Neurobehavioral effects of poverty
By: Daniel C. Marston, PhD, ABPP, guest editor
Poverty is a widespread problem throughout this country & throughout the world. According to the U.S. Census Bureau, 46.2 million now live below the official poverty line set by the U.S. government (Tavernise, 2011). Poverty significantly affects how people live their lives and what resources are available to them for addressing problems.
There is considerable evidence of the significant effect that poverty has on neurobehavioral development. Primary among this evidence is the significantly higher prevalence of neurobehavioral disorders for individuals who suffer in poverty. Bergen (2008) found that mental retardation occurs in three to five per 1,000 individuals in high-income countries but occurs in as much as 22 out of 1,000 individuals in developing countries. Hetzner, Johnson & Brook-Gunn (2010) found that children from poor families are more likely to experience developmental delays than middle class peers.
Data collected from the 1997-2008 National Health Interview Surveys (Boyle et al, 2011) found that family incomes below the federal poverty level were associated with higher levels of developmental disabilities, learning disabilities and intellectual disabilities. In addition, there were statistically higher amounts of the following disorders for children on Medical Assistance compared to children covered by private insurers: ADHD, learning disabilities, intellectual disabilities and developmental disabilities (e.g. autism). An earlier review of national data (Visser, Lesesne & Perou, 2007) also found higher prevalence of ADHD among children below the poverty level.
Bergen (2008) identified protein-energy malnutrition, dietary micronutrient deficiencies, environmental toxins and lack of early sensory stimulation or the ability to profit from it as major reasons for why there are higher rates of neurobehavioral disorders among individuals living in poverty. Morris (2008) found that maternal malnutrition during pregnancy significantly impacts on the development of communication and social abilities and contributes significantly to the higher level of developmental disabilities for individuals living in poverty.
Noble, Houston, Kan & Sowell (2012) found significantly lower brain volume in the hippocampus and amygdala in children from lower-income households compared to children from higher-income households. This would be consistent with a review from Evans & Schamberg (2009) showing that a number of animal and human studies indicate problems with working memory in lower-income individuals that are consistent with impairments in the hippocampus and amygdala.
Wilber et al (2011) found that chronic stress associated with poverty can significantly impact on development of the prefrontal cortex. Rinaldi, Peroddin & Markram (2008) and Price (2006) found that the prefrontal cortex has been extensively implicated in explaining deficits in executive functioning, cognition, language, sociability and emotion. This would be consistent with higher rates of neurobehavioral disorders associated with the prefrontal cortex, including autism and ADHD. Noble et al (2005) & Farah et al (2006) both support that the prefrontal cortex is one of the primary neurological systems impacted by poverty. This is consistent with research (e.g. Lipina et al, 2005 & Messacappa, 2004) showing significant difference in executive functioning, primarily found in the prefrontal cortex, between children from higher and lower income households.
Animal studies have shown that chronic stress also has a significant impact on the neurocircuitry in the hippocampus (Lipina & Posner, 2012). This often results in significant difficulties for the individual in terms of processing information in new situations and making decisions about how to cope with new challenges.
So, a review of the research shows that poverty is a significant contributing factor to impairments in the hippocampus, amygdala and prefrontal cortex. Among other problems these impairments contribute to significant problems with executive functioning, working memory, social comprehension and emotion regulation. These findings also are supported by research showing higher levels of autism, learning disabilities, ADHD and intellectual disabilities for individuals from lower-income households compared to individuals from higher-income households.
Traditionally, lack of access to appropriate care has been identified as one of the main reasons why people in poverty do not receive services to help address neurobehavioral problems. But research summarized in Porterfield & McBride (2007) shows that the problem may be more the lack of recognizing a need for behavioral health services than the lack of access.
These authors analyzed responses from 38,866 subjects with regards to their need for services. Their results showed that lower-income parents were significantly less likely than higher-income parents to say their children needed specialized health services. They concluded that children from poorer families were less likely to have access to specialized health services because their parents did not recognize the need for those services. Even if their children had been evaluated by a general practitioner or a counselor at their school they were less likely to have come away with an understanding that their children needed any sort of specialized care. This would lead to a more limited use of any type of behavioral health care specifically focused on helping to address neurobehavioral disorders.
A comprehensive review of the literature shows four ways that psychologists and other behavioral health professionals can help address difficulties associated with higher rates of neurobehavioral disorders associated with poverty:
Support programs like Head Start that help to address developmental and behavioral problems early (Hetzner, Johnson & Brook-Gunn, 2010).
Offer different ways of delivering services that are more convenient for families. This includes providing services in convenient settings, including individuals’ homes whenever possible and having offices on public transportation routes.
Research such as that conducted by Fox & Holtz (2009) show the importance of making services convenient if they are to be beneficial for families in poverty. They conducted a study of a treatment program specifically for behavior problems of children, many of whom had developmental disabilities, whose families were in poverty. One of the beneficial characteristics of this program was that the services were provided in the home. Results of this study showed significant decreases in the frequency & severity of behavior problems.
Develop a comprehensive assessment strategy that is cost-effective and limited in the amount of time required. If families are going to recognize the need for specialized treatment for their children it is important that a comprehensive assessment strategy be used so that they know what neurobehavioral conditions they are facing. It is also important that cost-effectiveness and time demands be taken into account since families in poverty will most often be using some type of Medical Assistance plan that likely pays less than other insurers.
Offer multiple types of assistance during sessions with clients who are suffering poverty. Helping individuals learn better ways of handling stressors is important. But individuals suffering poverty also often need help in navigating the complex web of social services. Nutritional issues also often need to be addressed given the significant impact that poor nutrition has on neurological development. These are all important issues that can and should be addressed in sessions with clients as they all contribute to difficulties faced by individuals dealing with neurobehavioral disorders.
About the Author
Daniel C. Marston, PhD, ABPP, Marston Psychological Services, LLC
Dr. Daniel Marston is division monitor to APA’s Committee on Socioeconomic Status for Division Six of APA (Behavioral Neuroscience and Comparative Psychology). He is a behavioral psychologist specializing in the assessment and treatment of neurobehavioral disorders (including autism and intellectual disabilities). He is the owner of Marston Psychological Services, LLC which is a group behavioral healthcare practice in Western Pennsylvania. He has been a licensed psychologist for over 15 years and an adjunct faculty member teaching statistics and research design at the college level for over 10 years. His research and training interests are primarily in the areas of neurological and psychological effects of poverty. He recently conducted an online training seminar for the National Association of Developmental Disabilities (NADD) on how professionals can help alleviate the impact of poverty for individuals with neurobehavioral disorders. He has published book chapters on the topics of psychiatry during the Industrial Revolution and the Modern School Movement. Both of those are topics relevant to the history of how professionals have tried to help people suffering poverty. He is a previous board member of Just Harvest which is an organization dedicated to helping people suffering poverty. He is a Fellow in Cognitive & Behavioral Psychology in the American Board of Professional Psychology and a Fellow in the American Academy of Cognitive & Behavioral Psychology.
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