Social Determinants of Mental Health

Both social and environmental factors have a significant impact on youth wellness related to physical and mental health outcomes. These factors, known as social determinants of health (SDOH), include a wide range of context including economic circumstances, physical living conditions, access to quality education, access to effective healthcare, family systems, and social and community structures.

Impact of social determinants of health on mental health

According to pediatric psychologist Jenna Glover, PhD, when these conditions are unstable or not met, children are at an increased risk for developing mental health problems. For example, research¹ has found that:

• Children from families experiencing low socioeconomic status or poverty are more likely to experience mental health problems, specifically externalizing disorders.
• They are more likely to be diagnosed with multiple mental health diagnoses.
• Improvement in economic circumstances leads to a reduction in mental health problems.

This is likely a result of a myriad of contributing factors as economic instability has wide-ranging impacts on access to housing, food and healthcare. This is just one example taken from a large body of research that reflects the impact of social determinants of health on mental health problems². Therefore, professionals working with youth need to focus on SDOH to support healthy development and growth in youth and mitigate the potential harmful outcomes that occur when SDOH are neglected. Below are considerations of the impact of SDOH in two areas and ways providers can assess and support families in these domains.

Healthy food options and mental health

Consistent access to food and the quantity and quality of foods we consume all have a major impact on our mental health. First, families that experience food insecurity have increased levels of stress as parents have to grapple with economic hardship decisions between paying housing cost, utility bills or buying groceries. Having to navigate trade-offs between food and other basic necessities increases parents’ risk for anxiety and depression, which can have a negative downstream impact on their children’s mental health³. Additionally, when families don’t have access to healthy food options, unhealthy eating patterns can develop, which also increases risk for anxiety and depression.

Given the direct connection between consistent access to quality food and mental health outcomes, it is important for providers to routinely screen families for food insecurity. This can be done utilizing the Hunger Vital Sign4, which is a validated two-question food insecurity screening tool⁴. A patient or family is given three response options to the statements below that include: often true, sometimes true or never true.

• Within the past 12 months, we worried whether our food would run out before we got money to buy more.
• Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.

A positive screen for food insecurity is the result of a patient or family responding with often or sometimes true to either or both statements. It is important to routinely screen all families because food insecurity is not an observable state and a family’s experience of food security can change rapidly. Additionally, it is important for providers to inquire about access to a range of healthy foods as there are many individuals who live in food deserts where access to diverse nutrition is unavailable.

Once this information is obtained, providers can work to implement interventions to address food insecurity including appropriate medical interventions and connecting patients to federal nutrition programs and local food resources. The American Academy of Pediatrics also has a comprehensive toolkit available to help assist providers who are seeking additional guidance on screening and interventions: Addressing Food Insecurity: A Toolkit for Pediatricians.  

Adverse childhood experiences and mental health

The Adverse Childhood Experiences (ACE) study is one of the largest research projects ever conducted on the impact of childhood abuse and neglect and the outcomes of these experiences on health and well-being in adulthood⁵. This landmark study asked over 17,000 participants to provide information regarding adverse childhood experiences, including physical, emotional or sexual abuse, witnessing intimate partner violence, loss of parent through divorce, death or abandonment and growing up in a household where there was substance use disorder, mental health problems or incarcerated family members.

Results of this study found a relationship between number of ACEs and physical and mental health problems specifically underscoring that these were dose dependent – meaning that those experiencing two or more ACES had a significantly higher risk of developing depression and substance use disorders than those with fewer ACEs. Knowing this makes it important that providers routinely screen for adverse childhood experiences using validated measures such as the Pediatric ACEs and Related Life Events Screener (PEARLS). The PEARLS can be used to screen children and teens from 0 to 19 years of age and includes versions for a parent to complete and versions for adolescent self-report.  

Finally, when patients are identified as experiencing adverse childhood events, providers can work on treatment planning options to help address these situations and related traumatic symptoms. Many youths will need to be referred for more in-depth mental health treatment and should be supported through empirically supported approaches (trauma-informed care) and treatments (Trauma-focused Cognitive Behavioral Therapy). Get more detailed information regarding screening and treatment for ACES.

References

1. Reiss, F. (2013) Socioeconomic inequalities and mental health problems in children and adolescents: A systematic review. Social Science and Medicine, 90, 24-31.
2. Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International review of psychiatry, 26(4), 392-407.
3. Knowles, M., Rabinowich, J., Ettinger de Cuba, S., Cutts, D. B., & Chilton, M. (2016). “Do you wanna breathe or eat?”: Parent perspectives on child health consequences of food insecurity, trade-offs, and toxic stress. Maternal and Child Health Journal, 20(1), 25-32.
4. Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., Cook, J. T., Ettinger de Cuba, S. E., Casey, P. H., Chilton, M., Cutts, D. B., Meyers A. F., Frank, D. A. (2010). Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. Pediatrics, 126(1), 26-32. doi:10.1542/peds.2009-3146.
5. Centers for Disease Control: About the CDC-Kaiser ACE Study