Prometheus 6   

Nature vs Nurture

More on the impact one's economic circumstances has on health, but this time it's emotional health.

The notion that poverty and mental illness are intertwined is nothing new, as past research has demonstrated time and time again. But finding evidence that one begets the other has often proved difficult.

Now new research that coincided with the opening of an Indian casino may have come a step closer to identifying a link by suggesting that lifting children out of poverty can diminish some psychiatric symptoms, though others seem unaffected.

A study published in last week's issue of The Journal of the American Medical Association looked at children before and after their families rose above the poverty level. Rates of deviant and aggressive behaviors, the study noted, declined as incomes rose.

"This comes closer to pointing to a causal relationship than we can usually get," said Dr. E. Jane Costello, a psychiatric epidemiologist at Duke who was the lead author. "Moving families out of poverty led to a reduction in children's behavioral symptoms."

The study took place over eight years in rural North Carolina and tracked 1,420 children ages 9 to 13, 25 percent of them from a Cherokee reservation. Tests for psychiatric symptoms were given at the start of the study and repeated each year.

When the study began, 68 percent of the children were from families living below the federally defined poverty line. On average, the poorer children exhibited more behaviors associated with psychiatric problems than those who did not live in poverty. But midway through the study, the opening of a local casino offered researchers a chance to analyze the effects of quick rises in income.

Just over 14 percent of the American Indian children rose above the poverty level when the casino started distributing a percentage of its profits to tribal families. The payment, given to people over age 18 and put into a trust fund for those younger, has increased slightly each year, reaching about $6,000 per person by 2001.

"This is unique because it's a situation where everybody got the extra money," Dr. Costello said. "You can't take a bunch of babies and randomly assign them to grow up in comfort or poverty. So this is about as close to a natural experiment as you can get."

When the researchers conducted their tests soon after, they noticed that the rate of psychiatric symptoms among the children who had risen from poverty was dropping. As time went on, the children were less inclined to stubbornness, temper tantrums, stealing, bullying and vandalism -- all symptoms of conduct and oppositional defiant disorders.

After four years, the rate of such behaviors had dropped to the same levels found among children whose families had never been poor. Children whose families broke the poverty threshold had a 40 percent decrease in behavioral symptoms. But the payments had no effect on children whose families had been unable to rise from poverty or on the children whose families had not been poor to begin with.

The researchers also found that symptoms of anxiety and depression, although more common in poor children, remained the same despite moving out of poverty.

The deciding factor appeared to be the amount of time parents had to supervise their children. Parents who moved out of poverty reported having more time to spend with their children. In the other groups, the amount of time the parents had on their hands was not much different.

"What this shows very nicely is that an economic shift can allow for more time and better parenting," said Dr. Nancy Adler, professor of medical psychology at the University of California at San Francisco.

In children, acting out is often a result of frustration that can stem from feeling ignored or not getting enough validation from the parents, said Dr. Arline Geronimus, a professor of public health at the University of Michigan.

As a result, behaviors associated with frustration would be the first to change when parents had more attention to devote to their children. "Anxiety and depression, on the other hand, are a little more extreme and might not be as susceptible to change," Dr. Geronimus added.

Recent research suggests that anxiety disorders and depression run in families and probably reflect a mix of genetic and environmental causes.

The study highlights the role that adult supervision may have on mental health in children, but another factor, Dr. Geronimus said, may be the psychological benefits that the casino payments produce.

The Indian families were much more likely to be poor than their non-Indian neighbors at the start of the study. After the payments, though, a higher proportion of Indian families moved out of poverty.

"There's the possibility that this improved the general outlook of the families -- that the whole community has more than before," Dr. Geronimus said. "In addition to the material resources, there might have been some psychological benefits."

Those psychological benefits may also be a byproduct of the jobs that the casino has generated, said James Sanders, director of an adolescent drug and alcohol treatment center on the reservation.

"The jobs give people the chance to pull themselves up by their bootstraps and get out of poverty," said Mr. Sanders, whose son took part in the study. "That carries over into less juvenile crime, less domestic violence and an overall better living experience for the families."

But one question that lingers is why the economic change had a significant effect on only a small proportion of the children. All of the families that received the payment were given the same amount of money, but only 14 percent moved out of poverty while 53 percent remained poor.

The answer could be related to the number of siblings in each family. A $6,000 payment could be a huge help to a poor family with one child, for example, "but that money might not go as far for a family with multiple children," Dr. Adler said.

In 2002, the average poverty threshold for a family of three was $14,348.

Though some questions remain, the study ultimately suggests that poverty puts stress on families, which can increase the likelihood that children will develop behavioral problems. That, said Dr. Geronimus, speaks to the notion that welfare policy is heading in the wrong direction.

"Parents on welfare are increasingly required to work more and more hours while spending less time with their families," she said. "These findings suggest the opposite: parents value having more time to spend with their kids, not less, and their kids respond favorably to that."