Understanding Socioeconomic Status and Adolescent Behavioral health—Time to Move Beyond Simplistic Measures and Cross-sectional Data
2021; Elsevier BV; Volume: 69; Issue: 5 Linguagem: Inglês
10.1016/j.jadohealth.2021.08.017
ISSN1879-1972
Autores Tópico(s)Health disparities and outcomes
ResumoSee Related Article on p.774Income inequality has steadily increased over the past several decades [[1]Bor J. Cohen G.H. Galea S. Population health in an era of rising income inequality: USA, 1980-2015.Lancet. 2017; 389: 1475-1490Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar]. Along with the growing wealth gap, we have also seen rising alcohol and drug use disorders, worsening mental health symptoms, and increasing deaths due to drug overdose and suicide [1Bor J. Cohen G.H. Galea S. Population health in an era of rising income inequality: USA, 1980-2015.Lancet. 2017; 389: 1475-1490Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar, 2Grant B.F. Chou S.P. Saha T.D. et al.Prevalence of 12-Month alcohol Use, High-risk drinking, and DSM-IV alcohol Use disorder in the United States, 2001-2002 to 2012-2013: Results from the National Epidemiologic survey on alcohol and related Conditions.JAMA Psychiatry. 2017; 74: 911-923Crossref PubMed Scopus (678) Google Scholar, 3Mojtabai R. Olfson M. Han B. National trends in the prevalence and treatment of depression in adolescents and young adults.Pediatrics. 2016; 138: e20161878Crossref PubMed Scopus (660) Google Scholar, 4Miron O. Yu K.H. Wilf-Miron R. Kohane I.S. Suicide Rates among adolescents and young adults in the United States, 2000-2017.Jama. 2019; 321: 2362-2364Crossref PubMed Scopus (114) Google Scholar]. Adolescents have not been spared from this mental health crisis; suicide is now the second leading cause of death among adolescents in the U.S., and deaths due to drug overdose are also increasing [[5]Gaither J.R. Shabanova V. Leventhal J.M. US National trends in Pediatric deaths from Prescription and illicit Opioids, 1999-2016.JAMA Netw Open. 2018; 1: e186558Crossref PubMed Scopus (157) Google Scholar,[6]Centers for Disease Control and PreventionUnderlying cause of death 1999-2019 on CDC WONDER online Database, released in 2020. Data are from the Multiple cause of death Files, 1999-2019, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.http://wonder.cdc.gov/ucd-icd10.htmlDate: 2020Date accessed: July 27, 2021Google Scholar]. These alarming trends have only escalated further with the COVID-19 pandemic [[7]Ahmad F.B. Rossen L.M. Sutton P. Provisional drug overdose death counts. National Center for Health Statistics.https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htmDate: 2021Date accessed: July 27, 2021Google Scholar]. Adolescents and their families continue to face unprecedented challenges because of social isolation, financial strain, and increased stress and anxiety. Families that were at the margins of the income gradient before the pandemic have suffered disproportionately. See Related Article on p.774 It is perhaps never been more critical to understand the association between socioeconomic status (SES) and behavioral health as we grapple with the fallout from the pandemic. However, despite decades of research regarding SES and health, much remains unknown regarding its association with behavioral health outcomes, including adolescent substance use. Although adolescent tobacco use is consistently associated with lower SES, findings regarding cannabis use or other illicit drug use are mixed, and in most cases, alcohol use appears more prevalent among those with higher income [8Moor I. Kuipers M.A.G. Lorant V. et al.Inequalities in adolescent self-rated health and smoking in Europe: Comparing different indicators of socioeconomic status.J Epidemiol Community Health. 2019; 73: 963-970Crossref PubMed Scopus (16) Google Scholar, 9Kwok K.H.R. Yuan S.N.V. Parental socioeconomic status and binge drinking in adolescents: A systematic review.Am J Addict. 2016; 25: 610-619Crossref PubMed Scopus (16) Google Scholar, 10Collins S.E. Associations between socioeconomic factors and alcohol outcomes.Alcohol Res-Curr Rev. 2016; 38: 83-94Google Scholar, 11Halladay J. Woock R. El-Khechen H. et al.Patterns of substance use among adolescents: A systematic review.Drug and Alcohol Dependence. 2020; 216: 108222Crossref PubMed Scopus (14) Google Scholar]. It is hard to know whether inconsistencies result from variations in SES measures (e.g., income, educational attainment, neighborhood poverty, cross-sectional or longitudinal measures) [[12]Elgar F.J. McKinnon B. Torsheim T. et al.Patterns of socioeconomic inequality in adolescent health differ According to the measure of socioeconomic Position.Social Indicators Res. 2016; 127: 1169-1180Crossref Scopus (43) Google Scholar]. The one-dimensional measures of SES typically used in prior studies may poorly characterize these associations. Newer data-driven approaches are needed to expand our understanding of the relationship between SES and substance use and are beginning to offer new insight [[11]Halladay J. Woock R. El-Khechen H. et al.Patterns of substance use among adolescents: A systematic review.Drug and Alcohol Dependence. 2020; 216: 108222Crossref PubMed Scopus (14) Google Scholar]. Lowthian et al. [[13]Lowthian E. Page N. Melendez-Torres G.J. et al.Using latent class Analysis to Explore complex associations between socioeconomic status and adolescent health and well-being.J Adolesc Health. 2021; 69: 774-781Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar] take an important step in this direction with their use of latent class analysis and multidimensional measures of SES to shed new light on this complex relationship. In their exploration of the multifaceted experience of SES, they jointly assess commonly used SES factors such as income and education, with additional less commonly used measures of family affluence and school-level deprivation. Results identified heterogeneity in the effects of SES on mental health outcomes, whereby adolescents whose families are at the margins, or who are “chronically poor,” as well as the “affluent” families in deprived schools experience higher levels of substance use and poorer mental well-being. These results suggest that we cannot focus on a single aspect of SES (e.g., income) because even those adolescents who are relatively higher in affluence but who attend schools where deprivation is more concentrated are at risk. We must consider the combined effects of these characteristics on behaviors. Still, the study had limitations. Although the analysis used a large sample of secondary school children, the sample was overwhelmingly white (91%) and was unable to assess patterning of substance use and mental health outcomes by race. Racial and ethnic minority status is tightly linked to both SES and health outcomes [[14]Akee R. Jones M.R. Porter S.R. Race Matters: Income Shares, income inequality, and income Mobility for All US races.Demography. 2019; 56: 999-1021Crossref PubMed Scopus (29) Google Scholar]. Despite small numbers, students in this sample who identified as racial/ethnic minorities were significantly more likely to be in the classes reflecting school-level deprivation, lower family affluence, and lower overall income (“nonworking”). This is not surprising given that systemic racism and segregation has led to greater concentration of racial/ethnic minority families in lower-resourced neighborhoods. Hopefully, future research could extend the findings of Lowthian et al. by including a more diverse student population that would enable examining the intersection of race/ethnicity with SES in contributing to risk for behavioral health outcomes. However, our understanding of the relationship between SES and mental health and substance use should move beyond reliance on survey-based assessments in school settings. This is likely to undervalue the relationship between SES and mental well-being or substance use, given that these surveys miss a particularly vulnerable population of adolescents and families—those who have dropped out of school and those experiencing homelessness. National school-based surveys cannot capture the families that are truly at the margins because the very instability of their lived experiences means that they may be unable to participate in data collection due to school absences. Thus, although the results of this work are compelling, it may only scratch the surface because the population at greatest risk for SES deprivation and poor mental health or substance-related outcomes may not be represented. As we move beyond the use of singular measures of SES, we should also move beyond single point-in-time assessments of mental health and well-being, substance use, and household financial stability, given their constant fluctuations. Prior studies have demonstrated the feasibility of ecological momentary assessment data collection among adolescents enrolled in schools, young adults in substance use treatment, and youth experiencing homelessness [15Boettner B. Browning C.R. Calder C.A. Feasibility and Validity of Geographically Explicit ecological momentary assessment with Recall-Aided Space-time Budgets.J Res Adolesc. 2019; 29: 627-645Crossref PubMed Scopus (11) Google Scholar, 16Dennis M.L. Scott C.K. Funk R.R. Nicholson L. A Pilot study to examine the feasibility and Potential Effectiveness of using smartphones to Provide Recovery Support for adolescents.Substance abuse. 2015; 36: 486-492Crossref PubMed Scopus (45) Google Scholar, 17Acorda D. Businelle M. Santa Maria D. Perceived Impacts, Acceptability, and Recommendations for ecological momentary assessment among youth experiencing homelessness: Qualitative study.JMIR Form Res. 2021; 5: e21638Crossref PubMed Scopus (2) Google Scholar]. The advantage ecological momentary assessment offers is that it can randomly sample health behaviors through prompted surveys to detect fluctuations in substance use patterns as well as their predictors [[18]Shiffman S. Stone A.A. Hufford M.R. Ecological momentary assessment.Annu Rev Clin Psychol. 2008; 4: 1-32Crossref PubMed Scopus (2945) Google Scholar]. As adolescents are difficult to engage in substance use treatment services, identifying ways to deliver prevention and treatment in an accessible and user-friendly way through smartphones could increase delivery at scale. As the digital divide in access to smartphones rapidly declines, research is needed to catch up and harness these opportunities for public health prevention. Lowthian et al. demonstrate the use of creative metrics and new analytic approaches for uncovering heterogeneity in a poorly understood area of research. A more complete understanding of the relationship between SES, mental health, and substance use among adolescents will be needed as the world begins to take stock of the immense effects of a pandemic on behavioral health. Adolescence is a critical period in growth and development when symptoms of depression, anxiety, and substance use often emerge for the first time. Early age of substance use initiation is associated with lifelong consequences including risk for substance use disorder in adolescence and adulthood [[19]Lopez-Quintero C. Perez de los Cobos J. Hasin D.S. et al.Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic survey on alcohol and related Conditions (NESARC).Drug and Alcohol Dependence. 2011; 115: 120-130Crossref PubMed Scopus (401) Google Scholar]. This research will hopefully inspire further work to understand opportunities for untangling the relationship between SES and mental health and substance use to importantly target prevention efforts. The first author did not receive a specific grant for this project from funding agencies in the public, commercial, or not-for-profit sectors. Using Latent Class Analysis to Explore Complex Associations Between Socioeconomic Status and Adolescent Health and Well-BeingJournal of Adolescent HealthVol. 69Issue 5PreviewResearch demonstrates a strong socioeconomic gradient in health and well-being. However, many studies rely on unidimensional measures of socioeconomic status (SES) (e.g. educational qualifications, household income), and there is often a more limited consideration of how facets of SES combine to impact well-being. This paper develops a multidimensional measure of SES, drawing on family and school-level factors, to provide more nuanced understandings of socioeconomic patterns in adolescent substance use and mental well-being. Full-Text PDF Open Access
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