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September 2001, Vol 91, No. 9 | American Journal of Public Health 1494-1498
© 2001 American Public Health Association

RESEARCH

Poverty, Race/Ethnicity, and Psychiatric Disorder: A Study of Rural Children

E. Jane Costello, PhD, Gordon P. Keeler, MS and Adrian Angold, MRCPsych

The authors are with the Developmental Epidemiology Program, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.

Correspondence: Requests for reprints should be sent to E. Jane Costello, PhD, Center for Developmental Epidemiology, Box 3454, Duke University Medical Center, Durham, NC 27710 (e-mail: jcostell{at}psych.mc.duke.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

Objectives. This study examined the effect of poverty on the prevalence of psychiatric disorder in rural Black and White children.

Methods. A representative sample of 541 Black children and 379 White children aged 9 to 17 was drawn from 4 predominantly rural counties. Structured interviews with parents and children collected information on psychiatric disorders, absolute and relative poverty, and risk factors for psychiatric disorder.

Results. Three-month prevalence of psychiatric disorder was similar to that found in other community samples (20%). Federal criteria for poverty were met by 18% of the White and 52% of the Black families. Black and White children were exposed to equal numbers of risk factors overall, but the association between poverty and psychopathology was stronger for White children (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.1, 4.2) than for Black children (OR = 1.5; 95% CI = 0.9, 2.6). Family history of mental illness, poor parenting, and residential instability mediated this association in both groups.

Conclusions. In this rural sample, poverty was only weakly associated with child psychiatric disorders. Risk factors for both racial/ethnic groups were family mental illness, multiple moves, lack of parental warmth, lax supervision, and harsh punishment.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Poverty can endanger children's mental health1–3 through exposure to a range of adversities. These may include poor housing; homelessness; multiple moves from one dwelling (and often school) to another; lack of health insurance4,5; and the stress that parents experience while raising a family in poverty, which can lead to harsh or noncontingent punishment, deficient parental supervision, or lack of warmth and love.2,6 Several researchers, who noted the high levels of psychiatric symptoms in minority children living in inner-city areas, have argued that the urban environment,7–9 minority status,10 or both together are harmful to emotional and behavioral development (but see Farrow and Schwartz11). An associated argument is that poor families are more likely to live in impoverished neighborhoods, with poor schools, antisocial peer groups, and little "social capital."12–14 The literature on social selection15 argues that families may become or remain poor because they lack the personal resources—mental health, education, social connections—to climb out of poverty. In an extension to this position, Dohrenwend et al.16 has shown that poverty also may be damaging when it puts families in a position of relative deprivation compared with others whom they regard as their natural comparison group.17 Clearly, many of these mechanisms could co-occur.

The goals of this study were (1) to compare the prevalence of psychiatric disorders in nonurban poor and nonpoor Black and White children, (2) to compare the types and numbers of family risk factors for child psychopathology in poor and nonpoor Black and White families, and (3) to examine the effects of the interaction of poverty and minority status on child psychopathology.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
A full description of the setting, sample, and data collection methods can be found elsewhere18 and is summarized here.

Setting
The 4 contiguous counties in North Carolina chosen for this study are poor but have no large cities, so poverty and inner-city residence are not confounded. The 1990 census data, which are the latest available by race/ethnicity within county, indicate that 76% of the population live in rural areas, and 50% of the area's children (aged 0 to 17 years) are Black. The remainder are White, except for a very few Native American and Latino inhabitants. Median household incomes for the 4 counties ranged from $20 554 to $31 708, compared with $31 548 for North Carolina and $37 303 for the United States. In the United States as a whole, median household incomes for Black households are approximately 60% of White household incomes; in the 4 counties studied, the range was 56% to 63%. Between 18% and 36% of the children were living in poverty in 1989, compared with 17% in North Carolina and 20% in the United States. On the basis of recent census projections, we expect that household incomes and poverty rates have changed very little between 1989 and 1997 to 1998, when the study was conducted.

Sample
The sampling frame was the 17 117 names and addresses of children aged 9 through 17 years provided by the public schools information management system. A random sample of 4500 was selected, and 3942 (88%) of the children were traceable, still in the area, and at the correct age.

Parents of 3615 (92%) completed a brief telephone questionnaire, on the basis of which a subsample of children was selected for intensive assessment. The screening questionnaire consisted of the "externalizing" broadband scale items from the Child Behavior Checklist (CBCL).19 The externalizing subscale was used as a brief screen because it correlates highly with the internalizing subscale in high-risk children.20

Scores were ranked and divided into 10 equal-sized groups of lowest to highest scores. We used a decision rule based on earlier work on the sensitivity and specificity of the screen relative to a full psychiatric assessment21 and randomly selected subjects from the 10 groups with probabilities ranging from 11% (lowest scoring group) to 51% (highest scoring group). The goal was to optimize the 2-stage design to provide the narrowest variance estimates and maximum statistical power from a sample of fixed size (determined by the budget).21–23

Of the 1333 parent–child pairs selected for interview, 29 could not be reached for further recruitment. Of the remaining 1304, complete interviews were obtained in 71% (n = 920). No significant differences in response rate were found at any stage by screen score, race/ethnicity, age, or sex. Following informed consent from parents and assent from the children, interviews were conducted at home, concurrently in separate rooms to ensure privacy.

Measures
Psychiatric disorders. The Child and Adolescent Psychiatric Assessment,24,25 a psychiatric interview for children aged 9 and older, elicits information about symptoms contributing to a wide range of computer-generated Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,26 symptom scales and diagnoses, based on combining symptoms from parents and children.

Risk factors for psychiatric disorder. The Child and Adolescent Psychiatric Assessment interview also collects information on a wide range of factors associated in several studies with increased risk for developing child psychiatric disorders; these are listed in Table 1Go, together with their prevalence in this sample.


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  		TABLE 1—— Definitions of Risk Factors for Child Psychiatric Disordera and Frequency in Black and White Rural Childrenb: North Carolina, 1997–1998
 
Income and poverty. The parent reported total income from all sources on a scale ranging from $0 to $60 000 or higher in $5000 increments. The mean of the range reported was taken as the best estimate of the family's annual income. We defined federal poverty on the basis of federal guidelines, which adjust income by family size, applying the Census Bureau's criteria for 1997 to 1998.

Relative deprivation is defined in terms of an implicit comparison group.17 We defined the comparison group as families of one's own self-defined race/ethnicity. Each family was ranked by income within its racial/ethnic group, and the range was divided into thirds. Relative affluence was defined as being in the top third of the White or Black group, respectively, and relative poverty was defined as being in the bottom two thirds.

Data Analysis
Unbiased general population prevalence estimates and group comparisons were calculated with the empirical option of the SAS program GENMOD to provide appropriately weighted parameter estimates and standard errors corrected for the study's sampling design.27,28


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Poverty and Race/Ethnicity
Table 2Go shows the differences between the 2 racial/ethnic groups on a range of measures of poverty. The Black families bore a much greater burden of poverty than did the White families. The mean income of the Black families was less than two thirds that of the White families (62%). Adjusted for family size, the mean annual income of the poorest third of the Black families was 44% that of the poorest White families. In the middle third of each racial/ethnic group, the Black family incomes were on average 51% of the White family incomes, and in the top third, they were 68% of the White family incomes. Thus, the racial/ethnic disparity in income increased as income decreased.


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  		TABLE 2—— Family Income and Poverty in Black and White Rural Children: North Carolina, 1997–1998
 
Poverty and Child Psychiatric Disorders
Table 3Go shows the 3-month prevalence of the major psychiatric disorders, by race/ethnicity and poverty level. Comparisons between the racial/ethnic groups overall (see Table 3Go superscript b, columns 1 vs 6) showed only 1 significant difference: the prevalence of depression was higher in the White children. The next set of comparisons (superscripts a and e, columns 2 vs 7 and 4 vs 9) tested for racial/ethnic differences at different levels of poverty. All the significant differences were confined to comparisons between poor children; there were no racial/ethnic differences by diagnosis in nonpoor children. Poor White children had more emotional disorders, particularly depression, and more oppositional defiant and conduct disorders when poverty was defined with federal criteria. When the relative poverty criterion was used, poorer White children had more emotional disorders, especially depression, and more oppositional disorders.


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  		TABLE 3—— Three-Month Prevalence of Psychiatric Disorders in Black and White Rural Children, by Income Category: North Carolina, 1997–1998
 
The next set of comparisons tested for differences between levels of poverty within each racial/ethnic group (superscripts c and d, columns 4 vs 5 and 7 vs 8). Among the Black children, the effects of poverty were small; the only significant difference was an excess of depression in the relatively poorer children. The poor White children, however, had a significantly higher risk of diagnosis than did the nonpoor White children. When absolute poverty was the criterion, this was the case for any diagnosis; any emotional disorder, especially depression; and any behavior disorder, especially oppositional and conduct disorders. When relative poverty was the criterion, an excess of disorders was found in poorer children overall; for emotional disorders, especially anxiety; and for behavior disorders, especially oppositional disorder. Thus, the racial/ethnic differences were largely accounted for by higher rates of disorder in the poor White children.

Table 4Go, Model I, shows the results of logistic regression analysis, with poverty as the predictor and with age and sex included as covariates. The White children in federal poverty were 80% more likely than the nonpoor White children to have a diagnosis, but the excess risk for poor compared with nonpoor Black children was only 40%. In a test of the effect of the interaction of race/ethnicity and poverty on psychopathology, the White children in poverty were 59% more likely than Black children in poverty to have a psychiatric diagnosis (interaction odds ratio [OR] = 0.12; 95% confidence interval [CI] = 0.01, 1.00, P = .049).


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  		TABLE 4—— Logistic Regression Models of Poverty, Risk Factors, and Psychiatric Disorder in Black and White Rural Children: North Carolina, 1997–1998
 
Poverty, Race/Ethnicity, and Exposure to Other Risk Factors for Child Psychopathology
The 2 racial/ethnic groups had similar mean numbers of risk factors (White = 2.6, SD = 1.9; Black = 2.7, SD = 1.8), and in both groups, poverty (relative or absolute) was associated with an increase in the mean number of risk factors from 2 to 5. The correlation between income and number of risk factors for psychiatric disorder was –0.25 (P < .001) in each racial/ethnic group.

Poverty, Race/Ethnicity, Risk Factors, and Child Psychiatric Disorder
The second model in Table 4Go adds number of risk factors to poverty, age, and sex. A large improvement in model fit occurred ({chi}21 deviance change > 12, P < .001 in every case). Once the number of risk factors was added, absolute poverty ceased to contribute significantly to the model for psychiatric disorder for either racial/ethnic group. In the case of relative poverty, however, risk was still significantly higher for poorer than for nonpoor White (but not Black) children.

We examined racial/ethnic differences in the relation between relative poverty and psychopathology at different levels of risk. Although the prevalence of psychiatric disorder steadily increased with increasing risk, the poor White children were especially vulnerable to the highest level of risk. Post hoc analysis showed that poorer White children with 5 or more risk factors were much more likely than equivalently disadvantaged Black children to have a psychiatric disorder (56% vs 34%, OR = 2.5; 95% CI = 1.2, 5.2, P = .015).

To examine which specific risk factors mediated the relation between poverty and psychopathology, we included all the variables in Table 1Go, along with sex, age, and poverty, in multivariate models for each racial/ethnic group. Five risk factors contributed to the model for both racial/ethnic groups and both definitions of poverty: (1) family history of psychiatric disorder, (2) multiple (4 or more) moves of home in the past 5 years, (3) lack of warmth in the parent–child relationship, (4) poor parental supervision of the child, and (5) harsh parental disciplinary style.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
This study of children in the rural South serves as a sort of natural experiment, permitting us to disentangle race/ethnicity, poverty, and inner-city residence as correlates of childhood psychiatric disorder. In this nonurban sample of children, we found that (1) Black children were 3 times as likely as White children to be living in poverty; (2) the association between poverty and a list of risk factors for psychiatric disorder was largely the same for Black and White children, even though exposure to poverty differed dramatically; (3) the prevalence of psychiatric disorder increased with the number of risk factors in all groups but most markedly in poor White children; and (4) after other risks were controlled for, poverty (especially relative poverty) continued to put White, but not Black, children at risk.

The relations among poverty, race/ethnicity, and risk for child psychiatric disorder described here replicate the associations found in our study of White and American Indian children carried out in another part of the same state.29 In that case also, the minority children were much more likely to be living in poverty than were the White children (66% vs 21%), but again poverty predicted child psychiatric disorder only in the White sample.

A small set of family and community risk factors more prevalent in poor families explains most of the effects of poverty on psychiatric disorders. This small set of variables, however, did not support any one causal pathway to the exclusion of all others. Among the adversities attendant on poverty, one that children were especially vulnerable to was the effect of having to move household (and probably school) multiple times. Among the social selection factors, a family history of mental illness was very powerful. This variable may reflect a genetic predisposition in the children, the problems of living with a mentally ill parent, or both. Child psychiatric disorder was strongly associated, in both Black and White children, with the "end-of-one's-rope" syndrome of poor parenting that may be either cause or consequence, or both, of the child's behavior.6

Some potential risk factors proved not to be important, however. Of note was the lack of significance of a single-parent household and of current maternal depression, once family psychiatric history was entered into the model. In general, the findings support the argument made by Rutter and Sandberg30 and others that it is important to take into account the total burden of risk.

Overall, the prevalence of child psychiatric disorder was the same as that found in almost every study conducted in the United States in the past 2 decades,31,32 indicating that compared with living in urban areas such as Boston, Mass,33 and Pittsburgh, Pa,34 living in this nonurban area did not necessarily protect children. In this rural area, it was not the Black but the White children who emerged as most vulnerable. Two studies of adults carried out in the same geographic area found low rates of psychiatric disorders in the rural Black participants, compared with the White and urban Black participants (apart from cognitive deficits associated with aging).9,35 One suggested explanation is migration9; this area has undergone steady outmigration since World War II, particularly of Black residents. However, the hypothesis of racial/ethnic differences in selection for outmigration needs further study.

Limitations of the Study
In addition to the fact that the survey was cross sectional, and therefore suited only to correlational analysis, some methodological aspects of the study could have affected the results. The analyses were based on the reports of parents and children alone and were limited to a single geographic area. Income data came from the interviewed parent, and some were not sure how much money their partners earned. For this reason, and to reduce noncompliance, we used broad ($5000) bands to categorize the family income, which inevitably reduced the accuracy of the estimates. However, the racial/ethnic differences and effect of poverty on other risk factors were sufficiently marked to survive a broad classification. Poverty was measured only in terms of the past year's income, whereas several researchers have associated poor outcome, especially for Black children, with persistent poverty.3,36 It seems highly likely, though, that in this rural area with few job opportunities, the poverty we observed was relatively chronic. Another limitation was the lack of better measures of "social capital,"13 such as job opportunities, community organizations, and mental health services. It seems unlikely, however, that social capital of this kind would prove to be much more readily available to Black than to White families.


   Acknowledgments
 
This research was supported by grants R01 MH48085, K02 MH01167, and P30 MH57761 from the National Institute of Mental Health and R01 DA11301 from the National Institute on Drug Abuse.

The authors wish to express their gratitude to the 4 school districts whose boards generously provided access to their student information management system database as a sampling frame for the study and to all study families who welcomed our interviewers so courteously. We also would like to thank Alaattin Erkanli, PhD, for designing the sampling plan and advising on statistical methods for the data analysis.


   Footnotes
 
E. J. Costello analyzed the data and wrote the paper. G. P. Keeler managed the database, created the data files, and generated the prevalence estimates and confidence intervals. A. Angold wrote the psychiatric interview used to collect the data, ran the study, and contributed to the writing of the paper.

Peer Reviewed


   References
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 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child. 1997;7:55–71.[Medline]

2. Bor W, Najman JM, Anderson MJ, O'Callaghan M, Williams GM, Behrens BC. The relationship between low family income and psychological disturbance in young children: an Australian longitudinal study. Aust N Z J Psychiatry. 1997;31:664–675.[Medline]

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4. Cowen EL, Wyman PA, Work WC, Kim JY, Fagen DB, Magnus KB. Follow-up study of young stressaffected and stress-resilient urban children. Dev Psychopathol. 1997;9:565–577.[Medline]

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6. Sampson RJ, Laub JH. Urban poverty and the family context of delinquency: a new look at structure and process in a classic study. Child Dev. 1994;65:523–540.[Medline]

7. Quinton D. Urbanism and child mental health. J Child Psychol Psychiatry. 1988;29:11–20.[Medline]

8. Tolan PH, Guerra NG, Kendall PC. A developmental-ecological perspective on antisocial behavior in children and adolescents: toward a unified risk and intervention framework. J Consult Clin Psychol. 1995;63:579–584.[Medline]

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11. Farrow JA, Schwartz RH. Adolescent drug and alcohol usage: a comparison of urban and suburban pediatric practices. J Natl Med Assoc. 1992;84:409–413.[Medline]

12. Wilson WJ. The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy. Chicago, Ill: University of Chicago Press; 1987.

13. Coleman JS. Social capital, human capital, and investment in youth. In: Petersen AC, Mortimer JT, eds. Youth Unemployment and Society. New York, NY: Cambridge University Press; 1994:34–50.

14. Allison KW, Burton L, Marshall S, et al. Life experiences among urban adolescents: examining the role of context. Child Dev. 1999;70:1017–1029.[Medline]

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16. Dohrenwend BP, Levav I, Shrout PE, et al. Socioeconomic status and psychiatric disorders: the causation-selection issue. Science. 1992;255:946–952.[Abstract/Free Full Text]

17. Runciman WG. Relative Deprivation and Social Justice: A Study of Attitudes to Social Inequality in Twentieth Century England. Berkeley: University of California Press; 1966.

18. Angold A, Erkanli A, Farmer EMZ, Fairbank JA, Burns BJ, Hohmann A. Caring for children in the community: a study of psychiatric disorder, impairment and service use in rural African American and white youth. Arch Gen Psychiatry. In press.

19. Achenbach TM. Manual for the Child Behavior Checklist 4–18 and 1991 Profile. Burlington: University of Vermont, Department of Psychiatry; 1991.

20. Costello EJ, Angold A, Burns BJ, et al. The Great Smoky Mountains Study of Youth: goals, designs, methods, and the prevalence of DSM-III-R disorders. Arch Gen Psychiatry. 1996;53:1129–1136.[Abstract]

21. Erkanli A, Soyer R, Angold A. Optimal Bayesian two-phase designs for prevalence estimation. J Stat Plann Inference. 1998;66:175–191.

22. Pickles A, Dunn G, Vazquez-Barquero J. Screening for stratification in two-phase (‘two-stage’) epidemiological surveys. Stat Methods Med Res.1995;4:73–89.[Abstract/Free Full Text]

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