Elsevier

Social Science & Medicine

Volume 73, Issue 7, October 2011, Pages 1088-1096
Social Science & Medicine

Childhood socio-economic status and the onset, persistence, and severity of DSM-IV mental disorders in a US national sample

https://doi.org/10.1016/j.socscimed.2011.06.011Get rights and content

Abstract

Although significant associations between childhood socio-economic status (SES) and adult mental disorders have been widely documented, SES has been defined using several different indicators often considered alone. Little research has examined the relative importance of these different indicators in accounting for the overall associations of childhood SES with adult outcomes. Nor has previous research distinguished associations of childhood SES with first onsets of mental disorders in childhood, adolescence, and adulthood from those with persistence of these disorders into adulthood in accounting for the overall associations between childhood SES and adult mental disorders. Disaggregated data of this sort are presented here for the associations of childhood SES with a wide range of adult DSM-IV mental disorders in the US National Comorbidity Survey Replication (NCS-R), a nationally-representative sample of 5692 adults. Childhood SES was assessed retrospectively with information about parental education and occupation and childhood family financial adversity. Associations of these indicators with first onset of 20 DSM-IV disorders that included anxiety, mood, behavioral, and substance disorders at different life-course stages (childhood, adolescence, early adulthood, and mid-later adulthood) and the persistence/severity of these disorders were examined using discrete-time survival analysis. Lifetime disorders and their ages-of-onset were assessed retrospectively with the WHO Composite International Diagnostic Interview. Different aspects of childhood SES predicted onset, persistence, and severity of mental disorders. Childhood financial hardship predicted onset of all classes of disorders at every life-course stage with odds-ratios (ORs) of 1.7–2.3. Childhood financial hardship was unrelated, in comparison, to disorder persistence or severity. Low parental education, although unrelated to disorder onset, significantly predicted disorder persistence and severity, whereas parental occupation was unrelated to onset, persistence, or severity. Some, but not all, of these associations were explained by other co-occurring childhood adversities. These specifications have important implications for mental health interventions targeting low-SES children.

Highlights

► Childhood financial hardship predicts first onset of DSM-IV mental disorders. ► Financial hardship predicts only child onsets after adjusting for other adversities. ► Parental education and occupation are unassociated with mental disorder onsets. ► Low parental education predicts greater severity of adult mental disorders. ► Low parental education predicts greater persistence of behavior disorders.

Introduction

Accumulating evidence suggests that childhood socio-economic status (SES) is an important marker of early-life environmental conditions that has lasting effects on health across the life-course (Davey Smith et al., 1997, Marmot et al., 2001, Power et al., 2007). Although much of the research on this topic has focused on physical health and mortality (Cohen et al., 2010, Galobardes et al., 2004), significant associations between childhood SES and adverse mental health outcomes in adulthood also have been reported in numerous studies (Fan and Eaton, 2001, Gilman et al., 2002, Gilman et al., 2003, Lundberg, 1993, Marmot et al., 2001, Power and Manor, 1992). However, knowledge of the relationship between childhood SES and adult mental health remains cursory due to several pervasive limitations in existing research. First, the specific dimensions of childhood SES that predict adult mental health remain to be identified due to a lack of studies that include a range of childhood SES indicators. Second, the extent to which childhood SES is associated with specific mental disorders or to other aspects of psychiatric morbidity such as disorder persistence and severity is unclear, as most studies have examined associations only with psychological distress. Third, because previous research has not had information on the age-of-onset of psychiatric outcomes, we know little about when in the life-course childhood SES first has effects on mental health. Finally, although the association between childhood SES and adult mental health may be accounted for by a wide range of other childhood adversities (CAs) that co-occur with low SES, existing research has largely failed to control for these important confounders. We address these gaps in the literature in the current report.

Section snippets

Dimensions of socioeconomic status

Childhood SES might contribute to the subsequent development of psychopathology through a number of pathways that are differentially related to aspects of childhood SES (Braveman et al., 2005, Galobardes et al., 2006, Krieger et al., 1997, Lynch and Kaplan, 2000). The three primary indicators of childhood SES are parental educational attainment, parental occupational status, and financial adversity. Low educational attainment reflects a persistent disadvantage in relative social position that

Dimensions of psychiatric morbidity

Most research on the long-term effects of childhood SES has examined its associations with psychological distress rather than with psychiatric disorders (Lahelma et al., 2006, Lundberg, 1993, Marmot et al., 2001, Power and Manor, 1992). Although some prior studies have examined mental disorders, many have focused exclusively on major depression (Fan and Eaton, 2001, Gilman et al., 2003, Ritsher et al., 2001, Stansfeld et al., 2008), precluding examination of differential effects of childhood

Other childhood adversities

Low childhood SES is associated with increased exposure to a range of other CAs such as parental psychopathology, maltreatment, and family violence (Tracy et al., 2008, Turner et al., 2006) that are associated with psychiatric disorders in adulthood (Green et al., 2010, Kessler et al., 1997, McLaughlin et al., 2010a, McLaughlin et al., 2010b). These CAs are likely confounders of the childhood SES-adult psychopathology association. Although several prior studies have examined this possibility,

Sample

The NCS-R was a face-to-face household survey of English-speaking respondents ages 18 and older carried out between February 2001 and April 2003 in a nationally-representative multi-stage clustered area probability sample of the US household population (Kessler & Merikangas, 2004). The response rate was 70.9%. The survey was administered in two parts. Part I included a core diagnostic assessment of mental disorders (n = 9282). Part II assessed risk factors, consequences, other correlates, and

Associations of childhood adversities with childhood SES and DSM-IV/CIDI disorders

We first conducted a series of analyses to determine whether CAs were associated with childhood SES and mental disorders and thus should be controlled in subsequent analysis. The 11 CAs were related both to childhood SES and to psychiatric disorders. Childhood SES indicators were examined as predictors of each of the 11 CAs in a series of logistic regression models, with controls for age, gender, and race/ethnicity. Financial hardship was associated with 10 of the 11 CAs, whereas parental

Discussion

This study provides useful new information about the associations of childhood SES with the onset, course, and severity of mental disorders. The reliance on retrospective reports is a potential limitation because of the possibility of recall bias (Simon & von Korff, 1995) which may persist despite the use of methods for prompting accurate recall of the onset and offset of disorders (Knauper et al., 1999). Although retrospective studies in representative samples such as this provide an

Acknowledgements

This project was supported by a National Institute of Mental Health grants (K01MH092526) to K. McLaughlin and (K01MH085710) to J. Green. The National Comorbidity Survey Replication (NCS-R) is supported by the National Institute of Mental Health (NIMH; U01-MH60220) with supplemental support from the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044780), and the John W. Alden Trust.

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