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Ivana Jakovljevic, MD, Ashley P. Miller, MDCM, FRCPC, Barbara Fitzgerald, MD, FRCPC

Children’s mental : Is the diagnosis?

Some of the concerns seen by childhood health professionals may not be diagnosable psychiatric conditions, but emotional and behavioral responses to family financial insecurity.

ABSTRACT: The case of a 6-year-old status. Poverty is a risk factor for Case data who was referred to a physician conditions in child- A 6-year-old boy was referred for by his school counselor for inves- hood and is associated with lower assessment and treatment recom- tigation of and possible at- academic achievement and impaired mendations by his school counselor tention deficit hyperactivity disor- cognitive development secondary because of anxiety, school difficul- der illustrates the need to consider to direct effects on the developing ties, and possible attention deficit the role of poverty when addressing hypothalamic-pituitary-adrenal axis hyperactivity disorder (ADHD). The mental health concerns. After deter- and indirect effects on a child’s en- boy was from a two-parent family mining that insecurity could vironment. British Columbia’s child- and had a 14-year-old brother. Both be contributing to the boy’s symp- hood poverty rate is well above the parents were employed, the father toms, the physician used a poverty national average and is compounded as a cargo delivery driver and the intervention tool to screen for the by significant unmet core housing mother in a hospital cafeteria. The effects of poverty and make rec- need and widening provincial income boy’s mother had started shift 6 ommendations to prevent adverse disparity. We recommend screening months previously and was working 6 health outcomes. Mental health and for poverty with office-based inter- days a week so that the family could behavioral concerns are common ventions and accounting for income meet increasing rent costs. They in children and youth presenting insecurity in all mental health diag- lived in a small two-bedroom apart- with undifferentiated complaints in noses and treatment plans. We also ment and the boy slept on the pull-out both pediatric and primary care set- strongly recommend implementing a couch in the living room because his tings. Psychiatric disorders are fre- national strategy 14-year-old brother demanded priva- quently multifactorial and require a to address determinants of comprehensive assessment of the health in the early years and improve Dr Jakovljevic is a PGY-5 resident in the De- patient’s environmental context, in- the health of future generations. partment of Psychiatry at the University of cluding the family’s socioeconomic British Columbia. Dr Miller is an assistant in the Department of Psychiatry at UBC and a child and adolescent psychia- trist at BC Children’s Hospital and Vancou- ver Community Mental Health Services. Dr Fitzgerald is a developmental pediatrician at Sunny Hill Health Centre for Children. She is also medical director of Alderwood Family Development Centre and a clinical associate professor in the Department of This article has been peer reviewed. Pediatrics at UBC.

454 bc medical journal vol. 58 no. 8, october 2016 bcmj.org Children’s mental health: Is poverty the diagnosis?

cy. The family could no longer afford below the diagnostic threshold for care had placed on the family after-school care for the boy as they ADHD. Written reports indicated the and affected the boy’s sense of secu- had done the previous year, so he was boy was slightly behind in reading rity. The impact of sleep on the boy’s picked up from school by the broth- skills for his age. The father stated ability to pay attention and manage er and watched TV and played video that the separation anxiety and prob- emotions was discussed and infor- games every day after school while lems at school had begun 6 months mation about sleep hygiene and his parents were working. earlier, coinciding with his mother’s asthma management was provided.

First visit The boy attended the first visit to the physician with his mother, who reported that the child had no previ- ous of anxiety or psychiatric concerns but did have a medical his- The World Health Organization tory of asthma. The mother described has declared poverty the single the boy’s recent separation anxiety, difficulty concentrating, trouble fall- largest determinant of health ing asleep, and tantrums during tran- for both adults and children. sitions at school. Teachers reported the boy was frequently anxious and inattentive in class. In the past the father had been diagnosed with a mild learning and the mother described herself as “frequently anx- ious,” although she had never been increased work hours, and that he had The parents were advised to file tax diagnosed with a psychiatric condi- started sleeping with his son on the returns so the family would be eligi- tion. During the visit the boy was shy, pull-out couch because of the boy’s ble for income supplements and sub- clung to his mother, and looked at her anxiety. sidized housing. Psychoeducational for answers. He occasionally gave Given the family’s economic sit- testing was recommended to rule one-word answers to questions. There uation, the physician chose to use a out a learning disability, even though were no other significant findings on screening and intervention tool for there was likely to be a long wait for the mental status exam. Teacher and poverty. The father disclosed that the testing in the public system, the only parent checklists were provided to family had not had enough money for option for the family. The parents collect further details and a second necessities for the previous 9 months were advised to enquire about getting visit was scheduled to complete the and had recently started going to the their son extra help with homework assessment. bank. The father also said he was through the school and were referred too ashamed to talk to his son’s school to a parenting group for parents of Second visit about their circumstances and asked children with anxious temperaments. At the second visit with the physi- the physician about resources for sub- The physician emphasized the parents cian, the boy was accompanied by his sidized housing. The family had not were doing their best to care for their father. The boy’s growth charts and filed a tax return for the previous year son and had given him a good founda- hearing and vision test results were because of the mother’s transitional tion. A follow-up visit was scheduled. reviewed. No deficits were identi- . fied and he was found to be on track Information gathered at the sec- Third visit developmentally. His asthma, while ond visit led to a number of recom- At the third visit the parents reported relatively mild, was found to be con- mendations for the family. The par- that their son was attending a subsid- tributing to sleep disturbances. Occa- ents were told that although their ized summer camp through his school. sional inattention and concentration child did not have a clinical anxiety The family had filed tax returns, ob- difficulties were noted on the teach- disorder or ADHD, their recent finan- tained low-cost transportation passes, er checklists, but the symptoms fell cial struggles and changes in child and been waitlisted for subsidized

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housing. The boy was receiving a or ensured the boy received learning undifferentiated complaints. These free breakfast and lunch at school and assistance for reading and tutoring conditions can include anxiety disor- seeing the school counselor regular- from a local high school student. With ders, ADHD, and other neurodevel- ly. The parents, however, were still the physician’s help, the parents even- opmental disorders. In addition, child struggling financially and reported tually obtained a for quality abuse, trauma, and early adversity that their experiences had affected after-school care and established a can have a significant impact on all their relationship. Although they were clear routine for their son, including aspects of and be- very eager to join the parenting group, two 30-minute sessions a week when havior. As children are embedded in they were unable to attend because of he would go to the park or have spe- their environments, a comprehensive their work schedules and lack of child cial play time with his mother. Within assessment and consideration of their care options. 3 months, the boy’s separation anxi- psychosocial circumstances is crucial for accurate diagnosis and treatment recommendations.

Childhood poverty in BC According to most recent estimates, approximately one in five BC children age 0 to 17 (20.4%) are living in pov- Poverty becomes biologically embedded, erty,3 and the numbers are significant- ly higher for children of immigrants, leading to both functional and structural visible minorities, and Aboriginal cit- changes of the developing brain. izens. British Columbia’s child pov- erty rate has remained consistently higher than the national average since 2000, and has increased significantly since the 1989 House of Commons all-party resolution to eliminate .3 Children of various fam- ily types live in poverty, but there is The mother was tearful during ety had improved significantly and an increase in families the appointment, and said she would his teacher noted better focus in class living in British Columbia, with one love to be able to spend quality time despite the family’s continued high in three poor children having at least with her son at home, like her own stress level and hectic work schedule one parent who works full time. As mother had with her, but was unable in attempts to make ends meet. of 2013, one-half of children in lone to leave her job. The mother was told parent families were living in poverty. that staying at home with children is Discussion Food bank use has increased by 25% not the only way to make them feel An estimated 12.6% of children and in British Columbia since 2008. Over secure, and that the quality of time youth age 4 to 17—almost 84 000 97 000 people used the food bank last spent together counts. The physician young British Columbians—are ex- year in BC, with 31% of users being acknowledged the family’s hard work periencing a mental health disorder at children.4 Furthermore, families with and provided information on parent- any given time.1 Mental health prob- the fewest economic resources are ing children with anxious tempera- lems in childhood and adolescence spending more of their income for ments and emphasized the impor- have a significant impact on child de- inadequate housing, with one-third of tance of regular follow-up with the velopment and have been identified all children in lone parent families in school counselor. by many as today’s leading pediatric BC living in core housing need, repre- problem.2 senting the highest rate of inadequate Outcomes Multiple childhood psychiatric housing for all provinces in .3 Subsequently, the boy’s parents met conditions come to mind when young Income inequality is on the rise with the school counselor for two children present to primary care phy- in Canada, and particularly in British parenting sessions, and the counsel- sicians or pediatric specialists with Columbia, where a family in the high-

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est income decile earns 13 times more environments rather than diagnosable food, adequate housing in safe neigh- than a family in the lowest income primary mental illnesses, as illustrat- borhoods, quality day care, and regu- decile. This staggering income dis- ed by the case. lar access to . Poor children parity is explained in part by the fact are also less likely to benefit from that individuals in BC’s lowest earn- Effects on cognition environmental complexity, exposure ing decile have the lowest income of Children from low-income house- to educational activities and materi- all Canadians.3 holds are less prepared for formal als, and positive parent-led experi- schooling and perform below their ences such as reading and conversa- Effects of poverty on children middle-class counterparts on tests tion.12 Moreover, children growing The World Health Organization has of intelligence and school achieve- up in poverty are disproportionately declared poverty the single largest ment.10 A recent Vancouver study more likely to be exposed to trauma determinant of health for both adults found that 38% of kindergarten chil- and stressful life events, including and children.5 Children affected by dren living in the lowest income divorce, domestic violence, and puni- poverty have higher rates of infant neighborhoods demonstrated vul- tive parenting practices. Poverty fur- mortality, low birth weight, childhood nerabilities in at least one area mea- ther negatively affects mental health hospitalizations, asthma, obesity, and sured by the Early Development through larger community factors, functional health impairments.6 Pov- Instrument, which considers physi- including social isolation, marginal- erty in early childhood is also asso- cal health and well-being, language ization, and violence.1 ciated with increased morbidity and and cognitive development, social The mechanism that allows pov- decreased lifespan in adulthood, an competence, emotional maturity, and erty to directly affect the developing association that persists irrespective communications skills.11 Children brain and contribute to psychopa- of the one acquires as living in poverty have also been found thology is now being elucidated by an adult.7 A large and growing body to have deficits in working memory, neuroscientists. Several explanations of research, including studies in Can- language abilities, and cognitive flex- have been proposed regarding the re- ada, the US, and the UK, demon- ibility when compared with their lationship between poverty and men- strates that children living in poverty middle-class counterparts.12 Recent tal health. The concept of allostatic are significantly more likely to have neuroimaging research suggests that load, or cumulative damage over psychiatric conditions and inferior these deficits are mediated by under- time, suggests that the excessive, mental health when compared with development of several brain areas, persistent, and uncontrollable adver- peers from families with higher soci- including the frontal and temporal sity experienced by children living in oeconomic status. This relationship lobes and the hippocampus. This poverty intensifies the activation of holds across developmental periods, is estimated to the hypothalamic-pituitary-adrenal and remains when operationalizing account for 15% to 20% of achieve- (HPA) axis and has an impact on the poverty through income, parental ment deficits.13 The longer children developing brain.14 Physiological re- employment, and neighborhood in- live in poverty, the greater their aca- sponses to stressful events are medi- come. Children from families living demic deficits and the more likely ated by the glucocorticoid and cat- in poverty are 3 times more likely, on they are to experience a lifetime of echolamine system, and prolonged average, to suffer from psychiatric reduced occupational achievement exposure to stressful environments conditions, including both externaliz- and the persistence of poverty across and subsequent heightened neuro- ing disorders such as ADHD, oppos- generations. endocrine responses are associated itional defiant disorder (ODD), and with the development of both depres- conduct disorder, and internalizing Impact on mental health and the sive symptomatology and the hippo- disorders such as depression, anxiety, developing brain campal neuron damage implicated in and poor coping skills.1,8,9 Further- Living in poverty increases the likeli­ impaired learning and memory.15,16 If more, experts in the field have recent- hood of and adverse early adversity during critical devel- ly questioned whether some of the childhood events that are themselves opmental periods leads to permanent behavioral concerns seen by child- known risk factors for the develop- changes in the functioning set-point hood mental health professionals are ment of mental illness. Children liv- of the HPA axis, then lasting and actually emotional and behavioral ing in poverty are more likely to lack potentially permanent alterations in responses to inadequate and chaotic basic resources such as nutritious neuroendocrine behavioral responses

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23 Table 1. Medication and medical services plans. .pdf), an evidence-based instrument developed by Dr Gary Bloch from the Plan Benefits University of , can be used to screen for poverty as a health-related Psychiatric Medications Covers psychiatric medications for individuals registered (Plan G) with a mental health service and demonstrating clinical and risk and to factor poverty into all financial need. clinical decision making. A positive answer to the screening question “Do Recipients of BC Income Covers eligible prescription costs for BC recipients of Assistance (Plan C) income assistance. you ever have diffculty making ends meet at the end of the month?” has a Fair Pharmacare Covers some of eligible prescription costs based on family income. sensitivity rate of 98% for identify- ing patients living in poverty.23 The Pharmacare Special Authority Grants full benefit status to a medication or medical supply targeted interventions outlined in the otherwise not covered for patients with specific medical circumstances. tool are designed to reduce the effects of poverty and adverse health out- Non-Insured Health Benefits for Covers medically necessary health services, equipment, and First Nations and Inuit medications not covered through private insurance or comes in low-income patients, and provincial programs for First Nations and Inuit. include specific questions for fami- lies with children, seniors, people Table 2. Income supplement programs. with , and First Nations patients living in poverty. Original- Program Benefits ly developed for use in Ontario, the tool is now available in BC-wide and Canada Child Tax Benefit Nontaxable monthly amount provided for families with (CCTB) www.cra-arc.gc.ca/E/ children under age 18. Kootenay-Boundary versions that pub/tg/t4114/README.html include resources and interventions Child Disability Benefit (CDB)/ Monthly amount for families caring for children under age 18 specific to British Columbia (www Disability Tax Credit (DTC) with a severe and prolonged impairment in physical or .divisionsbc.ca/kb/povertyinterven mental functioning (benefit included in the CCTB amount). tion).24 (DTC: www.cra-arc.gc.ca/E/pbg/tf/t2201/README.html) As demonstrated by the case de- Universal Child Care Benefit Taxable monthly amount for families with children under scribed here, a health care provider (UCCB) age 6. can attempt to mitigate the effects BC Early Childhood Tax Benefit Nontaxable monthly amount for qualifying families with of poverty by providing information children under age 6. about support available. This can in- BC Family Bonus Nontaxable monthly amount for low- and modest-income clude plans for low-cost or no-cost families with children under age 18. medications and medical services Registered Disability Savings Matching contribution from the Canadian government made ( Table 1 ) and programs for income Plan to registered savings plan for children with disabilities. supplements ( Table 2 ). Health care providers can also inform families working with the BC Ministry of Chil- can increase the likelihood of develop- cognitive flexibility, these brain struc- dren and Family Development that ing mental illness.14 Thus, poverty be- tures are particularly vulnerable to the they may be eligible for coverage of comes biologically embedded, lead- environmental effects of poverty.21 medically necessary treatments with a ing to both functional and structural physician’s letter of support. Finally, changes of the developing brain,17,18 a Assessing and addressing because families attempting to deal finding supported by studies demon- poverty with a mental health concern using a strating heightened baseline activa- Physicians often recognize the wide- first-line treatment recommendation tion of the stress response system in reaching impact of poverty on their may encounter barriers, including the children living in poverty.19,20 And be- patients but report feeling unable to cost of psychotherapy and academic cause of the protracted development address the issue in a systematic way.22 tutoring, health care providers can of brain structures critical for learning The poverty intervention tool (http:// also suggest solutions for overcom- and educational functioning, includ- ocfp.on.ca/docs/default-source/cme/ ing these barriers ( Table 3 ). ing sustained attention, planning, and poverty-and-medicine-march-2013 We recommend screening for

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Table 3. Possible solutions for families encountering barriers when attempting to obtain first-line treatment for behavioral and mental health concerns.

First-line treatment Barrier Possible solution

Medication for Cost • Government benefit programs: BC Pharmacare Plan G, Fair Pharmacare, psychiatric condition Special Authority program, Non-Insured Health Benefits (NIHB) program.

Medication for Cost • Substitutions medical condition • Generic preparations • Second-line therapies • Government benefit programs: BC Pharmacare Plan C, Fair Pharmacare

Psychotherapy Cost ($175–$200/hour for private • Free counseling through local community services. psychologist) • Counseling offered at a reduced rate or on a sliding scale by supervised psychology trainees at UBC, SFU, and University of Victoria psychology clinics.

Parenting support Difficulty attending free parenting • Free weekly telephone coaching for parents of children affected by temper group sessions because of work outbursts, behavioral difficulties, and anxiety through Confident Parents schedule or lack of child care options Thriving Kids program (http://cmha.bc.ca/programs-services/confident- parents-thriving-kids/). Referral from health care professional required. Materials provided include psychoeducation, manuals, and behavioral charts.

Psychoeducational Cost (~ $2000 for private testing) • Free testing in the public school system (wait list up to 2 years long). testing • Testing offered free or on a sliding scale for a limited number of clients at UBC and other university-based psychology training centres.

Academic tutoring Cost (> $20/hour) • Free tutoring or homework help offered through child’s school or by teacher and homework help Difficulty ensuring child attends after- or student volunteers. school sessions because of work schedule poverty and using office-based inter- and behavioral symptoms. Given the affordable housing, quality child care, ventions that account for income importance of the psychosocial envi- and regular health care, should be our in­security in all mental health diagno- ronment to child development, an top health priority if we want to ensure ses and treatment plans. And because assessment of the family and social the well-being of future generations. office based interventions don’t reach circumstances is important because all families living in poverty, we symptoms of living in poverty can Competing interests strongly advocate for implementation at first glance mimic the symptoms None declared. of a national poverty reduction strat- of mental illness. Income insecurity egy to address social determinants of is increasingly common in working References health in the early years and improve poor families and a growing number 1. Waddell C, Offord DR, Shepherd CA, et al. the health of future generations. of children live below the poverty line Child psychiatric epidemiology and Cana- in British Columbia. Poverty is a risk dian public policy-making: The state of the Summary factor for mental illness and can affect science and the art of the possible. Can J The case of a 6-year-old boy referred early cognitive development. Screen- Psychiatry 2002;47:825-832. by his school counselor because of ing for poverty and making treatment 2. Lipman EL, Boyle MH. Linking poverty anxiety and school difficulties illus- recommendations that address a fam- and mental health: A lifespan view. Otta- trates the need to consider the role ily’s lack of income and resources can wa: Provincial Centre of Excellence for of poverty when addressing mental lead to significant change for children. Child and Youth Mental Health at CHEO; health concerns. Children and youth Early childhood interventions that sup- 2008. Accessed 28 July 2016. www seen in primary care settings frequent- port the of children, includ- .excellenceforchildandyouth.ca/sites/ ly present with undifferentiated mood ing access to nutritious food, safe and default/files/position_poverty.pdf.

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3. First Call: BC Child and Youth Advocacy Socioeconomic disadvantage and behav- mood disorder effects on the brain. Biol Coalition. 2015 BC child poverty report ioral problems of children in Canada. J Psychiatry 2003;54:338-352. card. Accessed 28 July 2016. October Consult Clin Psychol 2002;70:378-389. 17. McEwen BS. Protective and damaging core combined.dochttp://firstcallbc.org/ 10. Bradley RH, Corwyn RF. Socioeconomic effects of stress mediators. N Engl J Med publications/2015-bc-child-poverty status and child development. Annu Rev 1998;338:171-179. -report-card. Psychol 2002;53:371-399. 18. McEwen BS. The neurobiology of stress: 4. Food Banks Canada. count 2014. 11. Hertzman C, McLean SA, Kohen DE, et al. From serendipity to clinical relevance. Brain Res 2000;886:172-189. 19. Lupien SJ, King S, Meaney MJ, McEwen BS. Child’s stress hormone levels corre- late with mother’s socioeconomic status and depressive state. Biol Psychiatry 2000;48:976-980. Screening for poverty and making treatment 20. Lupien SJ, King S, Meaney MJ, McEwen BS. Can poverty get under your skin? Bas- recommendations that address a family’s al cortisol levels and cognitive function in lack of income and resources can lead children from low and high socioeconom- ic status. Dev Psychopathol 2001;13:653- to significant change for children. 676. 21. Hair NL, Hanson JL, Wolfe B, Pollak SD. Association of child poverty, brain devel- opment, and academic achievement. JAMA Pediatri 2015;169:822-829. 22. Brcic V, Eberdt C, Kaczorowski J. Develop- ment of a tool to identify poverty in a fam- Accessed 28 July 2016. www.foodbanks Early development in Vancouver: Report ily practice setting: A pilot study. Int J Fam canada.ca/getmedia/d8b36130-cc83 of the Community Asset Mapping Project Med2011;2011:812182. -46ba-8183-d33d484c7591/Hunger (CAMP). Vancouver: Human Early Learn- 23. Bloch G. Poverty: A clinical tool for Count2014_revised.pdf.aspx?ext=.pdf. ing Partnership; 2002. Accessed 10 De- primary care in Ontario. Toronto: Ontario 5. World Health Organization. Poverty and cember 2015. https://secure.cihi.ca/free College of Family Physicians and Family social determinants. Accessed 28 July _products/ecd_van_e.pdf. and Community Medicine, University of 2016. www.euro.who.int/en/health 12. Farah MJ, Shera DM, Savage JH, et al. Toronto; 2013. Accessed 10 December -topics/environment-and-health/urban Childhood poverty: Specific associations 2015. http://ocfp.on.ca/docs/default -health/activities/poverty-and-social with neurocognitive development. Brain -source/cme/poverty-and-medicine -determinants. Res 2006;1110:166-174. -march-2013.pdf. 6. Gupta RP, de Wit ML, McKeown D. The 13. Luby JL. Poverty’s most insidious dam- 24. Divisions of Family Practice. Our impact: impact of poverty on the current and fu- age: The developing brain. JAMA Pediatr The poverty intervention tool. Accessed ture health status of children. Paediatr 2015;169:810-811. 28 July 2016. www.divisionsbc.ca/kb/ Child Health 2007;12:667-672. 14. Shonkoff JP, Boyce WT, McEwen BS. povertyintervention. 7. Kuh D, Hardy R, Langenberg C, et al. Mor- Neuroscience, molecular biology, and the tality in adults aged 26-54 years related to childhood roots of health disparities: Build- socioeconomic conditions in childhood ing a new framework for health promotion and adulthood: Post war birth cohort and prevention. JAMA 2009; study. BMJ 2002;325:1076-1080. 301:2252-2259. 8. Costello EJ, Angold A, Burns BJ, et al. The 15. Gianaros PJ, Jennings JR, Sheu LK, et al. Great Smoky Mountains study of youth. Prospective reports of chronic life stress Goals, design, methods, and the preva- predict decreased grey matter volume in lence of DSM-III-R disorders. Arch Gen the hippocampus. Neuroimage 2007;35: Psychiatry 1996;53:1129-1136. 795-803. 9. Boyle MH, Lipman EL. Do places matter? 16. Sheline YI. Neuroimaging studies of

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