Elsevier

Social Science & Medicine

Volume 90, August 2013, Pages 24-31
Social Science & Medicine

Review
Socioeconomic inequalities and mental health problems in children and adolescents: A systematic review

https://doi.org/10.1016/j.socscimed.2013.04.026Get rights and content

Highlights

  • The review clarifies the relationship between SES and mental health problems.

  • Children and adolescents with low SES are at higher risk of mental health problems.

  • Socioeconomic inequalities are stronger in children than in adolescents.

  • Inequalities are stronger for income or parental education than parental occupation.

Abstract

Socioeconomic inequalities in health are an important topic in social sciences and public health research. However, little is known about socioeconomic disparities and mental health problems in childhood and adolescence. This study systematically reviews publications on the relationships between various commonly used indicators of socioeconomic status (SES) and mental health outcomes for children and adolescents aged four to 18 years. Studies published in English or German between 1990 and 2011 were included if they reported at least one marker of socioeconomic status (an index or indicators, e.g., household income, poverty, parental education, parental occupation status, or family affluence) and identified mental health problems using validated instruments. In total, 55 published studies met the inclusion criteria, and 52 studies indicated an inverse relationship between socioeconomic status and mental health problems in children and adolescents. Socioeconomically disadvantaged children and adolescents were two to three times more likely to develop mental health problems. Low socioeconomic status that persisted over time was strongly related to higher rates of mental health problems. A decrease in socioeconomic status was associated with increasing mental health problems. The strength of the correlation varied with age and with different indicators of socioeconomic status, whereas heterogeneous findings were reported for gender and types of mental health problems. The included studies indicated that the theoretical approaches of social causation and classical selection are not mutually exclusive across generations and specific mental health problems; these processes create a cycle of deprivation and mental health problems. The review draws attention to the diversity of measures used to evaluate socioeconomic status, which might have influenced the comparability of international epidemiological studies. Furthermore, the review highlights the need for individual-level early childhood interventions as well as a reduction in socioeconomic inequalities at a societal level to improve mental health in childhood and adolescence.

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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