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Poverty and Adolescent Mental Health

Original
Blackwell
Malden,
Journal
JCAP
XXX
1744-6171
1073-6077
Poverty Article
of
USA
Publishing
Child
and and Adolescent
Inc MentalPsychiatric
Adolescent Health Nursing

Carol Dashiff, PhD, Wendy DiMicco, DSN, Beverly Myers, MSN, MA, and Kathy Sheppard, MSN, MA

PROBLEM: Poverty and accelerations of Carol Dashiff, PhD, is Professor, School of Nursing,
University of Alabama at Birmingham, Birmingham, AL;
inequality, manifested by the increasing difference Wendy DiMicco, DSN, is Assistant Professor, School of
between the richest and poorest populations, have Nursing, University of Alabama at Birmingham,
Birmingham, AL; Beverly Myers, MSN, MA, is Clinician,
significant effects on the mental health of Brookwood Medical Center, Birmingham, AL; and Kathy
vulnerable groups. Adolescents are vulnerable to Sheppard, MSN, MA, is Associate Professor, University of
Mobile, Mobile, AL.
the effects of poverty. As a time of change and
transition for youth and their families, adolescence
creates both challenges and opportunities to A dolescence is a time of major life transition in many
countries. In countries and communities with an abundance
intervene in the effects of poverty. of resources, the transition to adult responsibilities is gradual
PURPOSE: The purpose of this article is to discuss and extended. However, for youth in poorer countries and
communities, the assumption of adult responsibility is more
the significance of poverty and its impact on dramatic, truncated, and abrupt. Parents in poverty may
take on long work hours at minimum pay when opportunities
adolescent mental health and mental health for work are available resulting in increased demands for
maturity from their children. This is especially true in the
services. case of single-parent households (Leinonen, Solantaus, &
SOURCES: An interdisciplinary literature search Punamaki, 2003; Weinraub & Wolf, 1983). Similarly, researchers
note that many inner-city African American youth enter
was conducted on the topic of poverty and adult-like roles at a very early age (Cauce et al., 2002).
Thus, the developmental stage called “adolescence” is not as
adolescent mental health. uniform as it is characterized; developmental differences in
CONCLUSIONS: Results indicated that nurses the course of adolescence occur among socioeconomic
groups. Nevertheless, the change that occurs during this
need to remain active participants in the provision period, whether rapid or gradual, creates a vulnerability
that is accentuated by poverty. Poverty influences mental
of mental health services to adolescents in poverty health through a variety of paths during adolescence. There-
and increase their advocacy for the creation of fore, the purpose of this literature review is to discuss
how poverty is defined, the significance of poverty
policy changes that address mental health needs of worldwide and in the United States, the impact of poverty
on adolescent mental health, and the delivery of mental
this population. health services to adolescents. The implications for child
and adolescent psychiatric nursing and nursing practice in
Search terms: Adolescent, mental health,
general are also addressed. The review was conducted
parenting, poverty following a search of interdisciplinary databases with the
key words “adolescents,” “poverty,” and “mental health.” The
following databases were encompassed: Academic Search
doi: 10.1111/j.1744-6171.2008.00166.x Premier, CINAHL, MEDLINE, PsycINFO, and Social
Sciences Full Text. The review was limited to the years
Journal of Child and Adolescent Psychiatric Nursing, Volume 22, 2000–May, 2007, except for a few additional classic articles in
Number 1, pp. 23 –32 the field.

JCAPN Volume 22, Number 1, February, 2009 23


Poverty and Adolescent Mental Health

Definitions of Poverty define the international poverty line ($1 per day), which is
the standard for making comparisons among countries. In
A variety of terms are used to identify those who live in summary, definitions of poverty vary somewhat, but income
circumstances of poverty, including “the poor,” those living indicators are predominantly used, even though it is recog-
in circumstances of economic hardship, or neighborhood nized that poverty is characterized by broader deprivations.
disadvantage. Studies of poverty often employ a definition What we know about the impact of poverty is limited by
that is income based. Income-based definitions will exclude definitions that are narrow and conservative.
those marginally above the poverty level who suffer many
of the circumstances surrounding poverty that impact well- Significance of Poverty
being. Therefore, an understanding of what is known about
poverty and its impact on adolescent mental health must Poverty Worldwide
take into account terminology and definitions. The World
Health Organization (WHO, 2006) notes that many terms are Poverty is a global issue, and extreme poverty is a world-
used in discussions to indicate the various facets of poverty. wide health problem (WHO, 2000). Statistics indicate that
Some of these terms broaden conventional definitions of the economic distance between the world’s rich and poor
poverty to include other dimensions, such as social exclusion, countries is increasing (Timimi, 2005), and this disparity of
vulnerability, lack of satisfaction of basic needs, relative economic resources poses a risk for health by affecting the
deprivation, marginalization, and low income. development of infrastructures to support mental health
In the United States, the best known definitions of care. The difference in per capita income between the richest
poverty are those used by the government for statistical and the poorest countries has accelerated by a factor of five
purposes, which are based upon a family’s pretax monetary since the late 1800s (Guillen, 2001). Africa and developing
income. This operationalization of poverty varies according countries in Latin America are the poorest, while Japan and
to family size and composition. In 2006, a family of four with South Korea are the richest. When there is more equality
two children with an income of $20,444, excluding capital in the distribution of resources and wealth within and/or
gains and noncash benefits, was considered poor (living in across countries, overall health improves significantly
poverty) (U.S. Census Bureau, n.d.-a, n.d.-b). However, (Castells, 1998).
many seriously deprived families live above this threshold. Poverty has dramatic effects on behavior and emotions,
Therefore, this method of calculating poverty thresholds, which ultimately impact mental health, especially among
which originated in the mid-1960s, has been criticized as vulnerable groups (McMunn, Nazroo, Marmot, Boreham &
unrealistic (University of Michigan, n.d.). The U.S. Department Goodman, 2001; Rutter & Smith, 1995). Under conditions of
of Health and Human Services disseminates a different economic deprivation, children and adolescents are dis-
indicator of poverty on an annual basis: the “Federal Poverty proportionately affected because they are disproportionately
Guidelines” (Virginia Commonwealth University, n.d.). These represented among the poor (University of Michigan, n.d.).
guidelines characterize poverty based on the number of However, the relationship of poverty to mental health is
family members and the family’s geographic location, and difficult to capture with statistics (Call et al., 2002). Although
they are used to determine eligibility for some federal scholars and clinicians in the area of children’s mental health
programs (Virginia Commonwealth University). However, note that the rates of mental health problems have increased
the end result is roughly equivalent to the previously noted significantly among young people in Western society, the
guidelines. For example, in 2007, a family of four living in ability to detect rising or falling rates is partly a reflection of
the lower 48 states with an income of $20,650 was considered a country’s resources. Only one third of countries even have
poor (U.S. Department of Health and Human Services, a mental health budget that addresses needed infrastructure
2007). Thus, current U.S. governmental definitions of poverty to assess mental health. Among the remaining countries,
are very narrow and conservative. Many families exist at slightly more than a third spends only 1% of their public
basic survival levels above these thresholds. These federal health budget to address mental health problems. This
guidelines for defining poverty contrast with the view of results in biased statistics that favor more obvious mental
poverty put forth by the WHO (2006) in which poverty is disorders (Milne & Robertson, 1998). Rates may also be
thought to include diverse deprivations that interfere with inaccurate because assessments are made with Western
the ability of people to experience a basic level of well-being, medical standards alone, which do not account for culture-
including social exclusion and marginalization. This multidi- specific patterns in the manifestation of distress (Milne &
mensional approach moves beyond a focus on income to Robertson). A further complication in assessing rates of mental
include “voicelessness, vulnerability and powerlessness of disorder among adolescents is the adolescent’s dependency
people to influence decisions that effect their lives” (WHO, on the parents for accessing diagnostic and treatment services.
p. 4). Nevertheless, the WHO uses an income indicator to When services are meager and families are poor, parents are

24 JCAPN Volume 22, Number 1, February, 2009


less able to access services on their children’s behalf, further Marttunen, Pelkonen, von der Pahlen, and Kaltiala-Heino (2006)
contributing to underdetection. A cycle is established in found that adolescents are aware of economic difficulties in
which economic burden and poverty are reinforced by the their families, and that this influences their satisfaction with
failure to receive necessary services (Knapp et al., 2006). their family and environment. The perception by adolescents
that their parents have financial difficulties has been associated
with aspects of adolescent mental health, suggesting that
poverty can have strong direct effects on adolescent mood
Only one third of countries even have a mental states, in addition to the indirect effect through negative
changes in the parent–adolescent relationship (these are dis-
health budget that addresses needed cussed in the following section). For example, an awareness
of parental financial difficulties by Finnish adolescents was
infrastructure to assess mental health.
associated with adolescent girls’ depression and adolescent
boys’ drinking to the point of intoxication (Frojd et al.).
These adolescents’ awareness of parental economic hardship
was also associated with a reported sense of helplessness,
Poverty in the United States and feelings of shame and inferiority. Adolescents from low
socioeconomic environments are noted to be at greater risk
In the United States, a disproportionately large number of for teen suicide (Fergusson, Woodward, & Horwood, 2000)
children and adolescents remain vulnerable over time and the violence exposure experienced by adolescents living
regardless of how poverty is defined. Because the U.S. in high poverty neighborhoods has been associated with
Census Bureau reports poverty data for children under 18 as increased depressive symptoms, anxiety, and externalizing
a group, it is not possible to abstract data pertinent only to problem behaviors (Buckner, Beardslee, & Bassuk, 2004;
adolescents. As far back as the mid-1970s the poverty rate Buka, Stichick, Birdthistle, & Earls, 2001; Fitzpatrick, Piko,
for children under the age of 18 has been consistently higher Wright, & LaGory, 2005).
than the adult rate (DeNavas-Walt, Proctor, & Lee, 2006). In Poverty also seems to have cumulative effects. Chronic
2005, the rate for children was 17.6%, compared with a rate exposure to poverty increases adolescents’ risks for mental
of 11.1% for adults (age 18 – 64 years) and 10.1% for older disorders such as depression, behavioral risks such as
adults (age 65 years and older) (DeNavas-Walt, et al.). substance use (Fergusson et al., 2000), early sexual debut
Whereas children comprised 25% of the total U.S. population, (McBride, Paikoff, & Holmbeck, 2003), and criminal activity
they comprised 35% of the poor (University of Michigan, (Davis, Banks, Fisher, & Grudzinsksa, 2004). Timing of
n.d.). Black and Latino children under the age of 18 were chronic exposure to poverty is important; adolescent boys
more likely than other children to live in poverty; 61% of exposed to persistent poverty are more vulnerable to poor
Latino and black children live in low-income families (less academic achievement and an increase in behavior problems
than two times the federal poverty level, which is the amount (Wilkins et al., 2004).
necessary to meet basic needs), compared to 26% and 28% of A significant relationship between poverty and substance
white and Asian children, respectively (Douglas-Hall, Chau, abuse has been supported, as well as a significant relation-
& Koball, 2006). The child poverty rate differs on the basis ship between substance abuse and criminal offending.
of family composition. Children who lived in female-headed Thus, poverty may result in comorbid mental health
households had a poverty rate of 42.8%, compared with problems. High offenders had past histories of comorbid
8.5% of children who lived in married-couple families substance abuse and childhood placements in restrictive
(DeNavas-Walt et al.). Overall, these statistics indicate that residential programs. A peak in criminal activity occurred in
adolescents, especially those who are black or Latino, and late adolescence (age 18), which directly corresponded to the
those who reside in single-parent families, are more likely to adolescent’s loss of scaffolding welfare and special educa-
live in poverty circumstances, as defined by income. tion benefits (Davis et al., 2004). Thus, loss of an economic
scaffold and services seemed to contribute to problematic
Poverty and Adolescent Mental Health social behavior; this loss may occur in many states of the
United States, where adolescents are treated as adults by
Direct Affect of Poverty on Adolescent Mental the criminal justice system when they reach the age of 18.
Health They then do not qualify for many adult welfare benefits
and mental health services unless they have a psychiatric
Research suggests that poverty may have direct effects on diagnosis (Davis et al.). This demonstrates the importance
adolescent mental health. Poverty can also impact quality of of screening for psychiatric problems during this time of
life and social adjustment (Wilkins et al., 2004). Frojd, late adolescent transition.

JCAPN Volume 22, Number 1, February, 2009 25


Poverty and Adolescent Mental Health

Indirect Effect of Poverty on Adolescent Mental the number of lifetime partners increases, and because younger
Health Through Altered Parenting adolescents often do not use condoms (Donenberg, 2005).
However, despite these negative effects of poverty on
Poverty and economic distress also have an effect on parenting, some suggest that families have strengths that
parents, producing parental distress that disrupts parent– modify the effects of poverty. For example, parental and
adolescent relationships, and often leads to inconsistent family resiliency may mediate the effects of poverty. Stansfeld
discipline, decreased parental monitoring, and parent– and Haines (2004) failed to find an increase in depression
adolescent conflict (Stern, Smith, & Jang, 1999). Adolescent among Bangladeshi adolescents in the United Kingdom
depression, in particular, has been associated with adolescents’ who lived in extreme poverty because family cohesion, cultural
characterization of the parent–adolescent relationship as less identity, religious beliefs, and warm parent–adolescent
supportive and more punitive, blurring of intergenerational relationships buffered the distress of poverty. Although it is
boundaries, parents behaving as peers, and adolescent important to consider family strengths, an overemphasis can
assumption of parental roles (Sagrestano, Holmbeck, Paikoff, contribute to a process of victimizing families due to failure
& Fendrich, 2003). Lower school grades, conflicts with parents, to consider that chronic poverty is an encompassing adversity.
and impaired social relationships can occur when the
adolescent selectively attends to negative parent–adolescent Effect of Poverty on the Social Fabric of
interactions (Wadsworth & Berger, 2006). These findings Neighborhood and Place
support indirect effects of poverty on outcomes that occur
through alterations in parenting. Chronic poverty contributes to financial distress,
Poverty may similarly contribute to adolescent risk behaviors inadequate housing, substandard schools, and deteriorating
through its effect on the parent–adolescent relationship. neighborhood conditions for adolescents (Stern et al., 1999).
Poverty has cumulative effects that relate to parental unem- Poverty also disrupts the collective socialization of adolescents
ployment, underemployment, and unstable work conditions within communities. Poor neighborhoods are characterized
which, rather than poverty per se, lead to parent–adolescent by social disorganization, crime, and high rates of adult
conflict, unsupportive parenting, and harsh disciplinary unemployment, which create environments where adolescents
practices (Brooks-Gunn & Duncan, 1997; Duncan & Brooks- are exposed to gangs and violence (McLeod & Shanahan,
Gunn, 1997; McLeod & Shanahan, 1996). Research has shown 1996). Older children and adolescents living in poverty are
that parent–adolescent conflict is associated with adolescent more likely to be exposed to violence, either as victims,
substance use, early sexual debut, and criminal justice system witnesses, or perpetrators, than those living in higher
involvement (Donenberg, 2005; Goodman & Huang, 2002; income environments (Buckner et al., 2004). Low-income
McBride et al., 2003). The conflict between parent and people from various ethnic, cultural, and racial backgrounds
adolescent that occurs in association with poverty and parental tend to move to impoverished communities where ethnic
distress places adolescents at a significant risk for early sexual groups may be segregated. Segregation results in a lack of
debut. Early parenthood secondary to early sexual debut shared norms and this barrier to intergroup communication
can lead to mental health problems, such as adolescent then produces social isolation and despair (Wickrama &
depression and suicidal behaviors (Fergusson et al., 2000). Bryant, 2003). This has been called the “ghettoization of
poverty” (Fitzpatrick et al., 2005, p. 262). This social isolation
and despair may then be experienced by the family unit.
Residential instability and perceptions of the community as
Poverty may similarly contribute to adolescent disadvantaged have been associated with decreased feelings
of connection and less feelings of social obligation by the
risk behaviors through its effect on the parent– residents (Aptekar, Paardekooper, & Kuebli, 2000). Thus,
adolescent relationship. chronic poverty impacts the individual’s and family’s invest-
ment and commitment to the life of the overall community,
and opportunities for change are restricted.
Brody et al. (2003) demonstrated that the likelihood of
A spiral of adverse socioeconomic consequences can result developing a conduct disorder among young African
from the influence of poverty on the production of mental American adolescents was associated with parenting and
health problems and other outcomes, such as high school family factors, but these associations were strongest among
dropout, lack of employment opportunities, behavioral pro- families from the most disadvantaged neighborhoods. An
blems, social disorganization, and further increases in parent– experimental study of the effects of neighborhood on mental
adolescent conflict (Davis et al., 2004; Wickrama & Bryant, 2003). health demonstrated that parents who stayed in communities
Early sexual debut increases the risk of HIV/AIDS because with high poverty were more distressed than those who moved

26 JCAPN Volume 22, Number 1, February, 2009


to a low-poverty community, and their sons had more problems 2005). Health providers also need education. In low-income
with anxiety and depression. The mental health impact was countries and communities, health providers may be unaware
greater for youth than it was for their parents (Leventhal & of the results of existing clinical trials or systematic reviews
Brooks-Gunn, 2003). Thus, interventions that singularly address of intervention for poverty groups. As a result, health
the parent–adolescent relationship or the adolescent as an providers may resort to the lowest level of practice based on
individual rather than the neighborhood context are likely to outdated information or opinion (Knapp et al.).
have a limited effect on adolescent risk-taking behaviors in
communities that are characterized by deprivation. Insufficient Resources and Problems of Resource
In closing, poverty is associated with many adverse mental Distribution
health outcomes for adolescents directly through effects on
adolescents or indirectly through its effect on parenting A critical issue with regard to adequate mental health
behaviors. Poverty seems to stimulate negative parenting care for adolescents is the persistent shortage of mental
practices that may be a result of parental stress and that health providers. While the numbers of child and adolescent
contribute to parent–adolescent conflict. Increased parent– psychiatrists slightly increased in the United States between
adolescent conflict often leads to an increase in adolescent 1990 and 2001, the numbers still fall far below the estimated
risk-taking behaviors and mood disturbance. Early sexual number needed to adequately treat children and youth
debut, substance use, and criminal activity can increase the (Thomas & Holzer, 2006). Certainly child and adolescent
risks for repeating a cycle of social disadvantage. Inter- psychiatrists are not needed to treat all children, but when
ventions that target adolescent mental health in poverty only the youth with severe mental disorders are considered,
circumstances must acknowledge the adolescent’s contextual the ratio of child and adolescent psychiatrists per 1,000
and social realities and address multiple dimensions, including youth was 1.6 in 2001 (Shaffer et al., 1996). This severe and
investment in the community and community cohesion. serious shortage is accentuated by the fact that children and
youth in poverty are more likely to develop a mental health
Poverty and Service Delivery disorder (Center for Mental Health Services, 1997). States
with the highest percentage of children living in poverty
Knapp et al. (2006) list six separate economic barriers (over 20%), based on the U.S. census from 1990 to 2001, were
to obtaining health services: informational, insufficient nine southern states: Alabama, Arkansas, District of Columbia,
resources, problems of resource distribution, inappropriate Kentucky, Louisiana, Mississippi, New Mexico, Texas, and
resources, inflexible resources, and poor timing of resources. West Virginia. Across all states, only those counties with less
These barriers are more problematic in mental health con- than 20% of youth living in poverty had three or more child
texts and can be accentuated in poverty communities. Their and adolescent psychiatrists per 100,000 youth, which was
scope illustrates the multifaceted impact of impoverished the mean for all counties. The rate of available psychiatrists
environments on mental health services and their delivery. declined with each 1% increase in the numbers of youth
living in poverty (Thomas & Holzer). Rural areas were more
Informational Barriers highly impacted because of the larger percentage of poverty
households. Similar information about the distribution of
Informational barriers exist when the evidence base for other mental health professionals, including psychiatric clin-
practice does not exist or is not disseminated to practitioners ical nurse specialists and practitioners, is not published,
or used to change service delivery (Knapp et al., 2006). although these providers can fill the gap in services.
Although the evidence base for the treatment of adolescents
within a family context is growing (Diamond, 2005), few
mental health services have been configured specifically to
meet the unique characteristics and mental health needs of A critical issue with regard to adequate mental
adolescents and their families living in poverty (Diamond). health care for adolescents is the persistent
Thus, the evidence base for mental health practice with
adolescents living in poverty is limited. A lack of education shortage of mental health providers.
for families and the general public with regard to recogni-
tion and understanding of mental health issues during
adolescence affects help-seeking behavior in early stages of
mental health problems. Parents and adolescents who live in Inappropriate Resources
poverty need education about the impact of poverty on
parent and adolescent mental health and the risks that exist Cauce et al. (2002) noted that evidence suggests that
to healthy social and emotional development (Huang et al., minority adolescents of very low socioeconomic status are

JCAPN Volume 22, Number 1, February, 2009 27


Poverty and Adolescent Mental Health

high users of mental health services. However, high utiliza- Inflexible Resources and Poor Timing of Resources
tion does not equate to appropriate resources. Inappropriate
configuration of resources occurs when the services pro- Inflexibility is the result of services that are organized
vided are not congruent with the needs or preferences of the in a rigid manner driven by bureaucracy, that do not
potential consumers (Knapp et al., 2006). Even when support address consumer desires, or that are poorly coordinated.
services are provided that address family functioning, Among some subgroups, such service deficits have been
family crisis prevention, and the maintenance of children’s identified. Witt, Kasper, and Riley (2003) found that only
residence within the home, families identified as having 41.8% of disabled youth with poor psychosocial adjustment
serious financial challenges may show the least improve- received mental health services. Moreover, a lack of coor-
ment (Statham & Holtermann, 2004). Family-focused support dination of care was more common among those who were
interventions do not necessarily take into account the black and Hispanic, uninsured, poor, and in homes with
economic context of poverty living conditions, inadequate parents who had low educational attainment. Services were
housing, and lack of employment. Interventions that do not more readily utilized when the health provider or the health
address the social and economic context of family life have provider and the family were involved in coordination
limited potency. In an evaluation of a family support program of care.
to prevent family breakdown in homes with children over Another at-risk group is refugee adolescents. Increased
8 years of age in Wales, the financial stress of poverty that stress and mental disorders in refugees can result from a
interfered with effective coping by parents was barely multitude of adverse experiences related to environments
touched by a narrow family support intervention program and relationships they leave, as well as the communities to
from a single agency. Moreover, the resources desired by which they flee. Refugee status often results in financial
parents differed from the support services provided. Parents losses related to unemployment and lack of income. Refugee
wanted day care, accessible parent education services, youth have greater exposure to violence and other adversities,
earlier support for mental health problems in parents and such as lack of stable housing and social isolation, that
youth (indicative of poor timing of services), and assistance increase their need for mental health services, and that
with relationship problems. The broad scope of such services require special services to meet their needs (Howard &
requires interagency cooperation. Hodes, 2000). However, special mental health services are
The characteristics of adolescents require particularly seldom configured for this population.
sensitive services. Adolescents highly value privacy and Stop gap services are often available within the non–
personal choice. In their quest for autonomy and increasing mental health sector, such as medical offices, school systems,
self-reliance, they are less likely to be active seekers of help, juvenile justice system, and child welfare. Critical needs may
especially in Western societies. Self-reliance and privacy be met by these service settings, but less obvious needs
were top reasons for not seeking help among adolescents can be overlooked by providers who do not have expert
(Dubow, Lovko, & Kausch, 1990). Among minorities, mental knowledge and skill (Huang et al., 2005). Clarke, Coombs,
health problems are more likely to be shared with family and Walton (2003) demonstrated, however, how partnership
members or friends, while white parents are more likely to models between experts and generalists can be forged to
make contacts with formal mental health providers (McMiller facilitate flexible services. A school nurse and psychologist
& Weisz, 1996). This may be indicative of mistrust of formal partnership can result in school-based services that can meet
mental health systems by family and friendship networks both critical and less obvious needs. In this model, school
among the minority poor, which may be reinforced by more nurses were provided with mental health education and
coercive referral processes from formal agencies when support that enhanced the treatment of adolescents with
mental health problems become visible. Moreover, for those mental health issues and fostered early identification of
minorities in poverty, referrals to mental health services are adolescents with potential crises. In this environment,
more likely to come from non–mental health service providers, students encounter access to mental health care that is seen
whereas for those with greater financial resources, referrals as friendly, flexible, and accessible due to the familiarity of
come from family and friends. Taken together, these findings the young person within the school environment as opposed
suggest that resources are not formulated to be acceptable to to a mental health care facility. This flexible use of resources
impoverished minorities. resulted in early identification of mental health problems,
The overall structure of service delivery can also be which contributed to better timing of intervention delivery.
problematic. Concentration of resources within large urban In fact, this research has indicated that students with issues
institutions distances care from the places where adolescents will often approach a teacher prior to a healthcare professional.
and their families live their daily lives. Bureaucracy and It has been suggested that educational preparation about basic
formality within large structures are not likely to be appealing mental health awareness be included for these professionals
to adolescents or the poor. as well (Clarke et al.).

28 JCAPN Volume 22, Number 1, February, 2009


Implications Innovative strategies of service delivery are needed for
adolescent poverty groups who are difficult to access. For
Direct practice involves service provision to families in those in rural environments, two strategies that are being
poverty and must be multifaceted with interagency coopera- used are the provision of specialty services through tele-
tion and collaboration as well as multidisciplinary teams. medicine and the development of interdisciplinary outreach
Poverty creates a situation of challenge for the delivery of teams. Outreach teams travel periodically to distant sites
mental health services to adolescents and their families. This either as a group or cyclically as individuals. Partnerships
review suggests strategies that might be used to address the between specialists and generalists are being developed to
problem within the areas of direct practice and social action. expand the impact of expert knowledge through generalists,
Intervention programs to address adolescent mental who are more able to identify those at risk and in need of
health issues need to be delivered in a multisystemic manner preventative and screening services to promote early treat-
to provide the adolescent with needed coping skills, affect ment. Partnerships between school nurses and psychologists
parent–adolescent communication, intervene in parental or other experts, such as adolescent psychiatric nurses or
distress, and address the multitude of factors associated with adolescent psychiatrists, provide a model in which more
poverty that affect the safety and security of neighborhood informally structured services are directly available and
environment. Intervention requires that partnerships be easier for adolescents to access. Moreover, the utilization of
formed between mental health professionals and families a primary care provider in an accessible context has the
to develop a plan of coordinated care. Because poverty com- potential to make mental health services less stigmatizing for
munities are often multiethnic, the needs of specific cultural adolescents living in poverty (Huang et al., 2005). However,
groups must be taken into account to provide culturally recent research indicates that only one half of U.S. middle
competent services (Huang et al., 2005). One component of and high schools have any mental health counseling services
assessment of ethnic groups is whether there are unique available onsite and that a greater presence of mental health
patterns of distress that are not captured by traditional specialists is needed in the school setting (Slade, 2003).
diagnostic systems. The specific needs of unique populations
living in poverty (developmentally disabled and refugees)
may require unique services.
Clinicians working with poverty groups should routinely Routine assessment of adolescents living at or
screen for known mental health risks, such as depression,
substance abuse, and other comorbidities, and also be aware near the poverty threshold is needed to identify
of other health risks that are associated with these mental those at risk for mental health problems and
disorders. Moreover, routine assessment of adolescents
living at or near the poverty threshold is needed to identify offer preventative programs and services.
those at risk for mental health problems and offer preventative
programs and services. These assessments should include
the following areas: exposure to violence, academic achieve-
ment, conflict with parents, sexual risk behavior, impaired One program that is gaining popularity is that of mentoring.
social relationships, and age-related loss of scaffolding An adolescent who is at risk can be paired with an adult to
services. Prevention programs aimed at building family and meet regularly, engaging in activities and conversation.
community strengths can reduce feelings of powerless, These programs can be found within the community through
marginalization, and stigmatization. Educational programs agencies such as churches, colleges, social organizations, and
to increase awareness of the issues faced by adolescents and schools. Adult mentors have been responsible for providing
their families, their systemic nature, and the need for multi- many youth with meaningful social interaction, supervision
systemic treatment can be provided to these communities and guidance, cultural enrichment, spiritual guidance, sense
and their providers (Huang et al., 2005). This approach of self-worth, and other qualities that support mental health
provides an opportunity for community action, especially in this population (Bloomquist & Schnell, 2002).
when community advocacy groups have been formed. It can Within the focus of social action, the avoidance of gross
also set the stage for community input to and acceptance of generalizations about the adolescent developmental
services, such as short-term family therapy, which has proven period and families living in poverty were highlighted. The
to be beneficial for the adolescent and the family. Manual- experience and pattern of adolescent development varies with
based, focused interventions from this treatment approach cultural groups and economic circumstances. Poverty may
can be taught to providers, allowing for rapid treatment and create a situation that creates pressure to move more quickly
evaluation of the adolescent and family within a community into adult roles, and this should not be judged as non-
context (Diamond & Josephson, 2005). normative development. Similarly, families living in poverty

JCAPN Volume 22, Number 1, February, 2009 29


Poverty and Adolescent Mental Health

should not be stigmatized or blamed for poor adolescent Conclusions


outcomes that are a product of the families’ environmental
context. Worldwide, children and adolescents are disproportion-
Clearly, formal bureaucratic organizations and referral ately represented among the poor. Chronic exposure to
processes are intimidating and create suspiciousness among poverty increases adolescents’ risk for depression, substance
the poor, even though mental health services may be more use, early sexual debut, and criminal activity (Fergusson et al.,
frequently accessed by poverty groups who have public 2000). Numerous economic barriers have been identified that
health insurance. Indigenous community workers may be limit access to mental health services: barriers to evidence-
more favorable routes of referral. Partnerships are also based practice prevent the use of effective treatments; critical
needed between mental health service providers and family mental health provider shortages limit available services;
networks in poverty communities to enhance trust. The forma- and the inappropriate allocation of limited resources often
tion of community advisory groups that meet with providers leads to an uncoordinated provision of multiagency services
inside poverty communities is a strategy to build more trusting (Knapp et al., 2006). In order to meet the unique healthcare
relationships. Community forums encourage members to needs of adolescents, psychiatric nurses and nursing practice
develop cohesion and identify their needs. The public trust in general can benefit from the following recommendations:
engendered by nurses creates an opportunity for nurses to reduce the stigmatization of adolescents who live in
work collaboratively with communities to foster decreased poverty by providing culturally sensitive and social context
isolation and enhanced commitment to the community. appropriate care; participate in multidisciplinary partnerships
This literature review emphasizes the need for political to ensure a coordinated and appropriate delivery of services
action by mental health service providers and adolescent and advocate for economic resources to support these
psychiatric nurses. Advocacy is needed to promote govern- services; and develop or seek out innovative services, such
mental policies in the following areas: increased funding of as outreach teams, to increase the access to mental health
mental health services and preparation of providers to serve services for rural adolescents who live in poverty. In addition,
youth living in poverty, development of a less restrictive nurses need to remain active advocates and participants in
definition of poverty, development of coordinated systems the creation of policy changes that address mental health of
of care and family–provider partnerships, and development adolescents living in poverty.
and funding of innovative practice models that expand the
impact of mental health experts. Poverty must be recognized Author contact: dashiffc@uab.edu, with a copy to the Editor:
as a global issue. The ability of service providers to make poster@uta.edu
convincing arguments about the negative impact of poverty
locally and worldwide, as well as awareness of the success References
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32 JCAPN Volume 22, Number 1, February, 2009