The Link Between Low The Link Between Low Socioeconomic Status and Socioeconomic Status and

PsychopathologyPsychopathology

ArticleArticle

Explaining the Link Between Low Explaining the Link Between Low Socioeconomic Status and Socioeconomic Status and Psychopathology: Testing Two Psychopathology: Testing Two Mechanisms of Social Causation Mechanisms of Social Causation HypothesisHypothesis

Martha E. WadsworthMartha E. WadsworthThomas M. AchenbachThomas M. Achenbach

Review of the LiteratureReview of the Literature Rates of psychopathology and mental disorders are higher Rates of psychopathology and mental disorders are higher

among individuals of lower socioeconomic status.among individuals of lower socioeconomic status. This has been found for:This has been found for:

Major Depressive DisorderMajor Depressive Disorder Antisocial Personality DisorderAntisocial Personality Disorder Anxiety DisordersAnxiety Disorders Substance Use DisordersSubstance Use Disorders

Also found for measures of:Also found for measures of: DemoralizationDemoralization Depressive symptomsDepressive symptoms Nonspecific distressNonspecific distress

What is interestingWhat is interesting about the disorders found to be more about the disorders found to be more prominent in lower SES individuals?prominent in lower SES individuals?

Both Internalizing and Externalizing Both Internalizing and Externalizing DisordersDisorders

Internalizing DisordersInternalizing Disorders Major Depressive DisordersMajor Depressive Disorders Anxiety DisordersAnxiety Disorders

Externalizing DisordersExternalizing Disorders Antisocial Personality DisorderAntisocial Personality Disorder Substance Use DisorderSubstance Use Disorder

Robust support for the social causation Robust support for the social causation hypothesis in both Internalizing and hypothesis in both Internalizing and Externalizing disordersExternalizing disorders

Two Leading HypothesesTwo Leading Hypotheses

Social Selection Hypothesis or Social Selection Hypothesis or “Downward Drift” Hypothesis“Downward Drift” Hypothesis

Social Causation HypothesisSocial Causation Hypothesis

Social Selection HypothesisSocial Selection Hypothesis Individuals with psychological problems “drift” downward Individuals with psychological problems “drift” downward

because their impairment prevents them from functioning because their impairment prevents them from functioning in society and meeting societal role expectations. in society and meeting societal role expectations.

Initial causes of psychopathology are unrelated to SES (i.e., Initial causes of psychopathology are unrelated to SES (i.e., genetic liabilities)genetic liabilities)

What example was mentioned in the article?What example was mentioned in the article?

Support for hypothesis:Support for hypothesis: SES differences in rates of schizophrenia SES differences in rates of schizophrenia

(Dohrenwend et al., 1992)(Dohrenwend et al., 1992) Possibly rates of ADHD (Miech et al., 1999)Possibly rates of ADHD (Miech et al., 1999)

Social Causation HypothesisSocial Causation Hypothesis People with low SES develop psychological People with low SES develop psychological

problems as a result of the stress caused by problems as a result of the stress caused by economic difficulties.economic difficulties.

Poverty = an adverse event that may activate a Poverty = an adverse event that may activate a diathesis (i.e., genetic predisposition)diathesis (i.e., genetic predisposition)

Support for this hypothesis:Support for this hypothesis: High levels of environmental stress have been High levels of environmental stress have been

shown to produce PTSD, depression, and anxietyshown to produce PTSD, depression, and anxiety High incidence rates of mental disorders among High incidence rates of mental disorders among

people with low SESpeople with low SES

Like the age-old adage:Like the age-old adage:

Which came first, the chicken or the Which came first, the chicken or the egg?egg?

What would the diathesis stress What would the diathesis stress model for the social causation model for the social causation hypothesis look like?hypothesis look like?

Diathesis Stress ModelDiathesis Stress Model

Genetic Predisposition

Stressful situation(s)

related to low SES

Example: Not having enough money to pay

for basic needs (i.e., rent or utility bills)

Mental Disorder

ClipClip

What are your thoughts on the news What are your thoughts on the news story you just saw?story you just saw?

Does it help you understand how low Does it help you understand how low SES can create stresses that may SES can create stresses that may lead to psychological problems?lead to psychological problems?

Social Causation HypothesisSocial Causation Hypothesis Differential incidence hypothesisDifferential incidence hypothesis – –

• Previous studies testing the social causation Previous studies testing the social causation hypothesis have typically compared incidence rates.hypothesis have typically compared incidence rates.

Additional interpretation: Individuals from all SES Additional interpretation: Individuals from all SES levels are susceptible to psychological problems, but levels are susceptible to psychological problems, but low-SES individuals do not recover as quickly because low-SES individuals do not recover as quickly because they do not have the same access to treatment as they do not have the same access to treatment as middle and higher SES individualsmiddle and higher SES individuals

Differential cumulative prevalenceDifferential cumulative prevalence hypothesis hypothesis – – There is an accumulation of low-SES cases as new There is an accumulation of low-SES cases as new

cases occur and existing ones do not recover.cases occur and existing ones do not recover.

Previous studies have not tested Previous studies have not tested cumulative prevalence ratescumulative prevalence rates

Would provide information on: Would provide information on: • whether social causation effects are solely due to whether social causation effects are solely due to

increased incidence rates among low SES individualsincreased incidence rates among low SES individuals

OROR

• whether low SES individuals are less likely to recover whether low SES individuals are less likely to recover than higher SES individuals due to differences in access than higher SES individuals due to differences in access to effective treatment (differential cumulative to effective treatment (differential cumulative prevalence)prevalence)

What can be learned from children What can be learned from children and adolescents?and adolescents?

Better test of social causation hypothesis since Better test of social causation hypothesis since children’s behaviors do not affect a family’s SESchildren’s behaviors do not affect a family’s SES

Longitudinal studies:Longitudinal studies: Can track the child over time and examine the Can track the child over time and examine the

course of psychological problems and referrals for course of psychological problems and referrals for mental health treatment.mental health treatment.

Can examine differential incidence and cumulative Can examine differential incidence and cumulative prevalence hypothesesprevalence hypotheses

Current StudyCurrent Study Extended previous research of the social causation hypothesis by Extended previous research of the social causation hypothesis by

testing both the testing both the differential incidencedifferential incidence and and cumulative prevalencecumulative prevalence hypotheseshypotheses

Longitudinal data for children and youth aged 8-17Longitudinal data for children and youth aged 8-17 3 SES levels: Low, Middle, High3 SES levels: Low, Middle, High 4 assessment time points in 3-yr Intervals4 assessment time points in 3-yr Intervals Compared the Compared the newnew case incidence rates of seven forms of case incidence rates of seven forms of

psychopathologypsychopathology Compared utilization of mental health services after the first time Compared utilization of mental health services after the first time

pointpoint Examined cumulative prevalence findings for clinically elevated Examined cumulative prevalence findings for clinically elevated

cases by SES levelcases by SES level Also looked at Also looked at remissionremission rates by SES levels rates by SES levels

Also tested for changes in syndrome scores at time points 2, 3, 4.Also tested for changes in syndrome scores at time points 2, 3, 4.

Findings- Syndrome ScoresFindings- Syndrome Scores Looked at syndrome scores on thought problems, somatic Looked at syndrome scores on thought problems, somatic

complaints, attention problems, delinquent behavior, and complaints, attention problems, delinquent behavior, and aggressive behavior.aggressive behavior.

There were no significant differences between the middle There were no significant differences between the middle and high SES groups in differences of syndrome scores over and high SES groups in differences of syndrome scores over timetime

Syndrome scores for the low SES groups increased over Syndrome scores for the low SES groups increased over timetime

Refer to Figure 1 in article (pg. 1149)Refer to Figure 1 in article (pg. 1149)

FindingsFindings A different pattern was found for A different pattern was found for

anxious/depressed scores:anxious/depressed scores:• See Figure 2 (on pg. 1149)See Figure 2 (on pg. 1149)

Scores were higher for the low SES Scores were higher for the low SES group only at time point 4.group only at time point 4.

How do the authors explain this How do the authors explain this finding?finding?

Low SES children are no more at risk for Low SES children are no more at risk for anxious/depressed problems than higher SES anxious/depressed problems than higher SES children until young adulthoodchildren until young adulthood

Different finding may be due to proximal factors Different finding may be due to proximal factors associated with low SES (i.e., parental associated with low SES (i.e., parental depression)depression)

Does anyone have an example of this from the Does anyone have an example of this from the clip?clip?

Adults are more likely to be vulnerable to the Adults are more likely to be vulnerable to the demoralization and stress that can arise from low demoralization and stress that can arise from low status jobs or marital dissolution.status jobs or marital dissolution.

Finding- Cumulative PrevalenceFinding- Cumulative Prevalence An accumulation of elevated scores among individuals from low An accumulation of elevated scores among individuals from low

SES for all syndromes except anxious/depressed and somatic SES for all syndromes except anxious/depressed and somatic complaintscomplaints

No differences in remission rates by SES on thought problems, No differences in remission rates by SES on thought problems, delinquent behavior, or aggressive behaviordelinquent behavior, or aggressive behavior

Thus, the larger numbers of low-SES individuals reflect higher Thus, the larger numbers of low-SES individuals reflect higher incidence rates of elevated syndrome scores.incidence rates of elevated syndrome scores.

This result was not due to worse remission rates followed by This result was not due to worse remission rates followed by accumulation of casesaccumulation of cases

However, data indicated that low SES individuals did not get well However, data indicated that low SES individuals did not get well as quickly or to the same extent as middle and high SES as quickly or to the same extent as middle and high SES individuals with somatic complaints (at Time 2) and withdrawn (at individuals with somatic complaints (at Time 2) and withdrawn (at Time 3).Time 3).

Finding- Differential Mental Health Finding- Differential Mental Health ReferralsReferrals

Although the low SES group had Although the low SES group had higher problem scores on 5 of the 7 higher problem scores on 5 of the 7 syndromes, there were no syndromes, there were no differences between groups in differences between groups in utilization of mental health services utilization of mental health services

ConclusionsConclusions Low SES appears to contribute to more Low SES appears to contribute to more

new cases of several forms of new cases of several forms of psychopathology.psychopathology.

Low SES appears to limit access to mental Low SES appears to limit access to mental health care for some individuals who have health care for some individuals who have high problem scores.high problem scores.

These results combined with previous These results combined with previous studies showing social selection effects studies showing social selection effects may provide support for a temporal course.may provide support for a temporal course.

Support for a temporal course of Support for a temporal course of psychological problemspsychological problems

Social causation

effects

Initial psychological

problems(activates a diathesis)

Failure to

recover

Downward drift found in adult samples

(Social Selection effects)

Important to NoteImportant to Note Social causation by itself does not imply causation of Social causation by itself does not imply causation of

psychopathology:psychopathology:• Not all low SES individuals have mental disorders- Not all low SES individuals have mental disorders-

resiliencyresiliency

Implies that stresses resulting from having a low SES can Implies that stresses resulting from having a low SES can contribute to various levels of psychopathologycontribute to various levels of psychopathology

What do results of this study show us in light of the lecture What do results of this study show us in light of the lecture on Nature vs. Nurture debate?on Nature vs. Nurture debate?

Results of this study further support the Results of this study further support the Multiplicative/Interactive ApproachMultiplicative/Interactive Approach

Genes and the environment interact to produce Genes and the environment interact to produce psychopathologypsychopathology

Therefore, it is Therefore, it is naturenature AND AND nurturenurture, not one or , not one or the other.the other.

As aspiring clinicians, what are some As aspiring clinicians, what are some clinical implications of the present clinical implications of the present study?study?

Clinical Implications and Future Clinical Implications and Future DirectionsDirections

Increase access to effective healthcare and Increase access to effective healthcare and mental health services- mental health services-

• more mental health providers and prevention programs in more mental health providers and prevention programs in low income communitieslow income communities

• more affordable mental healthcaremore affordable mental healthcare

Treatments should address the stress and Treatments should address the stress and adversity related to having a low SESadversity related to having a low SES

Clinicians should be aware of potential biases Clinicians should be aware of potential biases they have with regard to low SES individualsthey have with regard to low SES individuals

More research on prevention programs that More research on prevention programs that address economic stress, stress reactivity, and address economic stress, stress reactivity, and copingcoping