Children and adolescents are at greater risk of experiencing poverty than any other segment of the U.S. population, and the dramatic increase in youth poverty over the past decade35
raises concerns about the implications of this trend for child health and development. Deprivation in resources needed to sustain health, including food, shelter, clothing, and access to health care, is one of the primary pathways through which poverty may have an adverse impact on health.10,13,36
The present findings suggest that, indeed, the lack of access to reliable and sufficient amounts of food is associated with increases in adolescent mental disorders. These findings are concerning because recent estimates have suggested that more than 20% of U.S. families with children experience at least some degree of food insecurity.37
Food insecurity is socially patterned in the NCS-A such that adolescents in families with lower parental education and income are more likely to have high levels of food insecurity than adolescents from families with higher education and income. This finding suggests that food insecurity is a marker of material deprivation. Previous studies also have found that food insecurity is inversely related to income and occurs more commonly in families experiencing poverty.6,15
Further, food insecurity is higher in adolescents who live in communities characterized by a greater inequality in income distribution. A potential explanation for this finding is that high levels of income inequality result in lower investment in social programs and human capital,38
which may decrease local funding for programs aimed at alleviating food insecurity, such as food banks. An alternative interpretation is that families living in unequal neighborhoods spend a larger proportion of household income on housing and consumer goods to maintain the material standard of living that is typical for their community,39
leaving less disposable income for food. If this is true, one would expect to see high levels of food insecurity in families experiencing greater relative deprivation (lower income compared with others in their community). However, the opposite relation was found between food insecurity and relative deprivation, such that higher relative deprivation was associated with lower food insecurity. This suggests that disinvestment in social programs may be a more likely explanation for the high levels of food insecurity observed in unequal communities.
Food insecurity was associated with adolescent mood, anxiety, behavior, and substance disorders after controlling for numerous other indicators of SES, such that a one standard deviation increase in food insecurity was associated with 14% greater odds of past-year mental disorder in adolescents. Importantly, food insecurity was more strongly related to adolescent mental disorders than traditional SES measurements, including parental education and income. The associations between food insecurity and adolescent mental disorders were not attenuated even when extreme poverty was controlled, suggesting that this aspect of material deprivation reflects a form of economic strain that has more pernicious consequences for adolescent mental health than simply living in a family with a very low income. Prior research has indicated that difficulty paying for the necessities of living is associated with poor physical health over and above the effects of income.13
Food insecurity was associated with mood disorders more strongly in adolescents living in families with low household income and high relative deprivation, consistent with prior research reporting the strongest associations between food insecurity and adverse physical health in low-income families.16
Together these findings suggest that extreme material deprivation not only is associated with behavioral problems in children,19–21
but also may be a determinant of mental disorders. The authors cannot determine in this study whether inadequate access to food specifically is related to mental disorders or whether these findings simply reflect an association of deprivation in access to basic necessities more broadly with adolescent psychopathology. This issue warrants further investigation in future research.
The authors’ previous study in this sample showed that adolescents’ perceptions of their social status were associated strongly with mental disorders. 12
In the final model of the present analysis, food insecurity and subjective social status were associated with past-year mood, anxiety, behavior, and substance disorders. Together these findings suggest two very different pathways through which SES might influence adolescent mental health: one that operates through material deprivation and another that operates through individual-level perceptions of status.
These findings highlight the importance of identifying the mechanisms linking food insecurity to adolescent mental health. Food insecurity likely represents a source of chronic stress for parents trying to provide basic necessities for their children and has been associated with parental mental health problems, including depression. 20,40
Food insecurity therefore may influence child mental health through pathways related to parenting quality. Indeed, evidence has suggested that food insecurity is associated with less sensitive and responsive parenting.40
Food insecurity may also increase the risk for youth mental disorders through more direct pathways. The hypothalamic–pituitary–adrenal (HPA) axis plays a central role in regulating appetite and energy balance,16
and hypothalamic–pituitary–adrenal (HPA) axis dysregulation has been implicated in the pathophysiology of numerous youth mental disorders. Experimental evidence has suggested that a low caloric intake is associated with heightened emotional and hypothalamic-pituitary-adrenal (HPA) axis reactivity to stress,41
and observational studies have reported associations of caloric restriction with increased cortisol secretion and perceived stress.42
Heightened emotional and physiologic reactivity in turn has been associated prospectively with the onset of mental disorders.43
The study findings should be interpreted in light of several noteworthy limitations. First, the NCS-A was conducted from 2001 through 2004. In the intervening decade, child poverty has increased dramatically and the number of youths experiencing food insecurity has likely increased. Although the authors have little reason to believe that the relation between food insecurity and mental health has changed over this period, the present findings warrant replication in samples collected more recently. Second, the sampling design may have resulted in an under-representation of adolescents who were homeless, did not speak English, and did not attend school. The prevalence of food insecurity6,15
and mental disorders44
is likely higher in these segments of the population, which may have attenuated the associations between food insecurity and mental disorders in the present analysis. Third, the NCS-A is a cross-sectional study, which raises concerns about reverse causality. Reverse causality is a particular concern when interpreting the associations of mental disorders with subjective social status. Parents also may be less likely to have stable employment in families where an adolescent has a severe mental disorder or having a child with a mental disorder may result in expenses that strain resources that would otherwise be available to purchase food, increasing the risk of food insecurity. Perhaps the most noteworthy limitation is the authors’ inability to determine whether food insecurity is a risk factor for adolescent mental disorders or a risk marker. Food insecurity may simply be a marker of other types of material deprivation, such as a lack of warm clothing in the winter or inadequate access to health care. These possibilities remain to be evaluated in future studies.
The inability to reliably access adequate amounts of food to meet basic needs is associated with a wide range of adolescent mental disorders. Given the dramatic increases in child poverty in the past decade, these findings argue for expanding programs aimed at alleviating hunger in children and economic strain in families. Consistent evidence has suggested that the Food Stamp Program, the Special Supplemental Food Program for Women, Infants, and Children, and school nutrition programs are successful at improving access to food and nutritional outcomes for children,45
although numerous barriers impede the use of these benefits by eligible families. The present study suggests that if a lack of access to food is specifically associated with adolescent mental disorders, then these programs may also have a meaningful impact on youth mental health, underscoring the importance of increasing their reach and uptake to assist families struggling to provide adequate food for their children.