The Issue. An appreciation of the role of social and emotional well-being in determining health outcomes is important in advancing the equity agenda.1 These aspects of health are adversely affected by inequity. They also are important as potential causal factors. Low levels of emotional and social well-being among the rich may be important in perpetuating health and social inequity. In the past, most research on inequity has focused on the negative end of the continuum of emotional and social health (eg, child abuse, conduct disorder, mental illness, drug and alcohol abuse) and concentrated on the problems of the poor, not the rich. The prevalence of emotional and social well-being has not been well studied. At the other end of the spectrum, emotional and behavioral problems now are the most important cause of disability in childhood,2 affecting between 10% and 20% of children.3 In between these 2 extremes, some children are socially competent, are liked by their peers, are resilient in the face of problems, know their own minds, are kind to others, and are able to handle conflict in a way that leads to resolution. Others are prone to aggression and deceit, are ostracized by their peer group, and create conflict and distress. These children may have very low self-esteem. They often are manifestly unhappy and anxious and certainly make others unhappy and anxious. This group may not meet the Diagnostic and Statistical Manual of Mental Disorders-defined criteria for emotional and behavioral problems; teachers therefore may be more aware of them and their impact on others than physicians. As a result, teachers and educational psychologists have been at the forefront of developing interventions to help this group.
RELATIONSHIP OF SOCIAL AND EMOTIONAL HEALTH TO SOCIAL INEQUALITIES
Data from the 1970 birth cohort study in the United Kingdom illustrate the way in which emotional and behavioral problems are related to social and economic circumstances.3 There is a well-defined social gradient in the distribution of these disorders. These child health problems therefore are important to a social equity research agenda. In the United Kingdom, the percentage of the total population of children and the absolute number of children in social classes IV and V (semiskilled and unskilled) is low relative to the percentage and number of children in other social classes, and most children with behavior problems are not from these groups. Traditional interventions related to health inequalities that focus on the poor are likely to be inefficient approaches to health improvement. Programs such as Sure Start in the United Kingdom and Head Start in the United States and many others that target communities and families at high risk will miss the majority of children with behavior problems.
IMPACT OF CHILDHOOD SOCIAL AND EMOTIONAL HEALTH ON ADULT HEALTH
Emotional and behavioral problems in childhood have a predictive effect on health in adulthood, including implications for mental health and personality disorders. Emotional and behavioral problems at age 16, for example, predict general physical well-being 7 years later.4 It is notable that their impact is independent of and stronger than the effect of traditional indicators of socioeconomic deprivation in childhood (eg, school absence, school qualifications, housing status [homeowner or renting], social class). Emotional and social well-being are important not just for consideration of child health inequities but also for understanding adult health disparities.
In almost all countries, death rates in adults vary by social class, as do infant mortality rates. The distribution of mortality rates by social class shows a much lower gradient in Sweden, where there is a more equitable distribution of income, than in the United Kingdom. Indeed, the death rates in the lower social classes in Sweden are lower than those in the upper social classes in England and Wales. This suggests that the overall health of a country’s population in all social classes is directly related to the degree of equity in the distribution of income. An important question arises, therefore: why do income inequalities exist at all? What are the psychosocial forces that encourage an unequal distribution of wealth if the health of the entire population of a country, including those in the highest socioeconomic classes, would be improved by social equity?5
Little research has been published relating to this important question. Research has focused on questions such as, “How does income inequality cause unhealthy lifestyles?” “What are the deprivations children experience as a result of these inequities?” “What is the impact of social and emotional inequities on educational outcomes?” “How do these risk factors cause disease and disability among children?” The key question—“Why do social inequalities exist at all when both rich and poor would be healthier and happier without them?”—has not been researched.
Consideration of the distribution of income in the United Kingdom provides some insight into the causes of inequity. The difference between average income in the bottom 2 quintiles of the distribution of income in the United Kingdom is small. The gap gets increasingly large as incomes rise. If it were possible to plot incomes in deciles or even smaller population groups, then the skewed distribution would become even more marked. Improving the income of people at the bottom end of the income distribution, even raising their income to those of people in the second quintile, would make very little difference to the disparity in income. Bringing the income of the richest quintile down to that of the second richest would, in contrast, have a dramatic effect on this disparity. The conclusion derived from these data is that income inequality is driven by the wealth of the rich and not solely by the poverty of the poor.
Given these perspectives, it is worth considering the reasons for the drive to accumulate wealth and the need by some to be richer than others. Security, comfort, status, power, and enjoyment come to mind. All of these are reasonable things to want; indeed, some have been defined as prerequisites for health.6 They become a social problem only when people need more than their fair share of these resources. Why does this happen? Psychotherapeutic theory suggests that people need more than their fair share of power because they feel powerless. They crave security because they do not feel safe. They need more than their share of status because they do not value themselves and the contributions they are making to society. It therefore may be a lack of emotional and social well-being among the rich that drives social inequity. It is curious that in considering interventions to reduce health problems related to inequity, the focus is always concentrated on the poor. Refocusing attention on the wealthiest social classes potentially could return a significant dividend with respect to improving the health and social well-being of all people across all social classes. This would be achieved by universal approaches to solving social inequity.
INTERVENTIONS THAT MIGHT PROMOTE EMOTIONAL AND SOCIAL WELL-BEING
There now is a range of interventions for parents and children to improve emotional and social well-being and prevent emotional and behavioral problems.7 The interventions enable parents to 1) parent in a way that is supportive of emotional and social development, 2) relate in different ways to their children, 3) develop insight into what is happening in their parent-child relationship, and 4) identify when the child is behaving in a difficult way. These programs have a beneficial effect on health in childhood and adulthood. They also should reduce the psychosocial problems that drive social inequalities. These interventions are delivered to parents on a one-to-one basis and in groups, in clinic settings, at home, and in the community. Some interventions are based on social learning theory and are behaviorist in their approach, and some are based on attachment theory and promote emotional literacy and healthy relationships. Many combine both approaches.
There is good evidence from systematic reviews that these programs do enable parents to change and that they reduce behavior problems in children.7 The evidence is stronger for behavioral programs than it is for programs based on attachment theory. Most of the research, however, has been undertaken with parents and children living in deprived communities and who have clinically defined emotional and behavioral problems. Most of this research has been done in the United States.8,9 Some programs also have an impact on other outcomes such as mothers’ mental health, mothers’ employment status, and health service use. There is some evidence that these programs work with volunteer parents in high-risk and other communities,10 but there has been limited research on the sort of universal approaches that would benefit the rich as well as the poor.
Interventions for children usually are based in schools. These programs develop self-esteem, social competence, and conflict management skills.11 Some also aim to develop emotional awareness and insight into the impact of emotions on behavior, both of self and of others. Systematic reviews of these mental health promotion programs in schools suggest that they work better when they take a universal or whole-school (cross-curricular) approach. In the United Kingdom, these programs often are labeled as “health-promoting school programs.” They work best when the schools are very much involved in developing and designing the programs, ensuring that they meet the perceived needs of the school and incorporate local as well as evidenced-based research solutions. This creates problems for research and evaluation because this empowering model is difficult to evaluate with randomized, controlled trials, the bedrock of evidence-based medicine.
EVALUATING INTERVENTIONS THAT MIGHT PROMOTE EMOTIONAL AND SOCIAL WELL-BEING
This problem is well illustrated by studies identified in a systematic review of the literature.12 Twelve studies evaluating the impact of the whole-school approach in controlled or observational studies were identified. An inverse relationship between study quality and intervention quality was found. Randomized, control trials may be the optimum method of avoiding investigator bias, but it may be necessary to develop alternative methods of dealing with the possibility of bias when evaluating interventions that aim to promote emotional and social well-being.
Defining outcome measures is another methodologic issue that must be addressed before further progress can be made with this research agenda. At present, the majority of emotional and social health measures have been developed by psychiatrists with a focus on pathology and clinical populations. There now is a need to develop measures that capture the positive aspects of health. For example, the New England Medical Center Child Health Questionnaire is a generic health status measure that captures some aspects of emotional well-being, happiness, cheerfulness, energy, and self-esteem. Few child health outcome measures include important aspects of emotional and social well-being such as resilience, empathy, resourcefulness, and social competence.
There is evidence that low levels of emotional and social well-being are important factors in the generation of health and social inequities and disparities in children and adults. They may be a consequence of inequity and a possible cause. Wider appreciation of these concepts is important for the development of effective interventions. To incorporate them into research in child health, there is a need for the development of better outcome measures. Consideration needs to be given to alternatives to randomized, controlled trials in evaluating these interventions. The Royal College of Paediatrics and Child Health-American Academy of Pediatrics Equity Project should include these issues in its research agenda.
- ↵Stewart-Brown S. Parenting well-being health and disease. In: Buchanan A, Hudson BL, eds. Promoting Children’s Emotional Well-Being: Messages From Research. Oxford, United Kingdom: Oxford University Press; 2000:28–47
- ↵Bone M, Meltzer H. The prevalence of disability among children. OPCS Surveys of Disability in Great Britain, Report 3. London, England: HMSO; 1989
- ↵Stewart-Brown S. The public health implications of childhood behaviour problems and parenting programmes. In: Buchanan A, Hudson BL, eds. Parenting, Schooling and Children’s Behaviour. Brookfield, VT: Ashgate Publishing; 1998:21–33
- ↵Power C, Manor O, Fox J. Health and Class: The Early Years. London, United Kingdom: Chapman and Hall; 1991
- ↵World Health Organization. Targets for Health for All: Targets in Support of the European Regional Strategy for Health for All. Copenhagen, Denmark: World Health Organization; 1985
- ↵Barlow J, Coren E, Stewart-Brown S. Meta-analysis of the effectiveness of parenting programmes in improving maternal psychosocial health. Br J Gen Pract.2002;52 :223– 233
- ↵Patterson J, Barlow J, Mockford C, Klimes I, Pyper C, Stewart-Brown S. Improving mental health through parenting programmes: block randomised controlled trial. Arch Dis Child.2002;87 :472– 477
- Copyright © 2003 by the American Academy of Pediatrics