Poverty as a Risk Factor for Mental Health Conditions in Childhood
The October 2016 edition of the BC Medical Journal (BCMJ) includes a report on Children’s mental health: Is poverty the diagnosis?
The report is written by Ivana Jakovljevic, MD, Ashley P. Miller, MDCM, FRCPC and Barbara Fitzgerald, MD, FRCPC. Dr Jakovljevic is a resident in the Department of Psychiatry at UBC. Dr Miller is an assistant professor in the UBC Psychiatry Department and a child and adolescent psychiatrist at BC Children’s Hospital and Vancouver Community Mental Health Services. Dr Fitzgerald is a developmental pediatrician at Sunny Hill Health Centre for Children, the medical director of Alderwood Family Development Centre, and a clinical associate professor in the Department of Pediatrics at UBC.
The article looks at the case of a 6-year-old boy referred by his school counselor because of anxiety and school difficulties, representative of many children and youth seen in primary care settings who frequently present with undifferentiated mood and behavioural symptoms. The study follows the child and his family through treatment and referral to a number of community supports, and the positive impact on his symptoms and on his family’s living situation, even though his family is still experiencing significant financial pressure.
The authors point out the challenges of income inequality in BC. “Income inequality is on the rise in Canada, and particularly in British Columbia, where a family in the highest income decile earns 13 times more than a family in the lowest income decile. This staggering income disparity is explained in part by the fact that individuals in BC’s lowest earning decile have the lowest income of all Canadians.”
They point out that the World Health Organization has declared poverty the single largest determinant of health for both adults and children. Children affected by poverty have higher rates of:
- Infant mortality
- Low birth weight
- Childhood hospitalizations
- Functional health impairments
“Poverty in early childhood is also associated with increased morbidity and decreased lifespan in adulthood, an association that persists irrespective of the social status one acquires as an adult….Children from families living in poverty are 3 times more likely, on average, to suffer from psychiatric conditions, including both externalizing disorders such as ADHD, oppositional defiant disorder (ODD), and conduct disorder, and internalizing disorders such as depression, anxiety, and poor coping skills.” They reference ongoing work in which “experts in the field have recently questioned whether some of the behavioral concerns seen by childhood mental health professionals are actually emotional and behavioural responses to inadequate and chaotic environments rather than diagnosable primary mental illnesses, as illustrated by the case.”
The authors also discuss the effects of poverty on the development of cognition. “A recent Vancouver study found that 38% of kindergarten children living in the lowest income neighborhoods demonstrated vulnerabilities in at least one area measured by the Early Development Instrument, which considers physical health and well-being, language and cognitive development, social competence, emotional maturity, and communications skills.” Children living in poverty demonstrate “deficits in working memory, language abilities, and cognitive flexibility when compared with their middle-class counterparts. Recent neuroimaging research suggests that these deficits are mediated by under-development of several brain areas, including the frontal and temporal lobes and the hippocampus. This underdevelopment is estimated to account for 15% to 20% of achievement deficits.” The authors point out that “the longer children live in poverty, the greater their academic deficits and the more likely they are to experience a lifetime of reduced occupational achievement and the persistence of poverty across generations”.
The article points out the associated issues of childhood poverty, including lack of:
- Nutritious food
- Adequate housing in safe neighborhoods
- Quality day care
- Regular access to health care
- Environmental complexity
- Exposure to educational activities and materials
- Positive parent-led experiences such as reading and conversation
And increased risk of:
- Trauma and stressful life events
- Social isolation
The authors discuss several hypotheses that are being explored around impact of prolonged poverty and brain development. These include the concept of allostatic load, or cumulative damage over time, which suggests that “the excessive, persistent, and uncontrollable adversity experienced by children living in poverty intensifies the activation of the hypothalamic-pituitary-adrenal (HPA) axis” has an impact on the developing brain. “Prolonged exposure to stressful environments and subsequent heightened neuro-endocrine responses are associated with the development of both depressive symptomatology and the hippocampal neuron damage implicated in impaired learning and memory.” Studies demonstrating heightened baseline activation of the stress response system in children living in poverty indicate “poverty becomes biologically embedded, leading to both functional and structural changes of the developing brain.”
They recommend the poverty intervention tool developed by Dr. Gary Bloch. The tool has currently been put into practice in Ontario and Prince Edward Island, and is in development for other provinces including British Columbia. They state, “A positive answer to the screening question ‘Do you ever have difficulty making ends meet at the end of the month?’ has a sensitivity rate of 98% for identifying patients living in poverty. The targeted interventions outlined in the tool are designed to reduce the effects of poverty and adverse health outcomes in low-income patients, and include specific questions for families with children, seniors, people with disabilities, and First Nations patients living in poverty.”
The authors conclude: “Given the importance of the psychosocial environment to child development, an assessment of the family and social circumstances is important because symptoms of living in poverty can at first glance mimic the symptoms of mental illness. Income insecurity is increasingly common in working families and a growing number of children live below the poverty line in British Columbia. Poverty is a risk factor for mental illness and can affect early cognitive development. Screening for poverty and making treatment recommendations that address a family’s lack of income and resources can lead to significant change for children. Early childhood interventions that support the basic needs of children, including access to nutritious food, safe and affordable housing, quality child care, and regular health care, should be our top health priority if we want to ensure the well-being of future generations.”