There exists a well-established link between poor health and low socioeconomic status (SES; here used interchangeably with low-income and poverty with recognition that they are not identical constructs). For many health outcomes, there is a steady SES-health gradient, with each step down the SES ladder associated with poorer health, including a variety of physical health conditions such as hypertension, heart disease, cancer and shorter life expectancy, as well as a wide range of mental health problems from depression to schizophrenia. The gradient is not small — some diseases increase ten-fold when comparing the highest rung of the socioeconomic ladder to the lowest¹. While less research attention has been paid to children than adults, existing research clearly shows that these associations hold for children as well. Compared to their more affluent peers, poor children are less likely to find educational or economic success and are at greater risk for developing internalizing and externalizing disorders and physical health problems ^2-5.

With a higher incidence of smoking, drinking, obesity, poor diet and sedentary lifestyle among individuals with lower SES, it is often assumed that poor lifestyle choices explain the SES-health gradient. However, multiple studies have shown that lifestyle risks only account for a small portion of the SES-health gradient⁶. Although access to healthcare is a real problem faced by many low-income families, it does not fully account for the SES-health gradient either. The gradient exists even in countries with socialized healthcare and for diseases that are not affected by preventative health care⁶. There is also no clear threshold on the ladder where healthcare access might create a “jump” in health, which would be expected if health-care access was the primary mechanism. What does explain the lion’s share of the SES-health gradient then?

Stress as the mechanism of the SES-health gradient

The answer appears to be stress. Chronic psychosocial stress is gaining recognition as a major mechanism through which poverty exerts a negative toll on children and adults. Ongoing stress associated with poverty, or the stress of living with less than one needs, creates constant wear and tear on the body, dysregulating and damaging the body’s physiological stress response system and reducing cognitive and psychological resources for battling adversity and stress ^7-9.

The stress of poverty is not simply worries about money — poverty creates a “context of stress”, in which conflict, family violence, food insecurity and residential mobility (to name a few) are also commonplace (McLoyd10). We refer to this type of stress as poverty-related stress (PRS11). In addition to the increased volume of stressors created by poverty’s context of stress ^12-13, poverty amplifies the negative effects of all types of stress⁷, ¹⁴ such that PRS impairs an individual’s ability to mount a response to new threats and challenges.

Some of the earliest research on the effects of PRS on adults came from Pearlin and colleagues who wrote of the experience of poverty from a “strain perspective”¹⁵. As indicated by their work, major events such as job loss or living in poverty result in day-to-day experiences that place strain on individuals as they strive for homeostasis. According to Kahn and Pearlin8, “…among the array of chronic stressors that people may confront in their daily lives, there is probably none more pivotal than economic hardships and strains” (p.18), which they found to lead directly to negative outcomes such as depression ⁸, ^15, anxiety¹⁶, alcohol use ¹⁶ and physical health conditions ^8.

Expanding this idea, Conger and colleagues identified economic stress as a particularly potent catalyst for a variety of family problems — problems that contribute to emotional and behavioral maladjustment in children, primarily via the effect of stress on parents and the interparental relationship. In a series of studies involving Iowa farm families who experienced severe income loss, Conger and colleagues developed the “Family Stress Model”^17-18 whereby low family income and negative financial events lead to economic pressure (stress) in the family ¹⁹, spawning parental distress and interparental conflict, both of which lead to parenting problems. Ultimately, these parenting problems and the spillover of interparental conflict and parental depression compromised children’s psychological functioning ^20-21. Thus, Conger and colleagues have demonstrated a causal pathway by which PRS (e.g., economic pressure) disrupts family relationships and contributes to psychological problems for adults and eventually, their children.

The SES-health gradient has also been found among children and adolescents, with global ratings of poorer health associated with lower SES. Younger children in poverty are at increased risk for injury, asthma and elevated blood pressure ²³; and acute conditions such as injuries and respiratory illness show a clear gradient by adolescence²². Stress resulting from unhygienic homes, disrupted family relationships, poor child-care services, more negative life events, and less healthc-are access appears to be the key mechanism for the SES-health gradient for children, and ultimately, across the life span. How does stress lead to health problems and what can be done to counteract it?

Dysregulated stress response systems

Under ideal circumstances, a stress response is quickly activated, appropriate in degree for the stressor at hand, and quickly terminated, providing protection for the organism while minimizing the harmful effects of chronic stress activation. The human body is not well equipped to handle a chronically activated sympathetic nervous system and its resultant rapid heart rate, interrupted digestion, and overactive immune response; thus, the majority of the negative consequences of stress are caused by our bodies’ own efforts to manage threat.

Chronic social stress of the type associated with poverty can actually sensitize multiple components of the nervous system, heightening physiological reactions to even mildly stressful or threatening events ^24. Under chronic stress, physiological responses not only occur more frequently, but also tend to increase in magnitude and duration, taking longer to recover to baseline levels²⁵. Over time, repeated and exaggerated stress responses become entrenched, placing individuals at risk for developing stable patterns of high-reactivity, and leading to higher resting heart rate, blood pressure, and circulating stress hormones such as cortisol²⁶. The repeated, excessive activations and inefficient down-regulation of the stress response systems — the sympathetic-adrenomedullary system (SAM) and hypothalamic-pituitary-adrenal axis (HPA) — lead to a condition referred to as allostatic load, resulting in impaired physical and mental health outcomes⁹. Appropriate physiologic stress responses are critical for normal health and functioning; therefore, a balance must be maintained so that stress responses are activated only when needed and to the degree necessary for meeting challenges.

Interventions that Can Help

Helping children remain resilient despite PRS can be approached in two ways: (1) by improving the functioning of their parents and (2) by helping the children develop skills to cope on their own. In fact, we have developed two family strengthening interventions to teach families living in poverty to adapt to PRS: one program for parents and one for children and parents. First, we conducted a large randomized controlled trial of a family strengthening program (FRAME) for low-income parents to encourage safe, healthy family relationships by counteracting the negative effects of poverty on their own functioning and helping them parent their children effectively. This intervention teaches skills and principles of healthy relationships, effective conflict resolution, prosocial methods for coping with stress, and child-centered parenting. We found that, relative to couples assigned to the no-intervention condition, parents who received the 14-hour intervention showed reduced financial stress, reduced disengagement coping and improved problem solving. These improvements predicted improvements in depressive symptoms for both men and women²⁷, increased father involvement²⁸ and improved emotional and behavioral functioning in the children²⁹.

The second program developed by our research team involves teaching coping skills directly to children facing PRS. Raviv and Wadsworth³⁰ used a multiple-baseline design to evaluate the feasibility and efficacy of the Families Coping with Economic Strain (FaCES) program. In this program, children and their parents learn about stress and its effect on their health as well as skills for emotion regulation and efficacious coping. Parents are encouraged to serve as coaches and model the skills for their children. Youths who participated in the intervention showed acquisition of the targeted secondary control coping skills, which were accompanied by decreases in involuntary engagement responses (e.g., intrusive thoughts, rumination) and internalizing and externalizing symptoms.

Since program accessibility is strongly linked to participation rates and overall program effectiveness, it is important to note that both programs were very accessible to participating families; and both had low attrition rates and high parent-reported program satisfaction. In conclusion, interventions focused on improving family relationships and increasing strategies for coping with PRS appear to be beneficial to low-income children and families and may represent an important adjunct to other efforts focused on improving family income and employment. Importantly, prevention approaches that target core underlying sources of dysfunction such as PRS, have the potential to produce permanent positive changes in the family system, with radiating effects on all family members.

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Martha Wadsworth, PhD, is an associate professor of psychology at the Pennsylvania State University and is a licensed clinical psychologist specializing in children and families. Her basic research program has led to the development of preventive interventions for families and children in poverty focused on strengthening both the family’s ability to stay strong in the face of hardship and the ability of parents and their children to cope effectively with poverty’s stress. Martha has served as the chair of APA’s Committee on Socioeconomic Status and she is currently an APA Council Representative for the Society of Clinical Child and Adolescent Psychology (Div 53 of APA).

 

Shauna Rienks, PhD, is a research associate for the federally funded Fatherhood Relationship and Marriage Education (FRAME) project — a randomized, controlled trial of a psychoeducation program that teaches communication, coping and parenting skills to couples with low-income.   Since 2006, she has been conducting research on the FRAME project. In addition to her work on couple and family relationships as they impact development across the life span, her research interests include schools as a context for child and adolescent development, and self and social identity with an emphasis on gender, ethnicity and culture. 

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