Mental health and substance use in urban left-behind children in China: A growing problem

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Highlights

  • Urban left-behind children showed higher mental health disorders than urban children.

  • Urban left-behind children showed more substance use than urban children.

  • Urban left-behind children even worse than rural left-behind children.

  • Parent-child communication and resilience were associated factors.

Abstract

Children left behind by their migrant parents in urban and rural areas represent two vulnerable but distinct populations that have emerged due to the large-scale population migrations that occur within China. In 2015, there were an estimated 28 million urban left-behind children and around 41 million rural left-behind children. The purpose of this study was to examine the mental health status and substance use behaviors of urban left-behind children and urban children still living with their parents in comparison to rural left-behind children. This study also sought to investigate how parent-adolescent communication and children’s resilience may moderate or exacerbate mental health status and/or substance use across children experiencing different forms of parental migration and hukou status (household registration system), using cross-sectional data from a school-based questionnaire survey with a sample of 4565 children living in both urban and rural counties of Anhui province. Regression model results suggest that, compared to urban children who lived with both parents, urban children who were currently left-behind appeared to exhibit higher mental health difficulties (emotional symptoms and total difficulties) and more substance use (smoking and drinking). Urban left-behind children were also found to experience more mental health problems and substance use than rural left-behind children. Our results indicated that both parent-adolescent communication and resilience were strongly associated with children’s mental health and substance use outcomes. These findings have significance for the creation and tailoring of interventions directed at urban left-behind children.

Introduction

Two demographic trends that have emerged in China in recent years deserve greater attention. The first is that, in 2011, the proportion of China’s population living in urban areas (51.3%) exceeded those living in rural areas (48.7%) for the first time (National Bureau of Statistics of China, 2012). China has experienced rapid urbanization since the government’s adoption of the reform and opening-up policy; China’s urban population increased from 21.1% of the population in 1982 to 56.1% in 2015, while the proportion of children living in urban areas increased from 16.6% in 1982 to 49.1% in 2015 (National Bureau of Statistics of China, 2016).

The second trend is a structural change in the nature of China’s internal migration patterns. Large-scale population migrations have occurred in China for at least the last four decades, with the migrant population increasing from 6.6 million in 1982 to 245 million in 2017 (National Health Commission of China, 2019). In 2015, rural-to-urban migration in China was in decline, while urban-to-urban migration was increasing. There are an estimated 61 million urban-to-urban migrants in China, accounting for roughly 25% of the total migrant population (National Health Commission of China, 2019). Chinese internal migration has always been controlled by the government, mainly through the household registration system, otherwise known as the hukou system. This is a place-based public resource distribution and management system which prevents migrants (rural-to-urban migrants or urban-to-urban migrants) and their children from accessing local social benefits in the cities to which they migrate, including medical insurance and public education (Zhou & Cheung, 2017). The increase in urban-to-urban migration has also resulted in a large and ever-growing population of urban left-behind children (LBC). From 2005 to 2015, estimates for the number of urban LBC increased from 14.7 to 28.3 million, while the number of rural LBC declined by 18 million, to around 40.5 million, across China (UNICEF, 2018). LBC are children “who live in their original domicile, but have not lived with their parents for over six months, as either one or both parents have migrated” (UNICEF, 2018). Urban LBC refer to LBC whose household registration locations are in urban areas. Rural LBC refer to LBC whose household registration locations are in rural areas.

Historically, in most circumstances, LBC only referred to children left-behind in rural areas. In the past two decades, a number of researchers have sought to determine the effects of parental migration on rural LBC. A systematic review and meta-analysis study demonstrated that parental migration is detrimental to the health of rural LBC, with no evidence of any benefit (Fellmeth et al., 2018). Compared with rural children living with both parents, rural LBC faced increased risks of depression, suicidal ideation, substance use and conduct disorders (Fellmeth et al., 2018, Lu, 2012, Wen et al., 2015, Wu et al., 2015). Despite the plethora of studies on rural LBC, far too little attention has been paid to urban LBC. This lack of research constrains our ability to examine the effects of parental migration on urban child development.

There is well-established evidence from the fields of child psychology and family studies that effective regular communication with parents can protect the mental health of children and reduce their risk of substance use. Munz defines parent-adolescent communication as “the verbal and non-verbal interaction between parents and children within a family system” (Munz, 2015). Parent-adolescent communication is an indicator of the strength of the parent-adolescent relationship and is emphasized as an important family factor that contributes to children’s development (Ackard, Neumark-Sztainer, Story, & Perry, 2006). Studies have demonstrated that higher levels of parent-adolescent communication are associated with better mental health and fewer behavioral problems (Lanz et al., 1999, Liu, 2003, Wang et al., 2013, Ying et al., 2015). For example, using data from the Eating Among Teens Survey (2001 Project EAT) in the United States, Ackard et al.’s study on 4767 adolescents demonstrated that perceived low parental communication levels were associated with depression, substance use and low self-esteem (Ackard et al., 2006). Ponnet et al analyzed data from 2707 children in Belgium and found that poor parent-adolescent communication was significantly related to children’s suicidal ideation and self-harming behavior (Ponnet et al., 2005). Research on rural LBC in China has also started to examine the association between parent-adolescent communication and children’s mental health and substance use. Some recent studies suggest that the quality of rural LBC’s parent-adolescent communication is significantly lower than that of their non-left-behind counterparts (Su, Li, Lin, Xu, & Zhu, 2013). Wang et al’s study in Anhui province found that rural LBC experienced greater problems in communicating with their parents than did children living with both parents, and that experiencing problems in communicating with parents was associated with higher levels of mental health difficulties (Wang et al., 2019). Despite a growing body of research on the association between parent-adolescent communication and rural LBC’s mental health and substance use, there is a lack of literature addressing this association for children left-behind in urban areas, particularly in the context of urban-to-urban migration in China.

Resilience has been defined as “a process in which individuals use their abilities, strengths, capacities, and resources to maintain healthy functioning or positively adapt within the context of risk experiences or adversities” (Luthar et al., 2000, Masten and Obradovic, 2006). Existing literature provides convincing evidence on the association between resilience and adolescents’ mental health and substance use (Ann et al., 1990, Jordan and Graham, 2012, Martinez-Torteya et al., 2009, Suniya and Edward, 1991). Nrugham et al found an association between children’s resilience and lifetime violent events and attempted suicide, using data from 2464 students followed over 6 years in Norway (Nrugham, Holen, & Sund, 2010). Drawing upon a sample of 2311 children who experienced the devastating Sichuan earthquake in China, Gan et al found that resilience moderated the effects of negative events on adolescent depressive symptoms (Gan, Xie, Wang, Rodriguez, & Tang, 2013). Studies in the Chinese context have also demonstrated the protective effects of resilience on the mental health and substance use of LBC in rural areas (Ai and Hu, 2016, Guo et al., 2015, Luo et al., 2016, Shi et al., 2016). Despite the well-established evidence for the association between resilience and child mental health and behavior, no previous study has tried to examine this association in urban LBC.

There is no empirical evidence on mental health and substance use for urban LBC in China, in part because this population is a relatively new phenomenon. To better understand the mental health and substance use of children in the rural–urban and urban-urban migration contexts, this study aims to compare urban LBC and rural LBC in Anhui Province, and to investigate how parent-adolescent communication and resilience affects children with regard to different forms of parental migration and hukou status. Anhui is an underdeveloped province with a population of 63 million (National Bureau of Statistics of China, 2019). It ranked 22nd in GDP (Gross Domestic Product) per capital in Mainland China in 2018 (National Bureau of Statistics of China, 2019) and is a feeder province for migrant workers, with both rural-to-urban migrants and urban-to-urban migrants, and housing nearly 5.1 million LBC (Duan, Lv, Guo, & Wang, 2013). Since the majority of migration flows are within the country, it is not uncommon that migrant parents return home after living apart from their child for an extended period. The effects on children after the return of parents is worthy of discussion based on our previous studies (Wang et al., 2019, Zhao et al., 2017). Then we compared five groups of children in this study: LBC with urban hukou status, previous LBC with urban hukou status, children with urban hukou status living with their parents, LBC with rural hukou status, and previous LBC with rural hukou status.

Section snippets

Participants and procedure

A cross-sectional survey using self-reported questionnaires was conducted in schools in urban and rural locations in Anhui Province. The urban location chosen for this study was Wuhu, the second largest city in the province. To make our sample more comparable, four townships (from Wuwei and Nanling county) at low economic development levels in Wuhu were further chosen to serve as the rural locations for this study. The survey was carried out from April 2018 to March 2019.

Currently, around 55%

Results

A total of 5393 5th-8th grade students from 18 schools in Anhui were selected for the study sample. Among these, 5253 respondents signed the consent form and completed the questionnaire, resulting in a response rate of 97%. Given that other forms of parental absence could exert a different effect on children, children whose parents have divorced or passed away were not included (n = 688). Therefore, the final sample for analysis included 4565 students, comprising 1093 U-CLBC, 857 U-PLBC, 890

Discussion

By drawing upon data selected from one Chinese province with widely varying levels of socioeconomic development, our findings highlight an important emerging problem in China. While the health impact of parental migration on rural LBC has been well documented, whether and to what extent migrating is beneficial or detrimental to the development and well-being of urban LBC has not been previously explored. This study represents an initial attempt to examine how left-behind experiences contribute

Conclusions

Despite these limitations, the findings of this study enhance our understanding of LBC’s mental health and substance use in urban China and provide important implications for the development of interventions and prevention programs for promoting these children’s well-being. Firstly, the present study strongly suggests that urban LBC have markedly higher mental health difficulties than U-NLBC, independent of socio-demographic variables, parent-adolescent communication and resilience. These

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The authors thank all the schools and children for their participation.

Funding

This research was funded by a grant from Zhejiang University Zijin Talent Project, China.

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