Patterns of Social Determinants of Health and Child Mental Health, Cognition, and Physical Health

Abstract

Importance: Social determinants of health (SDOH) influence child health. However, most previous studies have used individual, small-set, or cherry-picked SDOH variables without examining unbiased computed SDOH patterns from high-dimensional SDOH factors to investigate associations with child mental health, cognition, and physical health.

Objective: To identify SDOH patterns and estimate their associations with children's mental, cognitive, and physical developmental outcomes.

Design, setting, and participants: This population-based cohort study included children aged 9 to 10 years at baseline and their caregivers enrolled in the Adolescent Brain Cognitive Development (ABCD) Study between 2016 and 2021. The ABCD Study includes 21 sites across 17 states.

Exposures: Eighty-four neighborhood-level, geocoded variables spanning 7 domains of SDOH, including bias, education, physical and health infrastructure, natural environment, socioeconomic status, social context, and crime and drugs, were studied. Hierarchical agglomerative clustering was used to identify SDOH patterns.

Main outcomes and measures: Associations of SDOH and child mental health (internalizing and externalizing behaviors) and suicidal behaviors, cognitive function (performance, reading skills), and physical health (body mass index, exercise, sleep disorder) were estimated using mixed-effects linear and logistic regression models.

Results: Among 10 504 children (baseline median [SD] age, 9.9 [0.6] years; 5510 boys [52.5%] and 4994 girls [47.5%]; 229 Asian [2.2%], 1468 Black [14.0%], 2128 Hispanic [20.3%], 5565 White [53.0%], and 1108 multiracial [10.5%]), 4 SDOH patterns were identified: pattern 1, affluence (4078 children [38.8%]); pattern 2, high-stigma environment (2661 children [25.3%]); pattern 3, high socioeconomic deprivation (2653 children [25.3%]); and pattern 4, high crime and drug sales, low education, and high population density (1112 children [10.6%]). The SDOH patterns were distinctly associated with child health outcomes. Children exposed to socioeconomic deprivation (SDOH pattern 3) showed the worst health profiles, manifesting more internalizing (β = 0.75; 95% CI, 0.14-1.37) and externalizing (β = 1.43; 95% CI, 0.83-2.02) mental health problems, lower cognitive performance, and adverse physical health.

Conclusions: This study shows that an unbiased quantitative analysis of multidimensional SDOH can permit the determination of how SDOH patterns are associated with child developmental outcomes. Children exposed to socioeconomic deprivation showed the worst outcomes relative to other SDOH categories. These findings suggest the need to determine whether improvement in socioeconomic conditions can enhance child developmental outcomes.

Figure 1.. Study Pipeline

ABCD, Adolescent Brain Cognitive Development; AHRQ, Agency for Healthcare Research and Quality; CBCL, Child Behavior Checklist; CDC, Centers for Disease Control and Prevention; NIH, National Institutes of Health; SDOH, social determinants of health; WHO, World Health Organization; WISC-V, Wechsler Intelligence Scale for Children.

Figure 2.. Characteristics of the Identified Social Determinants of Health (SDOH) Patterns

Each bar shows the proportion of children with disadvantaged status in each (continuous) SDOH variable across SDOH patterns. Children with disadvantaged SDOH are those who have worse SDOH exposures than 75% of the population with regard to a specific SDOH variable. eFigure 4 in Supplement 1 provides more detailed information. ECE indicates early childhood education; SES, socioeconomic status.

Figure 3.. Associations Between the Identified Social Determinants of Health (SDOH) Patterns and Mental Health and Suicidal Behavior Outcomes of Children

Child mental health outcomes were measured based on Child Behavior Checklist (CBCL) symptom scales (continuous)^, and self-reported suicidal behaviors using the self-administered computerized version of the Kiddie Schedule for Affective Disorders and Schizophrenia for DSM-5 (Lifetime Version). A higher value on a CBCL symptom scale indicates worse mental illness of the child. For continuous outcomes (ie, CBCL symptom scales), β (95% CI) and P values were estimated based on linear mixed-effects regression analyses, adjusting for baseline age, sex, and race and ethnicity and including a random-effects term to account for within-site clustering. For binary outcomes (ie, suicidal behaviors), β (95% CI) and P values were estimated based on mixed-effects logistic regressions analyses, adjusting for baseline age, sex, and race and ethnicity and including a random-effects term to account for within-site clustering. P values can be found in eTable 3 in Supplement 1.

Figure 4.. Associations Between the Identified Social Determinants of Health (SDOH) Patterns and Cognitive Outcomes of Children

Cognitive intelligence total score was calculated as the summation of crystallized intelligence and fluid intelligence scores for children. For each score, a higher value indicates better cognitive health of the child. For continuous outcomes (ie, CBCL symptom scales), β (95% CI) and P values were estimated based on linear mixed-effects regression analyses, adjusting for baseline age, sex, and race and ethnicity and including a random-effects term to account for within-site clustering. For binary outcomes (ie, suicidal behaviors), β (95% CI) and P values were estimated based on mixed-effects logistic regressions analyses, adjusting for baseline age, sex, and race and ethnicity and including a random-effects term to account for within-site clustering. P values can be found in eTable 3 in Supplement 1.