Social inequalities in children's mental health: isn't it time for action?

Social inequalities with regard to children’s and adolescents’ mental health are documented for many years [1-4] and appear to have increased over time [5]. Moreover, while the relationship between family socioeconomic circumstances and children’s and adolescents’ risks of mental health difficulties largely reflects the role of determinants outside of the healthcare context, there is also evidence that even in universal healthcare systems, there are disparities with regard to access to care in case of psychological or neurodevelopmental disparities, which further increase socioeconomic inequalities in this area [6].

As we enter the third academic year following the onset of the COVID-19 epidemic, it is impossible to ignore the toll the epidemic has taken on youths and associated socioeconomic inequalities in schooling and mental health. In Europe as in other parts of the world, millions of children were affected by school closures, which impacted their learning, sociability and perspectives for the future [7]. For instance, in a study conducted for UNICEF in 2020 among 5000 children and adolescents, over half indicated that they learnt less since the beginning of the epidemic, 60% stated they preferred face-to-face learning, and 40% were worried about what would happen after the epidemic is over. Additionally, the epidemic has deprived children and adolescents of access to school-based healthcare and other services, leading to a reduction in the identification of cases of neglect and intra-familial violence which appear to have increased [8, 9]. Lockdowns have also been related to negative changes in youths’ health behaviours. For example, a nationwide Italian study showed that in 2020 over 30% of primary school and over 50% of middle school students spent more than two hours a day using a screen for purposes other than distance learning, while their physical activity levels significantly dropped [10]. Finally, numerous families have experienced COVID-19-related illness, sometimes death, financial difficulties and uncertainty about the future, which can also impact their children [9, 11].

Overall, consistent evidence indicates that youths levels of sleep as well as psychological difficulties are higher recently than in previous years, with unknown perspectives as of now. A recent meta-analysis, based on 23 studies, reported massive and higher than expected levels of mental health difficulties in children and adolescents in the context of the COVID-19 epidemic (symptoms of depression: 29%, anxiety: 26%, sleep problems: 44%, post-traumatic stress symptoms: 48%) [12]. It is important to note that this review was mostly based on cross-sectional data exclusively from China, there is, therefore, need for robust data from other areas of the world, including Europe. However, existing evidence suggests that in European countries levels of mental distress among children and adolescents have also increased [11, 13], as have levels of emergency room visits related to eating disorders and self-harm [14].

All of these mental health risks related to the COVID-19 pandemic and the associated preventive measures have had greater consequences on children and adolescents growing up in families experiencing disadvantage or in deprived neighbourhoods [11, 13–15]. These children have also disproportionately been affected in terms of academic achievement [7]. Hence, the COVID-19 pandemic could significantly impact the socioeconomic future of millions of children, fuelling a vicious circle of later academic, work-related and mental health difficulties.

The health crisis, which we are experiencing for the past 2 years, has shed light upon the extent of socioeconomic inequalities with regard to mental health in children and adolescents and their increase over time. As advocated by the WHO Commission on Social Determinants of Health 15 years ago, achieving health equity via action upon multiple determinants of health is possible (16). Among the overarching recommendations of this international working group, are improvements of “daily living conditions of girls, women and children” and massive investments in “early child development and education of boys and girls”. These are more necessary than ever to prevent the marginalization of large parts of the population and reduce the possible impacts on the mental health of the next generation.