Socioeconomic Status and the Fates of Adolescents

In this issue of Health Services Research, Newacheck and colleagues update the evidence on the association between socioeconomic status—specifically, income–and the health care and health status of adolescents in the United States. Using the 1999 and 2000 editions of the National Health Interview Survey, they find that poor and low-income adolescents are more likely than their more affluent counterparts to be in fair or poor (versus good or excellent) health, have limitations in their activities, and have had behavioral or emotional problems. Poor and low-income adolescents also are more likely than their peers to be uninsured, have no usual source of care, face financial and nonfinancial barriers to access, and have gone without medical or dental care during the preceding year. These findings are consistent with those of earlier studies (e.g., Montgomery, Kiely, and Pappas 1996; Ford, Bearman, and Moody, 1999), and reinforce concerns about the impact of low socioeconomic status on adolescent health.

Recent studies indicate that the association between low income and poor health has its origins in early childhood. Case and colleagues (2002) documented an inverse relationship between family income and health status among toddlers, and found that the income gradient in health became steeper with age. They also found that chronic conditions play a crucial role in the income gradient, and that high family income buffers children from the adverse health impact of chronic conditions. Parents' ability to manage successfully their childrens' chronic conditions is positively related to family income (e.g., Thompson, Auslander, and White 2001; Snodgrass et al. 2001). Interestingly, although children and adolescents with health insurance are healthier than their uninsured counterparts, insurance may not play an important role in creating the income gradient in health (Case, Lubotsky, and Paxson 2002).

The association between low income, on one hand, and reduced access to health care and worse health, on the other, represents just one manifestation of the effect of socioeconomic status on the life chances of adolescents. The main settings that influence the way children and adolescents grow up include families, neighborhoods, and schools. The quality of these settings, and whether they are supportive and nurturing or dangerous and destructive, has a profound influence on adolescents' chances for leading successful adult lives. Family income is perhaps the single most important factor in determining the quality of these settings (National Research Council 1995).

Recent changes in the structure of families, and the consequences for the family incomes of children and adolescents, have eroded the support that many adolescents receive as they grow up. As single-parent families spread during the past four decades, the proportion of children in such families rose from 10 percent in 1965 to 27 percent in 2001 (Ellwood and Jencks 2002). Single-parent families, especially those in which the parent is the mother, are much more likely than two-parent families to have low incomes. In fact, the growth in single-parent families was a major reason for the increase in the proportion of children living in poverty, from about 15 percent in 1970 to 23 percent in 1993 (Proctor and Dalaker 2002). The childhood poverty rate fell to 16 percent in 2001 in the wake of the economic expansion, but now is rising again. The poverty rate is even higher among children who belong to racial or ethnic minorities.

Changes in the family have affected two-parent families as well. Higher rates of participation in the labor force by mothers in two-parent families have helped to maintain family incomes, but they have also created stress for families and difficulties in caring for and supervising children and adolescents.

Although the strong correlation between single-parent families and low income makes it difficult to disentangle their effects, both factors seem to influence adolescent outcomes (National Research Council 1995). Economic stress may diminish the emotional well-being of parents, which has direct and indirect negative effects on children. Adolescents growing up in families under economic stress or with a single parent may be poorly supervised and often gain autonomy too early (Dornbusch et al. 1985). Unsupervised adolescents are more likely to smoke cigarettes, drink alcohol, use drugs, report depressed mood, and engage in risky behaviors (Richardson et al., 1993). Low family income has been associated with early sexual activity, cigarette smoking, adolescent pregnancy, and delinquency (National Research Council 1995; Blum et al. 2000).

Family income also affects the quality of the neighborhoods in which children and adolescents grow up. Compared with low-poverty neighborhoods, high-poverty neighborhoods have lower availability of high-quality public and private services such as parks, child care centers and preschools, community centers, and health care providers, as well as fewer social supports and less effective social networks (McLoyd 1998). Conversely, high-poverty neighborhoods are more likely to be physically deteriorated and to have more crime and street violence, greater availability of illegal drugs, and more negative peer influences and adult role models (McLoyd 1998; National Research Council 1995). These characteristics of high-poverty neighborhoods may have deleterious consequences for the cognitive functioning, socialization, physical health, emotional functioning, and academic achievement of children and adolescents (e.g., Ellen and Turner 1997).

Family income also has a profound influence on the educational opportunities available to adolescents and on their chances of educational success. Due to residential stratification and segregation, low-income students usually attend schools with lower funding levels, which result in reduced availability of textbooks and other instructional materials, laboratory equipment, library books, and other educational resources; low-level curricula; and less-qualified teachers and administrators (e.g., Kozol 1991; Oakes 1990; Ingersoll 1999). The effects of concentrated poverty in schools may include disciplinary problems and chaotic learning environments.

These school characteristics, combined with limited parental involvement in adolescents' education, have serious consequences. Not surprisingly, low-income adolescents have reduced achievement motivation and much higher risk of educational failure (Schultz 1993). In particular, compared with their more affluent counterparts, low-income adolescents receive lower grades, earn lower scores on standardized tests, and are much more likely to drop out of high school (e.g., Kao, Tienda, and Schneider 1996; Hauser, Simmons, and Pager 2000).

The cumulative effect of socioeconomic status on families, neighborhoods, schools, and health care guarantees that poor and low-income adolescents arrive at young adulthood in worse health, engaging in riskier and more dangerous behaviors, and with lower educational attainment and more limited career prospects than their more affluent counterparts. The repercussions of low socioeconomic status in childhood and adolescence are often felt throughout the life cycle. Studies of intergenerational income mobility have found a substantial correlation between the incomes of fathers and the incomes of their sons at corresponding points in their careers; the correlation between family income and children's incomes after they reach adulthood is even higher (Solon 1992; Zimmerman 1992). McMurrer and colleagues (1997) conclude that there remains a substantial component of income immobility across generations in the United States. Ironically, the intergenerational transmission of socioeconomic status is weakest for young adults who graduate from college, but low family income in childhood and adolescence markedly reduces the chances of obtaining a college degree.

Improving the settings in which many low-income children and adolescents grow up—that is, supporting their families, strengthening their neighborhoods, improving their schools, and making quality health care and other services more accessible to them—should be a policy priority for government at all levels and a research priority for social scientists from all disciplines. Ultimately, this is likely to be the only way to prevent the intergenerational transmission of poverty and exclusion from meaningful and rewarding participation in our society. The fates of poor and low-income children and adolescents are inextricably linked to our future as a nation.