022; Fry et al., 2017).
Nevertheless, the results have to be interpreted in light of some
limitations. First, due to data constraints, our analyses were
restricted to a 13‐year period from 2006 to 2019, which is relatively
short in historical terms. Future investigations on a broader time-
frame could offer deeper insights into the interplay between mental
disorders and academic achievement. Second, the data we have on
hand cannot establish a definite causal link between mental disorders
and educational performance. Our diagnostic data represent in-
dividuals receiving treatment for mental disorders but do not
encompass all cases within the population. Lastly, it's important to
acknowledge that educational performance and mental health have a
bi‐directional relationship and we cannot exclude the possibility that
the associations found in this study arise due to poor school per-
formance and not vice versa. Given that the average GPA showed an
increase in the time period, we standardized GPA scores within each
cohort, and analyses could not be based on absolute GPA scores
across the study period.
CONCLUSION
In conclusion, our study demonstrates a rising prevalence of inter-
nalizing disorders and ADHD from 2006 to 2019. We find no evi-
dence to support the idea that the increase in prevalence is
predominantly driven by high‐achieving students. Our analyses
indicate a gradual decline in the association between these disor-
ders and educational performance. We have discussed several
alternative explanations such as the possible benefits of treatment
and educational interventions, but place particular emphasis on the
hypothesis that the declining associations could reflect shifting
diagnostic thresholds. Given an overview of this literature, we
caution against uncritically interpreting increasing prevalences as
reflecting genuine increases in adolescent mental disorders. In order
to ensure the validity and utility of mental health diagnoses, it is
crucial for treatment providers to exercise prudence and caution in
their diagnostic practices, avoiding excessive use that could poten-
tially undermine the meaningful distinction between normal psy-
chological experiences and clinically significant, pathological
conditions.
AUTHOR CONTRIBUTIONS
Magnus Nordmo: Conceptualization; Formal analysis; Investigation;
Methodology; Validation; Visualization; Writing – original draft;
Writing – review & editing. Thomas H. Kleppestø: Conceptualization;
Investigation; Methodology; Writing – original draft; Writing – re-
view & editing. Bjørn‐Atle Reme: Conceptualization; Investigation;
Methodology; Writing – original draft; Writing – review & editing.
Hans Fredrik Sunde: Conceptualization; Investigation; Methodology;
Writing – original draft; Writing – review & editing. Tilmann von
Soest: Conceptualization; Investigation; Methodology; Writing –
original draft; Writing – review & editing. Fartein Ask Torvik:
Conceptualization; Investigation; Methodology; Supervision; Writing
– original draft; Writing – review & editing.
ACKNOWLEDGMENTS
This work was partly supported by the Research Council of Norway
through its Centres of Excellence funding scheme, project number
#262700. Tilmann von Soest's work with this article was supported
by a grant from the Research Council of Norway (grant # 300816).
CONFLICT OF INTEREST STATEMENT
The authors have declared that they have no competing or potential
conflicts of interest.
DATA AVAILABILITY STATEMENT
This is a registry study with no data available.
ETHICAL CONSIDERATIONS
The study was approved by the Regional Committee for Medical and
Health Research Ethics.
ORCID
Magnus Nordmo
https://orcid.org/0000-0002-1977-1038
Hans Fredrik Sunde https://orcid.org/0000-0001-8797-5422
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ENDNOTES
1
Given the calculation 0.013 (interactioncoefficient)*13(years)≈0.17.
2
The negative effect of ADHD in 1990 was −1,04 z‐scores. To calculate
the expected negative effect in 2003 we add the interaction parameter
for each of the 13 study years (0.013*13 =0.17). Next, we add this
amount to the 1990 coefficient giving us the predicted difference be-
tween 1990 and 2003 (−1.04 þ0.17 = −0.87). Lastly, we calculate the
proportion change this implies as 1 −−0;87 ð2003Þ
−1;04 ð1990Þ¼16 %.
3
Same procedure as above with 1 −−0:43 ð2003Þ
−0:59 ð1990Þ¼27 %.
REFERENCES
Askari, M. S., Mauro, P. M., Kaur, N., & Keyes, K. M. (2022). Age, period,
and cohort trends in perceived mental health treatment need and
differences by mental health severity in the United States, 2008–
2019. Community Mental Health Journal,59(4), 631–640. https://
doi.org/10.1007/s10597‐022‐01044‐3
Baker, H. J., Lawrence, P. J., Karalus, J., Creswell, C., & Waite, P. (2021).
The effectiveness of psychological therapies for anxiety disorders in
adolescents: A meta‐analysis. Clinical Child and Family Psychology
Review,24(4), 765–782. https://doi.org/10.1007/s10567‐021‐
00364‐2
Barsky, A. J. (1988). The paradox of health. New England Journal of Medicine,
318(7), 414–418. https://doi.org/10.1056/nejm198802183180705
Brayne, C., & Moffitt, T. E. (2022). The limitations of large‐scale volunteer
databases to address inequalities and global challenges in health and
aging. Nature Aging,2(9), 775–783. https://doi.org/10.1038/s43587‐
022‐00277‐x
Brinkmann, S. (2016). Diagnostic cultures: A cultural approach to the path-
ologization of modern life. Routledge.
Collishaw, S. (2015). Annual Research Review: Secular trends in child and
adolescent mental health. Journal of Child Psychology and Psychiatry,
56(3), 370–393. https://doi.org/10.1111/jcpp.12372
Conway, C. C., Krueger, R. F., Cicero, D. C., DeYoung, C. G., Eaton, N. R.,
Forbes, M. K., Hallquist, M. N., Kotov, R., Latzman, R. D., Ruggero,
C. J., Simms, L. J., Waldman, I. D., Waszczuk, M. A., Watson, D.,
Widiger, T. A., & Wright, A. G. C. (2021). Rethinking the diagnosis of
mental disorders: Data‐driven psychological dimensions, not cate-
gories, as a framework for mental‐health research, treatment, and
training. Current Directions in Psychological Science,30(2), 151–158.
https://doi.org/10.1177/0963721421990353
Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Noma, H., Stikkelbroek,
Y., Weisz, J. R., & Furukawa, T. A. (2023). The effects of psychological
treatments of depression in children and adolescents on response,
reliable change, and deterioration: A systematic review and meta‐
analysis. European Child & Adolescent Psychiatry,32(1), 177–192.
https://doi.org/10.1007/s00787‐021‐01884‐6
Cybulski, L., Ashcroft, D. M., Carr, M. J., Garg, S., Chew‐Graham, C. A.,
Kapur, N., & Webb, R. T. (2021). Temporal trends in annual incidence
rates for psychiatric disorders and self‐harm among children and
adolescents in the UK, 2003–2018. BMC Psychiatry,21(1), 229.
https://doi.org/10.1186/s12888‐021‐03235‐w
Davies, N. M., Dickson, M., Davey Smith, G., van den Berg, G. J., &
Windmeijer, F. (2018). The causal effects of education on health
outcomes in the UK biobank. Nature Human Behaviour,2(2),
117–125. https://doi.org/10.1038/s41562‐017‐0279‐y
Eriksen, I. M. (2021). Class, parenting and academic stress in Norway:
Middle‐class youth on parental pressure and mental health.
Discourse: Studies in the Cultural Politics of Education,42(4), 602–614.
https://doi.org/10.1080/01596306.2020.1716690
Finning, K., Ukoumunne, O. C., Ford, T., Danielsson‐Waters, E., Shaw, L.,
Romero De Jager, I., Stentiford, L., & Moore, D. A. (2019). The as-
sociation between child and adolescent depression and poor atten-
dance at school: A systematic review and meta‐analysis. Journal of
Affective Disorders,245, 928–938. https://doi.org/10.1016/j.jad.
2018.11.055
Flett, G. L., Hewitt, P. L., Nepon, T., Sherry, S. B., & Smith, M. (2022). The
destructiveness and public health significance of socially prescribed
perfectionism: A review, analysis, and conceptual extension. Clinical
Psychology Review,93, 102130. https://doi.org/10.1016/j.cpr.2022.
102130
Fry, A., Littlejohns, T. J., Sudlow, C., Doherty, N., Adamska, L., Sprosen, T.,
Collins, R., & Allen, N. E. (2017). Comparison of sociodemographic
and health‐related characteristics of UK Biobank participants with
those of the general population. American Journal of Epidemiology,
186(9), 1026–1034. https://doi.org/10.1093/aje/kwx246
Gage, S. H., & Patalay, P. (2021). Associations between adolescent mental
health and health‐related behaviors in 2005 and 2015: A population
cross‐cohort study. Journal of Adolescent Health,69(4), 588–596.
https://doi.org/10.1016/j.jadohealth.2021.03.002
Gubbels, J., van der Put, C. E., & Assink, M. (2019). Risk factors for school
absenteeism and dropout: A meta‐analytic review. Journal of Youth
and Adolescence,48(9), 1637–1667. https://doi.org/10.1007/
s10964‐019‐01072‐5
Haugan, J. A., Frostad, P., & Mjaavatn, P.‐E. (2021). Girls suffer: The
prevalence and predicting factors of emotional problems among
adolescents during upper secondary school in Norway. Social Psy-
chology of Education,24(3), 609–634. https://doi.org/10.1007/
s11218‐021‐09626‐x
Hermann, V., Durbeej, N., Karlsson, A.‐C., & Sarkadi, A. (2022). Feeling
mentally unwell is the “new normal”. A qualitative study on ado-
lescents’ views of mental health problems and related stigma. Chil-
dren and Youth Services Review,143, 106660. https://doi.org/10.
1016/j.childyouth.2022.106660
Högberg, B., & Horn, D. (2022). National high‐stakes testing, gender, and
school stress in Europe: A difference‐in‐differences analysis. Euro-
pean Sociological Review,38(6), 975–987. https://doi.org/10.1093/
esr/jcac009
Högberg, B., Strandh, M., & Hagquist, C. (2020). Gender and secular trends
in adolescent mental health over 24 years–the role of school‐related
stress. Social Science & Medicine,250, 112890. https://doi.org/10.
1016/j.socscimed.2020.112890
Holttinen, T., Pirkola, S., Rimpelä, M., & Kaltiala, R. (2022). Factors behind
a remarkable increase in adolescent psychiatric inpatient treatment
between 1980 and 2010–a nationwide register study. Nordic Journal
of Psychiatry,76(2), 120–128. https://doi.org/10.1080/08039488.
2021.1939780
Jackson, H. J., & Haslam, N. (2022). Ill‐defined: Concepts of mental health
and illness are becoming broader, looser, and more benign. Austral-
asian Psychiatry,30(4), 490–493. https://doi.org/10.1177/
10398562221077898
James, T. A., Weiss‐Cowie, S., Hopton, Z., Verhaeghen, P., Dotson, V. M., &
Duarte, A. (2021). Depression and episodic memory across the adult
lifespan: A meta‐analytic review. Psychological Bulletin,147(11),
1184–1214. https://doi.org/10.1037/bul0000344
Johnson, A. L. (2021). Changes in mental health and treatment, 1997‐
2017. Journal of Health and Social Behavior,62(1), 53–68. https://
doi.org/10.1177/0022146520984136
Keyes, K. M., Gary, D., O’Malley, P. M., Hamilton, A., & Schulenberg, J. (2019).
Recent increases in depressive symptoms among US adolescents:
Trends from 1991 to 2018. Social Psychiatry and Psychiatric Epidemiology,
54(8), 987–996. https://doi.org/10.1007/s00127‐019‐01697‐8
Lervik, L. V., Knapstad, M., & Smith, O. R. F. (2020). Process evaluation of
prompt mental health care (PMHC): The Norwegian version of
improving access to psychological therapies. BMC Health Services
Research,20(1), 437. https://doi.org/10.1186/s12913‐020‐05311‐5
Lillemoen, P. K., Kjosavik, S. R., Hunskår, S., & Ruths, S. (2012). Pre-
scriptions for ADHD medication, 2004‐08. Tidsskrift for den Norske
Legeforening,132(16), 1856–1860. https://doi.org/10.4045/tidsskr.
11.1270
Loeffler, L. A. K., Satterthwaite, T. D., Habel, U., Schneider, F., Radke, S., &
Derntl, B. (2019). Attention control and its emotion‐specific associ-
ation with cognitive emotion regulation in depression. Brain Imaging
and Behavior,13(6), 1766–1779. https://doi.org/10.1007/s11682‐
019‐00174‐9
Luthar, S. S., Kumar, N. L., & Zillmer, N. (2020). High‐achieving schools
connote risks for adolescents: Problems documented, processes
implicated, and directions for interventions. American Psychologist,
75(7), 983–995. https://doi.org/10.1037/amp0000556
ADOLESCENT MENTAL DISORDERS AND EDUCATIONAL PERFORMANCE FROM 2006–2019
-
9 of 10
Luthar, S. S., Suh, B. C., Ebbert, A. M., & Kumar, N. L. (2020). Students in
high‐achieving schools: Perils of pressures to Be “standouts”.
Adversity and Resilience Science,1(2), 135–147. https://doi.org/10.
1007/s42844‐020‐00009‐3
Madsen, O. J. (2021). The paradox of health. In O. J. Madsen (Ed.),
Deconstructing scandinavia's "achievement generation": A youth mental
health crisis? (pp. 193–224). Springer International Publishing.
https://doi.org/10.1007/978‐3‐030‐72555‐6_8
McTeague, L. M., Goodkind, M. S., & Etkin, A. (2016). Transdiagnostic
impairment of cognitive control in mental illness. Journal of Psychi-
atric Research,83, 37–46. https://doi.org/10.1016/j.jpsychires.2016.
08.001
Mojtabai, R., Olfson, M., & Han, B. (2016). National trends in the preva-
lence and treatment of depression in adolescents and young adults.
Pediatrics,138(6). https://doi.org/10.1542/peds.2016‐1878
Moore, S., Paalanen, L., Melymuk, L., Katsonouri, A., Kolossa‐Gehring,
M., & Tolonen, H. (2022). The association between ADHD and
environmental chemicals—A scoping review. International Journal of
Environmental Research and Public Health,19(5), 2849. https://doi.
org/10.3390/ijerph19052849
Nordmo, M., Kinge, J. M., Reme, B.‐A., Flatø, M., Surén, P., Wörn, J.,
Magnus, P., Stoltenberg, C., & Torvik, F. A. (2022). The educational
burden of disease: A cohort study. The Lancet Public Health,7(6),
e549–e556. https://doi.org/10.1016/S2468‐2667(22)00059‐7
Ormel, J., & Emmelkamp, P. M. G. (2023). More treatment, but not less
anxiety and mood disorders: Why? Seven hypotheses and their
evaluation. Psychotherapy and Psychosomatics,92(2), 1–8. https://doi.
org/10.1159/000528544
Ormel, J., Hollon, S. D., Kessler, R. C., Cuijpers, P., & Monroe, S. M. (2022).
More treatment but no less depression: The treatment‐prevalence
paradox. Clinical Psychology Review,91, 102111. https://doi.org/10.
1016/j.cpr.2021.102111
Owens, J. (2021). Parental intervention in school, academic pressure, and
childhood diagnoses of ADHD. Social Science & Medicine,272,
113746. https://doi.org/10.1016/j.socscimed.2021.113746
Paris, J. (2020). Overdiagnosis in psychiatry: How modern psychiatry lost its
way while creating a diagnosis for almost all of life's misfortunes. Oxford
University Press. Retrieved from https://books.google.no/books?
id=VxT0DwAAQBAJ
Patalay, P., & Gage, S. H. (2019). Changes in millennial adolescent mental
health and health‐related behaviours over 10 years: A population
cohort comparison study. International Journal of Epidemiology,48(5),
1650–1664. https://doi.org/10.1093/ije/dyz006
Petersen, A., & Madsen, O. J. (2023). The achievement society: Youths too
good for their own good? Subjectivity,30(1), 23–38. https://doi.org/
10.1057/s41286‐023‐00147‐w
Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C., & Rohde, L. A.
(2014). ADHD prevalence estimates across three decades: An
updated systematic review and meta‐regression analysis. Interna-
tional Journal of Epidemiology,43(2), 434–442. https://doi.org/10.
1093/ije/dyt261
Potrebny, T., Nilsen, S. A., Bakken, A., von Soest, T., Kvaløy, K., Samdal, O.,
Sivertsen, B., Aase, H., & Bang, L. (2024). Secular trends in mental
health problems among young people in Norway: A review and
meta‐analysis. European Child & Adolescent Psychiatry.https://doi.
org/10.1007/s00787‐024‐02371‐4
Raman, S. R., Man, K. K. C., Bahmanyar, S., Berard, A., Bilder, S., Boukhris,
T., Bushnell, G., Crystal, S., Furu, K., KaoYang, Y. H., Karlstad, Ø.,
Kieler, H., Kubota, K., Lai, E. C., Martikainen, J. E., Maura, G., Moore,
N., Montero, D., Nakamura, H., … Wong, I. C. K. (2018). Trends in
attention‐deficit hyperactivity disorder medication use: A retro-
spective observational study using population‐based databases. The
Lancet Psychiatry,5(10), 824–835. https://doi.org/10.1016/s2215‐
0366(18)30293‐1
Research Council of Norway. (2009). Evaluering av Opptrappingsplanen
for psykisk helse (2001–2009). Retrieved from https://www.
forskningsradet.no/siteassets/publikasjoner/1248431256883.pdf
Sandsør, A. M. J., Zachrisson, H. D., Karoly, L. A., & Dearing, E. (2023). The
widening achievement gap between rich and poor in a Nordic
country. Educational Researcher, 0013189X221142596. https://doi.
org/10.3102/0013189X221142596
Sawyer, M. G., Reece, C. E., Sawyer, A. C. P., Johnson, S. E., & Lawrence, D.
(2018). Has the prevalence of child and adolescent mental disorders
in Australia changed between 1998 and 2013 to 2014? Journal of the
American Academy of Child & Adolescent Psychiatry,57(5), 343–350.
e345. https://doi.org/10.1016/j.jaac.2018.02.012
Sellers, R., Warne, N., Pickles, A., Maughan, B., Thapar, A., & Collishaw, S.
(2019). Cross‐cohort change in adolescent outcomes for children
with mental health problems. Journal of Child Psychology and Psy-
chiatry,60(7), 813–821. https://doi.org/10.1111/jcpp.13029
Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G.,
Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho,
A. F., Seeman, M. V., Correll, C. U., & Fusar‐Poli, P. (2022). Age at
onset of mental disorders worldwide: Large‐scale meta‐analysis of
192 epidemiological studies. Molecular Psychiatry,27(1), 281–295.
https://doi.org/10.1038/s41380‐021‐01161‐7
Statistics Norway. (2023). Marks and national tests, lower secondary
school: 2009–2023. Retrieved from https://www.ssb.no/en/
statbank/table/07495
Stentiford, L., Koutsouris, G., & Allan, A. (2021). Girls, mental health and ac-
ademic achievement: A qualitative systematic review. Educational Re-
view,75(6), 1–31. https://doi.org/10.1080/00131911.2021.2007052
Sunde, H. F., Kleppestø, T. H., Gustavson, K., Nordmo, M., Reme, B.‐A., &
Torvik, F. A. (2022). The ADHD deficit in school performance across
sex and parental education: A prospective sibling‐comparison reg-
ister study of 344,152 Norwegian adolescents. JCPP Advances,2(1),
e12064. https://doi.org/10.1002/jcv2.12064
Thompson, E. J., Richards, M., Ploubidis, G. B., Fonagy, P., & Patalay, P.
(2021). Changes in the adult consequences of adolescent mental ill‐
health: Findings from the 1958 and 1970 British birth cohorts.
Psychological Medicine,53(3), 1–10. https://doi.org/10.1017/
S0033291721002506
Twenge, J. M. (2020). Increases in depression, self‐harm, and suicide
among U.S. Adolescents after 2012 and links to technology use:
Possible mechanisms. Psychiatric Research and Clinical Practice,2(1),
19–25. https://doi.org/10.1176/appi.prcp.20190015
WONCA. (2005). ICPC‐2‐R: International classification of primary care. Ox-
ford University Press.
World Health Organization. (2004). ICD‐10: International statistical classi-
fication of diseases and related health problems / world health organi-
zation. World Health Organization.
SUPPORTING INFORMATION
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How to cite this article: Nordmo, M., Kleppestø, T. H., Reme,
B.‐A., Sunde, H. F., v on Soest, T., & Torvik, F. A. (2024). The
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and educational performance from 2006–2019. JCPP
Advances,4(3), e12239. https://doi.org/10.1002/jcv2.12239
10 of 10
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NORDMO
ET AL.
