ReviewSocioeconomic inequalities and mental health problems in children and adolescents: A systematic review
Introduction
Social inequality has become one of the most commonly discussed topics in Europe and societies worldwide (Marmot & Bell, 2012; Wilkinson & Pickett, 2010). The increasing gap observed between socioeconomically advantaged and disadvantaged people has caused intensive debates in the social sciences and in politics. These discussions have noted the reproduction of social disparities across generations, which decreases the opportunities for social mobility within different population groups throughout the life course (Blackburn & Prandy, 1997). Poverty and low socioeconomic status (SES) affect different areas of social life, including access to education, the distribution of income, health status, and health care utilization. Dimensions of social inequalities in health are commonly measured by calculated SES indexes or various indicators defined by individuals' position in the labor market, education status, income, or material wealth (Currie et al., 2012). A social gradient in physical and mental health status has been widely reported (Fryers, Melzer, & Jenkins, 2003; Marmot & Bell, 2012). The World Health Organization has declared that mental health problems are a challenging public health issue worldwide, as 20–25% of individuals develop at least one mental disorder in their lifetime (World Health Organization, 2001).
Although the impact of social determinants on adult health dominates the research, examining this topic in early life has become more common. Children and adolescents suffer particularly from increasing poverty rates (UNICEF, 2005), and the consequences of socioeconomic disparities on health (Currie, Gabhainn et al., 2008; Holstein et al., 2009; World Health Organization, 2001, 2002). Children with low SES are not only more likely than other children to have worse health status and more injuries, but also to have significantly less access to routine medical care (Newacheck, Hughes, & Stoddard, 1996). Reviews on the prevalence of mental health problems estimated that approximately one in five children and adolescents suffer from psychiatric disorders (World Health Organization, 2012). Higher incidences of behavioral problems were found among pre-school children from low-income families (Qi & Kaiser, 2003), and adolescents living in poverty (Dashiff, DiMicco, Myers, & Sheppard, 2009). Several theoretical approaches were established to explain the differences in the rates of mental health problems. The social selection hypothesis (Eaton, 1980) assumes that people with mental health problems drift down in socioeconomic position because of their psychopathology and inability to fulfill expected role obligations. The social causation hypothesis (Dohrenwend & Dohrenwend, 1969) posits that mental health problems are a result of socioeconomic deprivation. Kessler et al. (2005) reported that half of all lifetime cases of mental disorders start by the age of 14, and low childhood SES was found to be associated with disadvantages in health and economic position in adulthood (Case & Paxson, 2006; Cohen, Janicki-Deverts, Chen, & Matthews, 2010; Poulton et al., 2002). These facts indicate the importance of mental health in youth. However, little systematic research has been conducted on the relationship between socioeconomic inequalities and mental health in childhood and adolescence.
The goals of this paper were (a) to investigate the definition and operationalization of SES and mental health, (b) to determine the association between low SES and mental health problems in children and adolescents, and (c) to discuss possible explanations for the associations found. In this review, a range of specific mental health problems were categorized as internalizing (emotional) or externalizing (behavioral) disorders (Angold & Costello, 1995). The term internalizing disorder is commonly used for children with introversive mood problems (e.g., depressive and anxiety disorders), whereas externalizing disorders affect children with social adaption problems (e.g., attention deficit hyperactivity disorder and conduct disorder). It was hypothesized that low SES is related to higher rates of mental health problems in childhood and adolescence.
Section snippets
Study selection
Between November 2011 and January 2012, a systematic literature search was performed to identify relevant studies. Articles were collected from an electronic database and through a manual search. The manual search was predominantly based on reference articles. The following databases were included in the search process: PubMed, The Social Science Citation Index, MEDLINE, Embase, PsycINFO, and PSYNDEX. The database search was focused on screening titles and abstracts for the following keywords:
Characteristics of included studies
In total, 55 studies met the inclusion criteria for the review. An overall correlation between at least one marker of SES and mental health problems was proven in 52 studies from a total of 23 countries. The majority of the studies were conducted in North America, Europe, and Australia. The number of publications increased between 1990 and 2011, especially between 2006 and 2011, which indicates a growing interest in socioeconomic determinants of children's mental health. A descriptive summary
Discussion
The review findings showed a clear relationship between socioeconomic deprivation and mental health problems in childhood and adolescence. In total, 52 of the 55 international studies included in the review reported an inverse association between at least one marker of SES and mental health problems. Children from socioeconomically disadvantaged families were approximately two to three times more likely to develop mental health problems than their peers from socioeconomically advantaged
Conclusion
Socioeconomic inequalities are associated with mental health problems in childhood and adolescence. In particular, persistently low SES and a decrease in SES are major predictors of the onset of mental health problems in children and adolescents. These results are particularly relevant for understanding the restricted social mobility of socioeconomically disadvantaged people and the transmission of poverty across generations. Future generations are not only affected by the socioeconomic
Acknowledgements
This systematic review was performed as a part of the PhD thesis. No external funding was received for this study.
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