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 “Investing in parental mental health, access to care and education, and early intervention are the best bet for kids in a low socioeconomic position. Some experimental studies show that that lifting children out of poverty can have very beneficial effects on their behaviour and their mental health in general”, says Maria Melchior, researcher at the Pierre Louis Institute of Epidemiology and Public Health, and member of ERES (Equipe de Recherche en Epidémiologie Sociale), the leading social epidemiology research team of the Sorbonne University and Inserm, the French national institute for health and medical research. Melchior was a keynote lecturer at the ESCAP 2017 Congress about Social inequalities in children’s mental health.

“Many parents in these situations are themselves dealing with mental health problems or substance abuse problems. It is very well known that maternal depression and other mental health problems have an impact on children, but it seems that a low socioeconomic position strengthens these associations. So treating or educating the parents in those situations will also help the children. Parental mental health is one really important thing and the first that practitioners should look at, because this is the key mechanism through which low-SES can influence children’s health. If the parents remain untreated they are simply not able to raise their children in a way that protects them from similar problems. This comes along with all the other daily hassles that go with low social-economic circumstances.” When it comes to solutions, Melchior puts the parents up front – as well as education, access to health care and early treatment.

Parents can make a difference
“Children from low socioeconomic backgrounds are always exposed to high risks for serious mental health problems. There is of course a lot of heterogeneity and a lot of individual variability. Most of the research that I am doing is about trying to understand the patterns. We found that there are different types of factors that could explain why children do quite well despite growing up in poverty. Social support is an important factor that really has an important beneficial effect on the children. The results are often good if this can be done in the family: if parents can spend time with their children despite difficult socioeconomic conditions, do activities with them, promote interactions that are positive rather than negative. Of course there are also more structural sources of institutional support. Access to early childcare is one type of support that could make a big difference.”

Homeless
The ERES team studies exactly these issues, to improve knowledge of different factors and processes which may be the causes or consequences of social inequalities in health. Socioeconomic status (SES) – the measure of an individual's or family's economic and social position, based on income, education and occupation – and its relationship to mental health outcomes as well as mental health care access for children and adolescents is the focus of Melchior within the team. “‘Socioeconomic position is a broad concept”, she says. “Basically it can be defined by either the parents’ SES: the level of their education or the level of income or the type of occupation – or a lack of occupation. But socioeconomic position can also be defined by neighbourhood or broader geographic characteristics that may not refer to one location or home. Children may live in poor areas, irrespective of their personal situation, or travel around a lot. I am involved in a study which has examined mental health among children whose families are homeless. They are all very poor. It is really important to understand among those families with really high needs, what specific risk factors are involved in relation to their children’s problems.”
“In Paris there are approximately 10,000 families with children that do not have stable housing, not even counting the ones that stay with friends or relatives. And these are figures from before the migrant crisis. These people apply every night for a place in a homeless shelter. In big European cities in general there is a huge housing problem. In these families we see very high levels of mental health difficulties, for a substantial part related to their living conditions.”

Food insecurity
“Other specific factors affect children from low-SES families, such as food insecurity: inadequate access to sufficient, safe, and nutritious food that meets their dietary needs. Food insecurity is quite prevalent, but we do not know exactly why children who grow up in food-insecure families have worse mental health than those who live in better conditions. Nutrition problems can play a role as well as in family structure. Food insecurity is either a marker of extreme poverty or a particular situation, which is related not only to the families’ socioeconomic means but also to what extent families – or mothers in many cases – are able to manage their resources. We find that food insecurity is especially common in families where the mothers themselves have mental health problems. So it is not only a matter of money; it also depends on how well the parents are able to manage the family and educate their children.”

From toddlerhood to adulthood
Maria Melchior has been involved in studies such as the GAZEL cohort follow-up study (showing that low SES predicts long-term depression), cohort studies on the relationship between food insecurity and mental health and various studies that associate negative childhood events to trajectories of internalizing symptoms and the correlation between socioeconomic circumstances and behavioural problems. The outcomes are often deplorable for families with low socioeconomic status. Inequality is very commonly related to the onset of mental health problems and their persistence over time. Maltreatment, neglect, an unbalanced diet, social isolation and severe mental health problems are more common in children from a low socioeconomic position. And the symptoms may persist during the whole transition from toddlerhood to adulthood, often leading up to severe behavioural problems and substance abuse.
Melchior: “We are very aware of these types of circumstances. Still, it is important to also keep an eye on other, more mundane forms of stress in children’s lives. This includes parental separation, social isolation from peers, etcetera. These types of events and especially their accumulation, when children are exposed to several events during a short period of time, could have an influence on their behaviour. And sometimes that effect is long lasting. We found an influence of low SES on children’s anxiety, sometimes with psychosocial or psychosomatic symptoms, and depressive symptoms in the older kids. In most cases the effect did not last very long, but in others it actually appeared to be a first step towards longer-term anxiety and depressive symptoms. In a study on food inequality we found a similar pattern.”
“On the upside: children almost instantly do better when the circumstances change. If they find a job, or they move somewhere else or the mother manages to stabilize her relationship or finds a partner who earns an income. Luckily there is a lot of flexibility in the first years of life.”

Extreme violence
“Extreme violence often originates from low SES situations. Not all, but many perpetrators come from deprived neighbourhoods, many of them have low levels of educational and they are more likely to be unemployed than others – this goes for many first- or second-generation migrants in the poor parts of town. All of these circumstances will have an impact on the children who grow up there.”
“Countries with strong social protection systems will have less inequality and fewer sources for stress. That does not exclude that there could always be one or two individuals that may show extreme behaviour that may put others in danger. But overall studies show that health is really related to the level of equality across the society as a whole. Decreasing inequality will have a positive impact on health. We are conducting a study that compares early day care for children in Canada, France and Denmark – Canada having little available, France for about half of the population and Denmark to a very high extent. We expect that the outcome will show that day care may contribute positively to preventing mental health problems. Together with parental education and good access to health care this could be yet another piece of the puzzle.”

WHO call
“But do keep in mind that most of the determents in mental health are beyond the control of the health care system. It is really difficult for public health decision-makers or clinicians to help improve access to health care for the most deprived families. This is mainly in the hands of politicians who are used to thinking in the short term. The World Health Organization commissioner on Social Determinants of Health recently recommended that all policies should be evaluated in terms of their impact on social inequalities and health. That would be a positive decvelopment, but personally I do not have the impression that politicians really listen to us. It always feels as if other considerations take precedence.”

View Maria Melchior's ESCAP 2017 keynote abstract and slide presentation (pdf, 28 pages).

Response by Levi van Dam, Child Psychologist (Netherlands):
Thanx for this interesting read, I totaly agree with the subject and call to action. Do you know the book Our Kids by Robert Putnam? Really interesting to read – recently they published a report on this social inequality gap: https://www.theopportunitygap.com/the-report/
Posted 21 July 2016.