Adolescent mental health and behavioural problems, and intergenerational social mobility: A decomposition of health selection effects
Introduction
Inequalities in health outcomes are ubiquitous, and this is true of mental as well as physical health. Explanations usually focus on the mechanisms of health selection and social causation (Dohrenwend et al., 1992, Miech et al., 1999, Power et al., 2002). The social causation hypothesis holds that low socioeconomic status entails greater exposure to factors which negatively influence mental health. In short, SES affects health. According to the health selection hypothesis, mental health contributes to the sorting of individuals into SES positions, whether by influencing educational attainment or labour market outcomes. In this case, health affects SES. A recent formulation states that ‘[the health selection] hypothesis gives causal priority to the onset of mental illness as a factor preceding the disadvantaged placement of individuals into socioeconomic positions or social classes’ (Muntaner et al., 2013: 219). Another is that ‘men and women with pre-existing illness drift down the social scale’ (Power et al., 2002: 1989).
To what extent is health selection driven by prior social causation? This paper attempts to quantify the extent to which health selection – here, restricted or downward intergenerational social class mobility due to poor mental health or behavioural problems – can be attributed to the influence of modifiable (that is, at least partially amenable to social policy) childhood risk factors. These risk factors for poor mental health and restricted mobility – here, socioeconomic deprivation and adversities – may account for an apparent health selection effect in two ways (Fig. 1). The first is that adolescent mental health (AMH) may mediate the effect of childhood factors on SES in young adulthood. This reflects social causation occurring during childhood, and is therefore referred to as mediated social causation. The second is that childhood factors may confound the relationship between adolescent mental health and SES in young adulthood. Despite similarly attributing causal priority to childhood environmental factors in accounting for the social gradient in mental health, this is referred to in the literature as the ‘indirect health selection’ hypothesis (DiStefano and Morgan, 2014, Wilkinson, 1986). This paper evaluates the joint contribution of these processes, but does not disentangle the two.
Health selection may occur both between and within generations. This paper focuses on intergenerational health selection. That is, when poor mental health restricts the intergenerational social mobility of an individual: her mental health prevents her from achieving the social class position relative to her parents' which she otherwise would have attained. There is much reason to expect such selection: most mental disorders begin in adolescence and young adulthood, with half of all lifetime cases having onset by age 14 (de Girolamo et al., 2012, Kessler et al., 2005), and poor mental health in adolescence interferes with education in particular and the status attainment process in general (Miech et al., 1999, Power et al., 2002, Schoon et al., 2003).
In sum, this paper examines the following two questions. First, are health selection effects upon intergenerational social mobility evident? Second, if health selection effects are evident, to what extent is health selection operating in the sense that poor AMH is independent of any measured risk factors, and to what extent, alternatively, does it simply represent mediation of, or confounding by, these risk factors?
Section snippets
SES and health: the importance of the transition to adulthood
The reality of the health selection and social causation theories of health inequality is likely that they are best viewed as intertwined, with reciprocal causation occurring between SES and health over the life course (Kröger et al., 2015, Mulatu and Schooler, 2002). The observation that social causation may precede and underlie health selection may therefore appear trivial, since this social causation may itself be driven by earlier health selection. However, though this picture of reciprocal
Previous work
The childhood environment is predictive of mental health in childhood and adolescence, though associations are stronger and more consistent for externalising problems, such as conduct problems and hyperactivity (Amone-P'Olak et al., 2011, Bolger et al., 1995). This body of research includes the natural experiment upon which Costello et al. (2003) capitalise, finding that an exogenous increase in income was associated with a substantial reduction in conduct and oppositional defiant disorders,
Data
The National Child Development Study (NCDS) follows a British cohort made up of all births in England, Scotland and Wales in a single week in 1958, collecting data in a variety of domains. Data collected at birth and ages 7, 11, 16, 23 and 33 are used here. The NCDS includes a rich set of measures of the childhood environment, and measures of adolescent mental health from multiple informants. At age 33, 11,468 cohort members were interviewed (70.7% of the eligible sample). These participants
Analytical strategy
Logistic regressions are used to model the probability both of upward (versus stable or downward), and of downward (versus stable or upward) mobility. Cases in the highest and lowest origin class are excluded from the analysis of upward and downward mobility, respectively, since one cannot be upwardly mobile from the highest origin class and vice versa. In each case, I use the KHB method to compare a reduced model with a full model, whilst adjusting for the rescaling of the coefficients due to
Results
Descriptive statistics for the 3321 complete cases are shown in Table 1. Due to standardisation of the latent variables in the CFA, the AMH factor scores each approximate a mean-centred normal distribution. The count of childhood socioeconomic deprivation items ranges from 0 to 21. The values at the 25th, 50th and 75th percentiles are 1, 3, and 6 respectively. As expected, childhood adversities are comparatively rare.
Table 2 is a mobility table for the complete-case sample. There is substantial
Discussion
Growing up in deprivation and experiencing adversities such as bullying could partially account for the health selection effect of poor adolescent mental health and behavioural problems on socioeconomic attainment in adulthood. Previous research has raised this point in passing but not examined it in detail. This paper uses the NCDS to examine, first, whether selection effects are evident, and if so, second, to what extent they are accounted for by modifiable factors that place children at risk
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