Poverty and Adolescent Mental Health

Original
Blackwell
Malden,
Journal
JCAP
XXX
1744-6171
1073-6077
Poverty Article
of
USA
Publishing
Child
and and Adolescent
Inc MentalPsychiatric
Adolescent Health Nursing

Carol Dashiff, PhD, Wendy DiMicco, DSN, Beverly Myers, MSN, MA, and Kathy Sheppard, MSN, MA

PROBLEM: Poverty and accelerations of Carol Dashiff, PhD, is Professor, School of Nursing,
University of Alabama at Birmingham, Birmingham, AL;
inequality, manifested by the increasing difference Wendy DiMicco, DSN, is Assistant Professor, School of
between the richest and poorest populations, have Nursing, University of Alabama at Birmingham,
Birmingham, AL; Beverly Myers, MSN, MA, is Clinician,
significant effects on the mental health of Brookwood Medical Center, Birmingham, AL; and Kathy
vulnerable groups. Adolescents are vulnerable to Sheppard, MSN, MA, is Associate Professor, University of
Mobile, Mobile, AL.
the effects of poverty. As a time of change and
transition for youth and their families, adolescence
creates both challenges and opportunities to A dolescence is a time of major life transition in many
countries. In countries and communities with an abundance
intervene in the effects of poverty. of resources, the transition to adult responsibilities is gradual
PURPOSE: The purpose of this article is to discuss and extended. However, for youth in poorer countries and
communities, the assumption of adult responsibility is more
the significance of poverty and its impact on dramatic, truncated, and abrupt. Parents in poverty may
take on long work hours at minimum pay when opportunities
adolescent mental health and mental health for work are available resulting in increased demands for
maturity from their children. This is especially true in the
services. case of single-parent households (Leinonen, Solantaus, &
SOURCES: An interdisciplinary literature search Punamaki, 2003; Weinraub & Wolf, 1983). Similarly, researchers
note that many inner-city African American youth enter
was conducted on the topic of poverty and adult-like roles at a very early age (Cauce et al., 2002).
Thus, the developmental stage called “adolescence” is not as
adolescent mental health. uniform as it is characterized; developmental differences in
CONCLUSIONS: Results indicated that nurses the course of adolescence occur among socioeconomic
groups. Nevertheless, the change that occurs during this
need to remain active participants in the provision period, whether rapid or gradual, creates a vulnerability
that is accentuated by poverty. Poverty influences mental
of mental health services to adolescents in poverty health through a variety of paths during adolescence. There-
and increase their advocacy for the creation of fore, the purpose of this literature review is to discuss
how poverty is defined, the significance of poverty
policy changes that address mental health needs of worldwide and in the United States, the impact of poverty
on adolescent mental health, and the delivery of mental
this population. health services to adolescents. The implications for child
and adolescent psychiatric nursing and nursing practice in
Search terms: Adolescent, mental health,
general are also addressed. The review was conducted
parenting, poverty following a search of interdisciplinary databases with the
key words “adolescents,” “poverty,” and “mental health.” The
following databases were encompassed: Academic Search
doi: 10.1111/j.1744-6171.2008.00166.x Premier, CINAHL, MEDLINE, PsycINFO, and Social
Sciences Full Text. The review was limited to the years
Journal of Child and Adolescent Psychiatric Nursing, Volume 22, 2000–May, 2007, except for a few additional classic articles in
Number 1, pp. 23 –32 the field.

JCAPN Volume 22, Number 1, February, 2009 23

Poverty and Adolescent Mental Health
Definitions of Poverty
A variety of terms are used to identify those who live in
circumstances of poverty, including “the poor,” those living
in circumstances of economic hardship, or neighborhood
disadvantage. Studies of poverty often employ a definition
that is income based. Income-based definitions will exclude
those marginally above the poverty level who suffer many
of the circumstances surrounding poverty that impact well-
being. Therefore, an understanding of what is known about
poverty and its impact on adolescent mental health must
take into account terminology and definitions. The World
Health Organization (WHO, 2006) notes that many terms are
used in discussions to indicate the various facets of poverty.
Some of these terms broaden conventional definitions of
poverty to include other dimensions, such as social exclusion,
vulnerability, lack of satisfaction of basic needs, relative
deprivation, marginalization, and low income.
In the United States, the best known definitions of
poverty are those used by the government for statistical
purposes, which are based upon a family’s pretax monetary
income. This operationalization of poverty varies according
to family size and composition. In 2006, a family of four with
two children with an income of $20,444, excluding capital
gains and noncash benefits, was considered poor (living in
poverty) (U.S. Census Bureau, n.d.-a, n.d.-b). However,
many seriously deprived families live above this threshold.
Therefore, this method of calculating poverty thresholds,
which originated in the mid-1960s, has been criticized as
unrealistic (University of Michigan, n.d.). The U.S. Department
of Health and Human Services disseminates a different
indicator of poverty on an annual basis: the “Federal Poverty
Guidelines” (Virginia Commonwealth University, n.d.). These
guidelines characterize poverty based on the number of
family members and the family’s geographic location, and
they are used to determine eligibility for some federal
programs (Virginia Commonwealth University). However,
the end result is roughly equivalent to the previously noted
guidelines. For example, in 2007, a family of four living in
the lower 48 states with an income of $20,650 was considered
poor (U.S. Department of Health and Human Services,
2007). Thus, current U.S. governmental definitions of poverty
are very narrow and conservative. Many families exist at
basic survival levels above these thresholds. These federal
guidelines for defining poverty contrast with the view of
poverty put forth by the WHO (2006) in which poverty is
thought to include diverse deprivations that interfere with
the ability of people to experience a basic level of well-being,
including social exclusion and marginalization. This multidi-
mensional approach moves beyond a focus on income to
include “voicelessness, vulnerability and powerlessness of
people to influence decisions that effect their lives” (WHO,
p. 4). Nevertheless, the WHO uses an income indicator to
24
define the international poverty line ($1 per day), which is
the standard for making comparisons among countries. In
summary, definitions of poverty vary somewhat, but income
indicators are predominantly used, even though it is recog-
nized that poverty is characterized by broader deprivations.
What we know about the impact of poverty is limited by
definitions that are narrow and conservative.
Significance of Poverty
Poverty Worldwide
Poverty is a global issue, and extreme poverty is a world-
wide health problem (WHO, 2000). Statistics indicate that
the economic distance between the world’s rich and poor
countries is increasing (Timimi, 2005), and this disparity of
economic resources poses a risk for health by affecting the
development of infrastructures to support mental health
care. The difference in per capita income between the richest
and the poorest countries has accelerated by a factor of five
since the late 1800s (Guillen, 2001). Africa and developing
countries in Latin America are the poorest, while Japan and
South Korea are the richest. When there is more equality
in the distribution of resources and wealth within and/or
across countries, overall health improves significantly
(Castells, 1998).
Poverty has dramatic effects on behavior and emotions,
which ultimately impact mental health, especially among
vulnerable groups (McMunn, Nazroo, Marmot, Boreham &
Goodman, 2001; Rutter & Smith, 1995). Under conditions of
economic deprivation, children and adolescents are dis-
proportionately affected because they are disproportionately
represented among the poor (University of Michigan, n.d.).
However, the relationship of poverty to mental health is
difficult to capture with statistics (Call et al., 2002). Although
scholars and clinicians in the area of children’s mental health
note that the rates of mental health problems have increased
significantly among young people in Western society, the
ability to detect rising or falling rates is partly a reflection of
a country’s resources. Only one third of countries even have
a mental health budget that addresses needed infrastructure
to assess mental health. Among the remaining countries,
slightly more than a third spends only 1% of their public
health budget to address mental health problems. This
results in biased statistics that favor more obvious mental
disorders (Milne & Robertson, 1998). Rates may also be
inaccurate because assessments are made with Western
medical standards alone, which do not account for culture-
specific patterns in the manifestation of distress (Milne &
Robertson). A further complication in assessing rates of mental
disorder among adolescents is the adolescent’s dependency
on the parents for accessing diagnostic and treatment services.
When services are meager and families are poor, parents are
JCAPN Volume 22, Number 1, February, 2009
less able to access services on their children’s behalf, further
contributing to underdetection. A cycle is established in
which economic burden and poverty are reinforced by the
failure to receive necessary services (Knapp et al., 2006).
Only one third of countries even have a mental
health budget that addresses needed
infrastructure to assess mental health.
Poverty in the United States
In the United States, a disproportionately large number of
children and adolescents remain vulnerable over time
regardless of how poverty is defined. Because the U.S.
Census Bureau reports poverty data for children under 18 as
a group, it is not possible to abstract data pertinent only to
adolescents. As far back as the mid-1970s the poverty rate
for children under the age of 18 has been consistently higher
than the adult rate (DeNavas-Walt, Proctor, & Lee, 2006). In
2005, the rate for children was 17.6%, compared with a rate
of 11.1% for adults (age 18 – 64 years) and 10.1% for older
adults (age 65 years and older) (DeNavas-Walt, et al.).
Whereas children comprised 25% of the total U.S. population,
they comprised 35% of the poor (University of Michigan,
n.d.). Black and Latino children under the age of 18 were
more likely than other children to live in poverty; 61% of
Latino and black children live in low-income families (less
than two times the federal poverty level, which is the amount
necessary to meet basic needs), compared to 26% and 28% of
white and Asian children, respectively (Douglas-Hall, Chau,
& Koball, 2006). The child poverty rate differs on the basis
of family composition. Children who lived in female-headed
households had a poverty rate of 42.8%, compared with
8.5% of children who lived in married-couple families
(DeNavas-Walt et al.). Overall, these statistics indicate that
adolescents, especially those who are black or Latino, and
those who reside in single-parent families, are more likely to
live in poverty circumstances, as defined by income.
Poverty and Adolescent Mental Health
Direct Affect of Poverty on Adolescent Mental
Health
Research suggests that poverty may have direct effects on
adolescent mental health. Poverty can also impact quality of
life and social adjustment (Wilkins et al., 2004). Frojd,
JCAPN Volume 22, Number 1, February, 2009
Marttunen, Pelkonen, von der Pahlen, and Kaltiala-Heino (2006)
found that adolescents are aware of economic difficulties in
their families, and that this influences their satisfaction with
their family and environment. The perception by adolescents
that their parents have financial difficulties has been associated
with aspects of adolescent mental health, suggesting that
poverty can have strong direct effects on adolescent mood
states, in addition to the indirect effect through negative
changes in the parent–adolescent relationship (these are dis-
cussed in the following section). For example, an awareness
of parental financial difficulties by Finnish adolescents was
associated with adolescent girls’ depression and adolescent
boys’ drinking to the point of intoxication (Frojd et al.).
These adolescents’ awareness of parental economic hardship
was also associated with a reported sense of helplessness,
and feelings of shame and inferiority. Adolescents from low
socioeconomic environments are noted to be at greater risk
for teen suicide (Fergusson, Woodward, & Horwood, 2000)
and the violence exposure experienced by adolescents living
in high poverty neighborhoods has been associated with
increased depressive symptoms, anxiety, and externalizing
problem behaviors (Buckner, Beardslee, & Bassuk, 2004;
Buka, Stichick, Birdthistle, & Earls, 2001; Fitzpatrick, Piko,
Wright, & LaGory, 2005).
Poverty also seems to have cumulative effects. Chronic
exposure to poverty increases adolescents’ risks for mental
disorders such as depression, behavioral risks such as
substance use (Fergusson et al., 2000), early sexual debut
(McBride, Paikoff, & Holmbeck, 2003), and criminal activity
(Davis, Banks, Fisher, & Grudzinsksa, 2004). Timing of
chronic exposure to poverty is important; adolescent boys
exposed to persistent poverty are more vulnerable to poor
academic achievement and an increase in behavior problems
(Wilkins et al., 2004).
A significant relationship between poverty and substance
abuse has been supported, as well as a significant relation-
ship between substance abuse and criminal offending.
Thus, poverty may result in comorbid mental health
problems. High offenders had past histories of comorbid
substance abuse and childhood placements in restrictive
residential programs. A peak in criminal activity occurred in
late adolescence (age 18), which directly corresponded to the
adolescent’s loss of scaffolding welfare and special educa-
tion benefits (Davis et al., 2004). Thus, loss of an economic
scaffold and services seemed to contribute to problematic
social behavior; this loss may occur in many states of the
United States, where adolescents are treated as adults by
the criminal justice system when they reach the age of 18.
They then do not qualify for many adult welfare benefits
and mental health services unless they have a psychiatric
diagnosis (Davis et al.). This demonstrates the importance
of screening for psychiatric problems during this time of
late adolescent transition.
25
Poverty and Adolescent Mental Health
Indirect Effect of Poverty on Adolescent Mental
Health Through Altered Parenting
Poverty and economic distress also have an effect on
parents, producing parental distress that disrupts parent–
adolescent relationships, and often leads to inconsistent
discipline, decreased parental monitoring, and parent–
adolescent conflict (Stern, Smith, & Jang, 1999). Adolescent
depression, in particular, has been associated with adolescents’
characterization of the parent–adolescent relationship as less
supportive and more punitive, blurring of intergenerational
boundaries, parents behaving as peers, and adolescent
assumption of parental roles (Sagrestano, Holmbeck, Paikoff,
& Fendrich, 2003). Lower school grades, conflicts with parents,
and impaired social relationships can occur when the
adolescent selectively attends to negative parent–adolescent
interactions (Wadsworth & Berger, 2006). These findings
support indirect effects of poverty on outcomes that occur
through alterations in parenting.
Poverty may similarly contribute to adolescent risk behaviors
through its effect on the parent–adolescent relationship.
Poverty has cumulative effects that relate to parental unem-
ployment, underemployment, and unstable work conditions
which, rather than poverty per se, lead to parent–adolescent
conflict, unsupportive parenting, and harsh disciplinary
practices (Brooks-Gunn & Duncan, 1997; Duncan & Brooks-
Gunn, 1997; McLeod & Shanahan, 1996). Research has shown
that parent–adolescent conflict is associated with adolescent
substance use, early sexual debut, and criminal justice system
involvement (Donenberg, 2005; Goodman & Huang, 2002;
McBride et al., 2003). The conflict between parent and
adolescent that occurs in association with poverty and parental
distress places adolescents at a significant risk for early sexual
debut. Early parenthood secondary to early sexual debut
can lead to mental health problems, such as adolescent
depression and suicidal behaviors (Fergusson et al., 2000).
Poverty may similarly contribute to adolescent
risk behaviors through its effect on the parent–
adolescent relationship.
A spiral of adverse socioeconomic consequences can result
from the influence of poverty on the production of mental
health problems and other outcomes, such as high school
dropout, lack of employment opportunities, behavioral pro-
blems, social disorganization, and further increases in parent–
adolescent conflict (Davis et al., 2004; Wickrama & Bryant, 2003).
Early sexual debut increases the risk of HIV/AIDS because
26
the number of lifetime partners increases, and because younger
adolescents often do not use condoms (Donenberg, 2005).
However, despite these negative effects of poverty on
parenting, some suggest that families have strengths that
modify the effects of poverty. For example, parental and
family resiliency may mediate the effects of poverty. Stansfeld
and Haines (2004) failed to find an increase in depression
among Bangladeshi adolescents in the United Kingdom
who lived in extreme poverty because family cohesion, cultural
identity, religious beliefs, and warm parent–adolescent
relationships buffered the distress of poverty. Although it is
important to consider family strengths, an overemphasis can
contribute to a process of victimizing families due to failure
to consider that chronic poverty is an encompassing adversity.
Effect of Poverty on the Social Fabric of
Neighborhood and Place
Chronic poverty contributes to financial distress,
inadequate housing, substandard schools, and deteriorating
neighborhood conditions for adolescents (Stern et al., 1999).
Poverty also disrupts the collective socialization of adolescents
within communities. Poor neighborhoods are characterized
by social disorganization, crime, and high rates of adult
unemployment, which create environments where adolescents
are exposed to gangs and violence (McLeod & Shanahan,
1996). Older children and adolescents living in poverty are
more likely to be exposed to violence, either as victims,
witnesses, or perpetrators, than those living in higher
income environments (Buckner et al., 2004). Low-income
people from various ethnic, cultural, and racial backgrounds
tend to move to impoverished communities where ethnic
groups may be segregated. Segregation results in a lack of
shared norms and this barrier to intergroup communication
then produces social isolation and despair (Wickrama &
Bryant, 2003). This has been called the “ghettoization of
poverty” (Fitzpatrick et al., 2005, p. 262). This social isolation
and despair may then be experienced by the family unit.
Residential instability and perceptions of the community as
disadvantaged have been associated with decreased feelings
of connection and less feelings of social obligation by the
residents (Aptekar, Paardekooper, & Kuebli, 2000). Thus,
chronic poverty impacts the individual’s and family’s invest-
ment and commitment to the life of the overall community,
and opportunities for change are restricted.
Brody et al. (2003) demonstrated that the likelihood of
developing a conduct disorder among young African
American adolescents was associated with parenting and
family factors, but these associations were strongest among
families from the most disadvantaged neighborhoods. An
experimental study of the effects of neighborhood on mental
health demonstrated that parents who stayed in communities
with high poverty were more distressed than those who moved
JCAPN Volume 22, Number 1, February, 2009
to a low-poverty community, and their sons had more problems
with anxiety and depression. The mental health impact was
greater for youth than it was for their parents (Leventhal &
Brooks-Gunn, 2003). Thus, interventions that singularly address
the parent–adolescent relationship or the adolescent as an
individual rather than the neighborhood context are likely to
have a limited effect on adolescent risk-taking behaviors in
communities that are characterized by deprivation.
In closing, poverty is associated with many adverse mental
health outcomes for adolescents directly through effects on
adolescents or indirectly through its effect on parenting
behaviors. Poverty seems to stimulate negative parenting
practices that may be a result of parental stress and that
contribute to parent–adolescent conflict. Increased parent–
adolescent conflict often leads to an increase in adolescent
risk-taking behaviors and mood disturbance. Early sexual
debut, substance use, and criminal activity can increase the
risks for repeating a cycle of social disadvantage. Inter-
ventions that target adolescent mental health in poverty
circumstances must acknowledge the adolescent’s contextual
and social realities and address multiple dimensions, including
investment in the community and community cohesion.
Poverty and Service Delivery
Knapp et al. (2006) list six separate economic barriers
to obtaining health services: informational, insufficient
resources, problems of resource distribution, inappropriate
resources, inflexible resources, and poor timing of resources.
These barriers are more problematic in mental health con-
texts and can be accentuated in poverty communities. Their
scope illustrates the multifaceted impact of impoverished
environments on mental health services and their delivery.
Informational Barriers
Informational barriers exist when the evidence base for
practice does not exist or is not disseminated to practitioners
or used to change service delivery (Knapp et al., 2006).
Although the evidence base for the treatment of adolescents
within a family context is growing (Diamond, 2005), few
mental health services have been configured specifically to
meet the unique characteristics and mental health needs of
adolescents and their families living in poverty (Diamond).
Thus, the evidence base for mental health practice with
adolescents living in poverty is limited. A lack of education
for families and the general public with regard to recogni-
tion and understanding of mental health issues during
adolescence affects help-seeking behavior in early stages of
mental health problems. Parents and adolescents who live in
poverty need education about the impact of poverty on
parent and adolescent mental health and the risks that exist
to healthy social and emotional development (Huang et al.,
JCAPN Volume 22, Number 1, February, 2009
2005). Health providers also need education. In low-income
countries and communities, health providers may be unaware
of the results of existing clinical trials or systematic reviews
of intervention for poverty groups. As a result, health
providers may resort to the lowest level of practice based on
outdated information or opinion (Knapp et al.).
Insufficient Resources and Problems of Resource
Distribution
A critical issue with regard to adequate mental health
care for adolescents is the persistent shortage of mental
health providers. While the numbers of child and adolescent
psychiatrists slightly increased in the United States between
1990 and 2001, the numbers still fall far below the estimated
number needed to adequately treat children and youth
(Thomas & Holzer, 2006). Certainly child and adolescent
psychiatrists are not needed to treat all children, but when
only the youth with severe mental disorders are considered,
the ratio of child and adolescent psychiatrists per 1,000
youth was 1.6 in 2001 (Shaffer et al., 1996). This severe and
serious shortage is accentuated by the fact that children and
youth in poverty are more likely to develop a mental health
disorder (Center for Mental Health Services, 1997). States
with the highest percentage of children living in poverty
(over 20%), based on the U.S. census from 1990 to 2001, were
nine southern states: Alabama, Arkansas, District of Columbia,
Kentucky, Louisiana, Mississippi, New Mexico, Texas, and
West Virginia. Across all states, only those counties with less
than 20% of youth living in poverty had three or more child
and adolescent psychiatrists per 100,000 youth, which was
the mean for all counties. The rate of available psychiatrists
declined with each 1% increase in the numbers of youth
living in poverty (Thomas & Holzer). Rural areas were more
highly impacted because of the larger percentage of poverty
households. Similar information about the distribution of
other mental health professionals, including psychiatric clin-
ical nurse specialists and practitioners, is not published,
although these providers can fill the gap in services.
A critical issue with regard to adequate mental
health care for adolescents is the persistent
shortage of mental health providers.
Inappropriate Resources
Cauce et al. (2002) noted that evidence suggests that
minority adolescents of very low socioeconomic status are
27
Poverty and Adolescent Mental Health
high users of mental health services. However, high utiliza-
tion does not equate to appropriate resources. Inappropriate
configuration of resources occurs when the services pro-
vided are not congruent with the needs or preferences of the
potential consumers (Knapp et al., 2006). Even when support
services are provided that address family functioning,
family crisis prevention, and the maintenance of children’s
residence within the home, families identified as having
serious financial challenges may show the least improve-
ment (Statham & Holtermann, 2004). Family-focused support
interventions do not necessarily take into account the
economic context of poverty living conditions, inadequate
housing, and lack of employment. Interventions that do not
address the social and economic context of family life have
limited potency. In an evaluation of a family support program
to prevent family breakdown in homes with children over
8 years of age in Wales, the financial stress of poverty that
interfered with effective coping by parents was barely
touched by a narrow family support intervention program
from a single agency. Moreover, the resources desired by
parents differed from the support services provided. Parents
wanted day care, accessible parent education services,
earlier support for mental health problems in parents and
youth (indicative of poor timing of services), and assistance
with relationship problems. The broad scope of such services
requires interagency cooperation.
The characteristics of adolescents require particularly
sensitive services. Adolescents highly value privacy and
personal choice. In their quest for autonomy and increasing
self-reliance, they are less likely to be active seekers of help,
especially in Western societies. Self-reliance and privacy
were top reasons for not seeking help among adolescents
(Dubow, Lovko, & Kausch, 1990). Among minorities, mental
health problems are more likely to be shared with family
members or friends, while white parents are more likely to
make contacts with formal mental health providers (McMiller
& Weisz, 1996). This may be indicative of mistrust of formal
mental health systems by family and friendship networks
among the minority poor, which may be reinforced by more
coercive referral processes from formal agencies when
mental health problems become visible. Moreover, for those
minorities in poverty, referrals to mental health services are
more likely to come from non–mental health service providers,
whereas for those with greater financial resources, referrals
come from family and friends. Taken together, these findings
suggest that resources are not formulated to be acceptable to
impoverished minorities.
The overall structure of service delivery can also be
problematic. Concentration of resources within large urban
institutions distances care from the places where adolescents
and their families live their daily lives. Bureaucracy and
formality within large structures are not likely to be appealing
to adolescents or the poor.
28
Inflexible Resources and Poor Timing of Resources
Inflexibility is the result of services that are organized
in a rigid manner driven by bureaucracy, that do not
address consumer desires, or that are poorly coordinated.
Among some subgroups, such service deficits have been
identified. Witt, Kasper, and Riley (2003) found that only
41.8% of disabled youth with poor psychosocial adjustment
received mental health services. Moreover, a lack of coor-
dination of care was more common among those who were
black and Hispanic, uninsured, poor, and in homes with
parents who had low educational attainment. Services were
more readily utilized when the health provider or the health
provider and the family were involved in coordination
of care.
Another at-risk group is refugee adolescents. Increased
stress and mental disorders in refugees can result from a
multitude of adverse experiences related to environments
and relationships they leave, as well as the communities to
which they flee. Refugee status often results in financial
losses related to unemployment and lack of income. Refugee
youth have greater exposure to violence and other adversities,
such as lack of stable housing and social isolation, that
increase their need for mental health services, and that
require special services to meet their needs (Howard &
Hodes, 2000). However, special mental health services are
seldom configured for this population.
Stop gap services are often available within the non–
mental health sector, such as medical offices, school systems,
juvenile justice system, and child welfare. Critical needs may
be met by these service settings, but less obvious needs
can be overlooked by providers who do not have expert
knowledge and skill (Huang et al., 2005). Clarke, Coombs,
and Walton (2003) demonstrated, however, how partnership
models between experts and generalists can be forged to
facilitate flexible services. A school nurse and psychologist
partnership can result in school-based services that can meet
both critical and less obvious needs. In this model, school
nurses were provided with mental health education and
support that enhanced the treatment of adolescents with
mental health issues and fostered early identification of
adolescents with potential crises. In this environment,
students encounter access to mental health care that is seen
as friendly, flexible, and accessible due to the familiarity of
the young person within the school environment as opposed
to a mental health care facility. This flexible use of resources
resulted in early identification of mental health problems,
which contributed to better timing of intervention delivery.
In fact, this research has indicated that students with issues
will often approach a teacher prior to a healthcare professional.
It has been suggested that educational preparation about basic
mental health awareness be included for these professionals
as well (Clarke et al.).
JCAPN Volume 22, Number 1, February, 2009
 Implications
Direct practice involves service provision to families in
poverty and must be multifaceted with interagency coopera-
tion and collaboration as well as multidisciplinary teams.
Poverty creates a situation of challenge for the delivery of
mental health services to adolescents and their families. This
review suggests strategies that might be used to address the
problem within the areas of direct practice and social action.
Intervention programs to address adolescent mental
health issues need to be delivered in a multisystemic manner
to provide the adolescent with needed coping skills, affect
parent–adolescent communication, intervene in parental
distress, and address the multitude of factors associated with
poverty that affect the safety and security of neighborhood
environment. Intervention requires that partnerships be
formed between mental health professionals and families
to develop a plan of coordinated care. Because poverty com-
munities are often multiethnic, the needs of specific cultural
groups must be taken into account to provide culturally
competent services (Huang et al., 2005). One component of
assessment of ethnic groups is whether there are unique
patterns of distress that are not captured by traditional
diagnostic systems. The specific needs of unique populations
living in poverty (developmentally disabled and refugees)
may require unique services.
Clinicians working with poverty groups should routinely
screen for known mental health risks, such as depression,
substance abuse, and other comorbidities, and also be aware
of other health risks that are associated with these mental
disorders. Moreover, routine assessment of adolescents
living at or near the poverty threshold is needed to identify
those at risk for mental health problems and offer preventative
programs and services. These assessments should include
the following areas: exposure to violence, academic achieve-
ment, conflict with parents, sexual risk behavior, impaired
social relationships, and age-related loss of scaffolding
services. Prevention programs aimed at building family and
community strengths can reduce feelings of powerless,
marginalization, and stigmatization. Educational programs
to increase awareness of the issues faced by adolescents and
their families, their systemic nature, and the need for multi-
systemic treatment can be provided to these communities
and their providers (Huang et al., 2005). This approach
provides an opportunity for community action, especially
when community advocacy groups have been formed. It can
also set the stage for community input to and acceptance of
services, such as short-term family therapy, which has proven
to be beneficial for the adolescent and the family. Manual-
based, focused interventions from this treatment approach
can be taught to providers, allowing for rapid treatment and
evaluation of the adolescent and family within a community
context (Diamond & Josephson, 2005).
JCAPN Volume 22, Number 1, February, 2009
Innovative strategies of service delivery are needed for
adolescent poverty groups who are difficult to access. For
those in rural environments, two strategies that are being
used are the provision of specialty services through tele-
medicine and the development of interdisciplinary outreach
teams. Outreach teams travel periodically to distant sites
either as a group or cyclically as individuals. Partnerships
between specialists and generalists are being developed to
expand the impact of expert knowledge through generalists,
who are more able to identify those at risk and in need of
preventative and screening services to promote early treat-
ment. Partnerships between school nurses and psychologists
or other experts, such as adolescent psychiatric nurses or
adolescent psychiatrists, provide a model in which more
informally structured services are directly available and
easier for adolescents to access. Moreover, the utilization of
a primary care provider in an accessible context has the
potential to make mental health services less stigmatizing for
adolescents living in poverty (Huang et al., 2005). However,
recent research indicates that only one half of U.S. middle
and high schools have any mental health counseling services
available onsite and that a greater presence of mental health
specialists is needed in the school setting (Slade, 2003).
Routine assessment of adolescents living at or
near the poverty threshold is needed to identify
those at risk for mental health problems and
offer preventative programs and services.
One program that is gaining popularity is that of mentoring.
An adolescent who is at risk can be paired with an adult to
meet regularly, engaging in activities and conversation.
These programs can be found within the community through
agencies such as churches, colleges, social organizations, and
schools. Adult mentors have been responsible for providing
many youth with meaningful social interaction, supervision
and guidance, cultural enrichment, spiritual guidance, sense
of self-worth, and other qualities that support mental health
in this population (Bloomquist & Schnell, 2002).
Within the focus of social action, the avoidance of gross
generalizations about the adolescent developmental
period and families living in poverty were highlighted. The
experience and pattern of adolescent development varies with
cultural groups and economic circumstances. Poverty may
create a situation that creates pressure to move more quickly
into adult roles, and this should not be judged as non-
normative development. Similarly, families living in poverty
29
Poverty and Adolescent Mental Health
should not be stigmatized or blamed for poor adolescent
outcomes that are a product of the families’ environmental
context.
Clearly, formal bureaucratic organizations and referral
processes are intimidating and create suspiciousness among
the poor, even though mental health services may be more
frequently accessed by poverty groups who have public
health insurance. Indigenous community workers may be
more favorable routes of referral. Partnerships are also
needed between mental health service providers and family
networks in poverty communities to enhance trust. The forma-
tion of community advisory groups that meet with providers
inside poverty communities is a strategy to build more trusting
relationships. Community forums encourage members to
develop cohesion and identify their needs. The public trust
engendered by nurses creates an opportunity for nurses to
work collaboratively with communities to foster decreased
isolation and enhanced commitment to the community.
This literature review emphasizes the need for political
action by mental health service providers and adolescent
psychiatric nurses. Advocacy is needed to promote govern-
mental policies in the following areas: increased funding of
mental health services and preparation of providers to serve
youth living in poverty, development of a less restrictive
definition of poverty, development of coordinated systems
of care and family–provider partnerships, and development
and funding of innovative practice models that expand the
impact of mental health experts. Poverty must be recognized
as a global issue. The ability of service providers to make
convincing arguments about the negative impact of poverty
locally and worldwide, as well as awareness of the success
or failure of programs to ameliorate poverty and its con-
sequences, is crucial to influencing policy-makers.
Increasing the funding of mental health services for
adolescents in poverty is a formidable task. It is imperative
that policy-makers recognize adolescents’ mental health
needs and the associated crisis in funding mental health
services. Although funding is limited, a shifting of mental
health focus from inpatient centers to community-based
services could result in tremendous savings, ultimately
resulting in greater coverage for adolescents in need of these
services (Huang et al., 2005).
Nurses need to remain active advocates and
participants in the creation of policy changes
that address mental health of adolescents living
in poverty.
30
Conclusions
Worldwide, children and adolescents are disproportion-
ately represented among the poor. Chronic exposure to
poverty increases adolescents’ risk for depression, substance
use, early sexual debut, and criminal activity (Fergusson et al.,
2000). Numerous economic barriers have been identified that
limit access to mental health services: barriers to evidence-
based practice prevent the use of effective treatments; critical
mental health provider shortages limit available services;
and the inappropriate allocation of limited resources often
leads to an uncoordinated provision of multiagency services
(Knapp et al., 2006). In order to meet the unique healthcare
needs of adolescents, psychiatric nurses and nursing practice
in general can benefit from the following recommendations:
reduce the stigmatization of adolescents who live in
poverty by providing culturally sensitive and social context
appropriate care; participate in multidisciplinary partnerships
to ensure a coordinated and appropriate delivery of services
and advocate for economic resources to support these
services; and develop or seek out innovative services, such
as outreach teams, to increase the access to mental health
services for rural adolescents who live in poverty. In addition,
nurses need to remain active advocates and participants in
the creation of policy changes that address mental health of
adolescents living in poverty.
Author contact: dashiffc@uab.edu, with a copy to the Editor:
poster@uta.edu
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