Social Determinants of Mental Health Considerations for Counseling Children and Adolescents

ABSTRACT

Childhood is a crucial period for developing a strong social and emotional foundation critical for mental well-being. Given that the childhood developmental period is vital for mental health, it is essential to address social determinants that can disrupt development and have lasting adverse effects on psychological and physical health. Therefore, professional counselors specializing in children and adolescent mental health care can benefit from understanding and utilizing the social determinants of mental health (SDOMH) framework in practice. This article details the SDOMH framework and considerations for SDOMH-informed treatments for professional counselors working in settings with children and adolescents.

KEYWORDS:

• Social Determinants of Mental Health (SDOMH)
• counseling children
• counseling adolescents
• cultural responsive care
• assessment

Counseling youth implores the clinician to be aware of typical emotional, social, and cognitive developmental milestones and potential disruptions to youth meeting said milestones (Clark et al., 2022; Moreno & Corona, 2021). Youth experiencing an adverse childhood experience before age 18 can lead to possible disruptions of typical development (Noble et al., 2021). Research highlights that children who experience more than four adverse childhood experiences (ACE), such as abuse, neglect, and household dysfunction, are at greater risk of chronic health conditions and long-term poor health outcomes (Boullier & Blair, 2018; Kalmakis & Chandler, 2015). Experiencing ACE has also been negatively correlated to employment and adult learning potentials (Metzler et al., 2017). In other words, counselors must seek to understand and explore the underlying cause of their child and adolescent clients’ challenges. This understanding of underlying causes may significantly impact the overall health, development of the child, and stability as an adult.

For example, Maslow described five essential needs of all human beings (Harper et al., 2003); physiological needs, safety, belonging, esteem, and self-actualization. Research highlights that children who do not have basic needs met can have disruptions in meeting developmental milestones and mental health (Harper et al., 2003). The ease in which one can meet basic needs is based on multiple, complex, intersecting social factors, including access to power, privilege, and resources, alluding to the social determinants of mental health (SDOMH; Plamondon et al., 2020; World Health Organization [WHO], 2022). Although counselors acknowledge the critical role of SDOMH in mental health outcomes and disparities (Waters et al., 2022), more attention is needed toward the role that professional mental health and school counselors have in addressing SDOMH in counseling by using their power, privilege, and resources within their spheres of influence (Gantt et al., 2021; Johnson & Brookover, 2021). This manuscript introduces the SDOMH framework, specific SDOMH areas of concern for clinicians working with children and adolescents, and provides evidence-based recommendations for intervening on SDOMH at the individual and systems levels.

Social determinants of mental health considerations for youth

Social Determinants of Mental Health (SDOMH) are systems and environmental factors that impact an individual’s health and wellbeing (WHO, 2022). Similar to Social Determinants of Health (SDOH), which are defined similarly, but with a broader focus on physical health outcomes (Braveman & Gottlieb, 2014). Broadly, SDOMH includes economic and social policies, economic and political systems, development agendas, and social norms that can positively and negatively influence the health and wellbeing of individuals and communities (WHO, 2022). Research has established a clear link between wealth distribution and health outcomes, pointing to these social and political environments as the root cause of health inequity (Plamondon et al., 2020). Efforts to close these equity gaps have been marked by a reorientation of thought in academic, political, and public spaces in hopes of sparking socio-political action (Ottersen et al., 2014).

For children and youth, the SDOMH can be defined through five domains: economic stability, education access and quality, health-care access and quality, neighborhood and built environment, and social and community context (Alegría et al., 2018; Johnson & Brookover, 2021). Each domain contains several important indicators and a significant body of research, and guiding efforts to decrease disparities in wellbeing. It is essential to consider specific adverse impacts on children and adolescents within each domain, as they are a particularly vulnerable population.

Economic stability

The first domain refers to issues around poverty and employment and the affordability of housing, childcare, health care, and food (USDHHS ODPHP, n.d.). One specific concern related to children and adolescents in the economic stability domain is the percentage of children living in homes without at least one parent who works full time. As of 2017, two years before the COVID-19 pandemic and the beginning of the “great resignation,” 22.1% of children lived in homes without a full-time working parent (U.S. Census Bureau, 2017). Children and adolescents in these homes are more likely to experience economic instability and suffer from issues around housing, lack of viable childcare, food insecurity, and inequitable healthcare (Dickman et al., 2017). Further, many adolescents have employability concerns, as 11.2% of individuals aged 16 to 24 were not enrolled in school or were unemployed (U.S. Census Bureau, 2017). Addressing economic stability through economic and social policies and systems is imperative for meeting the needs of the next generation.

Education access and quality

The second domain pertains to educational disparities experienced by people of color, individuals with disabilities, and individuals experiencing poverty (USDHHS ODPHP, n.d.). The impact of this domain on children and adolescents is clear. Children and adolescents living in poverty are more likely to experience hardships around education, including an increased likelihood of living in an area with poorly performing schools (Taylor et al., 2020), challenges associated with paying for quality early childhood education (Gould & Cooke, 2015), and challenges associated with paying for college or post-secondary training (Herbers et al., 2012). Additionally, vulnerable youth are more likely to struggle with math and reading (Byrd, 2020), which is negatively associated with graduation rates, college attendance, and future earnings (Herbers et al., 2012).

Healthcare access and quality

The third domain refers to an individual’s or community’s access to high-quality health-care services (USDHHS ODPHP, n.d.). The healthcare access and quality domain includes issues around proximity to health-care providers and affordability of care or medication, often associated with a lack of health insurance coverage (Woolhandler & Himmelstein, 2017). Families in situations where they do not have access to quality healthcare due to their geographic location or lack of insurance cannot receive proper medical care for their children, which leads to poor long-term health outcomes (Woolhandler & Himmelstein, 2017). Unsurprisingly, health insurance coverage varies by employment status, income, and education level (Singh et al., 2017). According to the 2020 census, uninsured rates of children under 19 who were experiencing poverty had increased from 2018 to 2020 from 1.6 percentage points to 9.3% (U.S. Census Bureau, 2020). Issues around healthcare access and quality are heightened for families with developmental delays as they require appropriate intervention services for their children (Rosenberg et al., 2008). Those without access to healthcare see an increased risk of serious long-term health repercussions for their children (Singh et al., 2017).

Neighborhood and built environment

The fourth domain contains the physical location of communities, including rates of neighborhood violence, social cohesion, air quality, water quality, other safety risks, infrastructure, and access to green spaces (USDHHS ODPHP, n.d.). Research shows that childhood exposure to neighborhood conditions significantly impacts later development (Leventhal & Dupéré, 2019). Even the physical condition or state of deprivation of a neighborhood alone is associated with poor academic achievement, teenage pregnancy, youth violence, and poor mental health (Leventhal & Dupéré, 2019). In addition, several studies have shown that children experience continuous trauma by living in unsafe environments (Murray et al., 2013). Thus, clinicians need to become aware of SDOMH concerns and engage in trauma-informed interventions that prioritize the safety of the youth and engage community and family support that can increase resilience and decrease risk involvement.

Social and community context

The final domain is the social and community context, which pertains to the importance of relationships and interactions with family, friends, and community members and the impact of these relationships on an individual’s health and well-being (USDHHS ODPHP, n.d.). Positive and caring relationships with family members, teachers, individuals in the community, and peers have all been shown to serve as protective factors for children, buffering against the impacts of trauma (McMahon et al., 2020). The effect of relationship quality at home is a significant factor; however, low family income is negatively related to parental relationship quality, as the parent requires more time to earn money for food and shelter (Walker, 2021).

Further, researchers have received considerable attention for teacher–student relationships due to their long-term benefits for children and adolescents (Ansari et al., 2020). However, children experiencing poverty and children from minoritized backgrounds are more likely to exhibit externalizing behaviors (Lamblin et al., 2017; Leventhal & Dupéré, 2019), resulting in poorer quality teacher–student relationships (Ansari et al., 2020). As noted in the literature, SDOMH domains in which “need” is unaddressed can result in harmful outcomes for children and adolescents. Action on SDOMH challenges is a social justice issue that professional counselors in the community or school settings should be aware of and support action to address. Therefore, it is essential for mental health professionals working with youth to address social determinants of mental health through counseling and advocacy.

Intervention and prevention: social determinants of mental health through counseling and advocacy

The SDOMH are complex challenges that require both an individual and systems-level approach (Braveman & Gottlieb, 2014). Counselors are implored to use their positionality, counseling, and advocacy skills to address SDOMH challenges that most impact youth within their communities (Johnson & Brookover, 2021). Through intervening on SDOMH challenges, counselors are implored to use best practices for counseling children and community activism. Centering the child counseling competencies allows counselors to be responsive to both individual and community-level needs of youth. The ten child counseling competencies include a passion for children, authenticity, advocating for children, evidence-based treatments, knowledge of legal and ethical issues with counseling children, using congruence, empathy, and non judgment, meeting children where they are, multicultural competence with children, speaking the language of children, and self-reflection (Clark et al., 2022). With the child counseling competencies as a foundation, provided are evidence-based recommendations for intervening on SDOMH in educational settings, community mental health settings, and at the community level.

Addressing SDOMH in educational settings

School-aged children spend a significant amount of time in the educational setting, and school counselors and other mental health school personnel can shape children’s mental health outcomes (Gantt et al., 2021). Specifically related to SDOMH, school counselors can provide time-bound individual and group counseling to students, classroom lessons, and school-wide initiatives that are culturally responsive and trauma-informed. For example, a school counselor might consider doing a developmentally appropriate classroom lesson that discusses a social need within the SDOMH domains, like food insecurity. The lesson provides an opportunity for the teacher to define the social need and invite students who need support to learn about how the school and community address food insecurity. Next, school counselors can align their direct comprehensive school counseling program (CSCP) services with educational initiatives already present in the school, such as multi-tiered support systems (MTSS). MTSS is a nationally implemented framework currently used in schools to frame the delivery of prevention for all students and increase intervention for students with high needs, using data-driven, evidence-based support (Goodman-Scott et al., 2019).

Indirectly, school counselors can address SDOMH through several actions. School counselors can adapt a public health approach for addressing SDOMH. For instance, researchers have noted that policies promoting inclusivity and equality can directly address structural drivers of mental health (Hernandez et al., 2022; Nelson et al., 2022). Hence, school counselors can provide individual and family services that promote inclusivity and equality, such as addressing school climate and connectedness, which are worthy targets to build positive SDOMH within education access and quality (Alegría et al., 2018). In addition, the school is a part of the community. School counselors can address the SDOMH community and social context by creating support groups through collaboration with community centers that offer resources and training for parents and families on issues such as healthy food consumption, dental and physical health, mental health and psychological wellbeing, and access to community resources (Huang et al., 2013). These interventions can bring parents’ awareness to the health needs of their children and highlight where they can access resources in the community to address those needs. These efforts enable collaboration between parents, students, and the community to address SDOMH concerns. Beyond assessing school climate, school counselors can lead the charge in universal screening to address health concerns. Universal screening for social and mental health needs is an important, albeit underutilized, part of making data-based decisions for identification and intervention purposes (Johnson & Mahan, 2020). There has been little to no empirical research on universal screening for SDOMH in schools. Still, emerging conceptual research suggests it could be beneficial to identify students’ SDOMH needs, create targeted individual interventions, and increase family support (Johnson & Brookover, 2021). By implementing a CSCP, school counselors can begin to address elementary, middle, and high school students’ SDOMH through both indirect and direct counseling services.

Addressing SDOMH in community mental health settings

An SDOMH-informed approach centers on the need to assess and address social health needs within counseling (Johnson & Brookover, 2021). The foundation for a SDOMH-informed approach, is addressing the “root cause” of mental health challenges, so that efforts to address mental health symptoms are not futile (Johnson et al., 2021). In a community mental health setting, a universal SDOMH screening tool is useful for treatment planning, wrap-around services, and referrals (Johnson & Mahan, 2020). There are many SDOMH screening tools (see SDOMH tool kit: https://nasdoh.org/screening-tools-and-tool-kits/); however, we suggest considering the WELLRX (Page-Reeves et al., 2016), which is at a fourth grade reading level minimizing literacy barriers for adults and youth, can be self-administered, free to use, and includes 11 yes or no questions that assess each SDOMH domain. The WELLRX to date has been used with adults, however, because the tool is accessible to people who read/comprehend at a fourth-grade level or above, it may be reasonable to utilize the tool with children above the age of nine (i.e., fourth grade). In addition, there is no comparable self-administered tool to use with children younger than nine. With clients younger than nine years old or developmentally functioning below nine years of age, a clinician should collect SDOMH information from a parent or guardian.

Strategies for implementing the SDOMH screener include incorporating SDOMH questions in the first session as a part of the child/family’s background or history or incorporating SDOMH questions throughout counseling sessions. Asking SDOMH questions during a session might look like such: “(Counselor Speaking) I am going to ask a few questions that you can just answer with ‘Yes, No, or I don’t know.’ These questions will help me identify other ways that my colleagues or I might be able to support you and your family. There are no right or wrong answers, and you cannot get into any trouble.” A counselor can also consider using the WELLRX screening tool during the counseling session, example: “(Counselor Speaking) I am hoping that we can talk through this form (i.e., The WELLRX) that asks questions about non-medical things you might need help with. The form is called the WELLRX, it has 11 yes or no questions, and there are no right or wrong answers. Please let me know if you would like to complete the form on your own and talk through your answers after; or would you prefer for me to read the questions and talk through the form with you as you go?” The options provide the client with agency in how they share feedback related to any SDOMH challenges. Additionally, it is important to also ask, if the client would like help or resources as it relates to the SDOMH challenges indicated on the form.

A more indirect approach may include incorporating the SDOMH screener with the intake paperwork or a few select SDOMH questions on intake paperwork (Johnson et al., 2021). Of importance is ensuring that the screener tool is at a fourth grade reading level or uses a universal design learning approach that eliminates barriers to completing the tool, such as using technology and a text-to-audio feature or pictures to aid in understanding the questions (Johnson & Brookover, 2020). There are many SDOMH screener tools, but the WellRX is suitable for counselors to use in mental health settings because it is free, has 11 yes or no questions at the fourth-grade reading level, and can be modified to use all or some of the items (Johnson et al., 2021). The counselor can use the child’s and the guardian’s responses to triangulate stated needs and develop a plan to address the identified SDOMH concerns. Therefore, treatment planning that uses an SDOMH-informed approach should address mental and SDOMH needs. Additionally, counselors who assess the SDOMH/social health needs of their clients can identify these needs in the electronic health record or to the insurance company by using ICD-10-CM codes in categories Z55-Z65 (Maksut et al., 2019); these specific codes identify non-medical factors that influence health status (i.e., Z59 ‘problems related to housing and economic circumstances). Lastly, identifying the need through assessment requires follow-up, warm-handoffs, consultation, and collaboration to assist the client and their guardian in connecting to needed services to support their mental health and overall wellbeing (Gantt et al., 2021; Johnson et al., 2021).

Addressing SDOMH through community advocacy

As noted earlier, SDOMH challenges are often system-level issues that require advocacy and action at the national, state, and local levels (WHO, 2022). Engaging the system for counselors can start through understanding community-level needs, which can help with targeted advocacy efforts. Community-level SDOMH indicators refer to population groups rather than individuals (Wiseman et al., 2007). These community-level indicators provide objective measures of outcomes within a community rather than on an individual level (Wiseman et al., 2007). For example, community-level indicators in the educational access and quality domain might monitor pre-school registration and waitlist (or budget expenditures for early childhood education) rather than polling parents on their child’s enrollment status in pre-kindergarten. Community-level indicators also help determine what is happening in communities concerning youth (Wall et al., 2009; Wiseman et al., 2007); for example, the number of children receiving free or reduced-price school lunches or the number of schools instituting free breakfast programs can indicate child poverty rates within the community (Herbers et al., 2012). This community-level information can inform targeted advocacy efforts that counselors can lead or collaborate in for change. For example, counselors should engage and influence politics and policies that will benefit their clients, but the first step in enacting change is awareness of the needs (Crucil & Amundson, 2017; McDonald & Chang, 2022).

Further, to increase awareness of counselors, several resources and support are available to encourage and support counselors’ community advocacy efforts. For example, the ACA advocacy toolkit provides counselors with information on federal and state issues and different legislations. The toolkit also provides actionable steps and strategies for counselors to engage in advocacy through the organization. Crucil and Amundson (2017) suggest through awareness, counselors can then share information, data, and expert testimony to impact policy. In addition, the center for disease control has a section on their website providing guidance on policy resources to support social determinants of health needs: https://www.cdc.gov/socialdeterminants/policy/index.htm (Centers for Disease Control and Prevention [CDC], 2021). There are also resources and support through the American Counseling Association Government Affairs and public policy section on their website: https://www.counseling.org/government-affairs/public-policy.

Prevention considerations

Prevention is fundamental to addressing the SDOMH systemically and individually. Addressing systemic inequalities within communities is a targeted prevention effort (Alegría et al., 2018). First, through forming partnerships with community leaders and advocates, clinicians can amplify and create visibility for the most pressing SDOMH issues that impact youth in their community (Alegría et al., 2018). A partnership that seeks to understand the values, needs, and interest of a community, with the clinician utilizing cultural humility (i.e., a process of self-reflection and decentering yourself as the expert), has the potential to be a strong preventive force toward harm reduction and negative mental health outcomes (Alegría et al., 2018). Children’s needs are interconnected to their family and community systems, and when meaningful care and access is addressed, it assists in the formation of safety and growth (Moreno & Corona, 2021). Secondly, creating and utilizing already designed programs funded through state and city partnership that utilize other social services can allow for a deeper influence, which is why policy makers are essential to preventative care (CDC, 2021). All together, it is possible to create communities where root causes are being treated instead of solely intervening once negative outcomes are being presented.

Discussion

Counselors have a duty to address social factors that impact clients’ mental health, which is especially crucial during childhood (Marshall-Lee et al., 2020; Pearrow & Fallon, 2020). Additionally, society’s sociopolitical climate and other contextual factors determine much of what happens in people’s lives. Youth are vulnerable during this period where they are socialized and develop their sense of self (Meca et al., 2021; Moreno et al., 2021). Because of societal structuring, youth who are already marginalized for their socioeconomic class, disability status, and race or ethnicity are most susceptible to adverse outcomes (Moreno & Corona, 2021). Utilizing the SDOMH-informed framework in school and community counseling settings can support mental health prevention and intervention (Johnson & Brookover, 2021). This framework is especially prudent as youths undergo many changes through their development (Taylor et al., 2020); those changes impact mental health and overall wellbeing and are largely shaped by the SDOMH (McDonald & Chang, 2022). Not addressing SDOMH impacts youth mentally and physiologically (Lamblin et al., 2017). This crucial developmental period requires more attention, innovative practice, advocacy, and effort from counselors in all settings that work with youth (Marshall-Lee et al., 2020).

To engage in practice that uses a SDOMH informed framework, counselors must assess their own cultural competence and ability to provide culturally responsive and affirming services (McDonald & Chang, 2022). There are several surveys that are available to self-evaluate cultural competence, one such form is the Multicultural Counseling Awareness, Knowledge, and Skills survey (MAKSS; D’Andrea et al., 1991). For additional resources on assessing cultural competence visit the National Center for Cultural Competence (http://nccc.georgetown.edu). In addition to using a standardized survey, clinicians can engage in self-reflection around their actions, thoughts, and beliefs about cultural competence, SDOMH, and the community they serve (Johnson, 2021). Some potential self-reflection prompts can include:

• Actions – Who have I acted/advocate on behalf of within the last month, who have I choose not to act/advocate on behalf of and why; what actions have I taken within the last month to support my clients that are disproportionately impacted by SDOMH, what actions could I have taken but did not and why?

• Thoughts – What are some of my automatic thoughts about SDOMH; When I think about how SDOMH can be address am i focusing on the individual (i.e., the parents should change employment to have a greater income) or the system (i.e., Jobs should pay a living wage). As a note, you want to focus on interrogating the system and not the client or their family (Johnson, 2021).

• Beliefs – What beliefs do I hold about cultural competence that can be supportive in addressing youth SDOMH needs?; What beliefs do I hold about cultural competence that can be detrimental in addressing youth SDOMH needs?; What beliefs do I hold that can reduce the efficacy of providing culturally responsive and affirming counseling services (i.e., unhelpful beliefs might be that counseling services do not have to be modified based on cultural nuances or As the expert it is not necessary to learn about my clients culture because everyone will receive the same counseling services).

The self-reflection loop involves critical self-evaluation for the purpose of identifying bias, analysis of potential impact, and the development of an action plan aimed at increasing cultural competence and providing responsive and affirming care. The loop is a continuous process that involves repeating the steps of self-reflection and adjusting the action plan as necessary to reflect progress in increasing cultural competence. The ultimate goal is to continually evaluate and improve one's ability to provide culturally responsive and affirming care.

Lastly, engaging in education to increase cultural competence and ability to provide culturally responsive and affirming counseling services to youth impacted by SDOMH is important. Counselors should seek out professional development that provides opportunities to hear from community members and youth about their experiences of SDOMH and ways that counselors can be supportive. Utilize government websites, such as the Center for Disease Control that has reputable and recent information on how to address SDOMH (https://www.cdc.gov/socialdeterminants/tools/index.htm) or the Office of Disease Prevention and Health Promotion which sets goals for addressing SDOMH, list government priority areas, and tools for action (https://health.gov/healthypeople/priority-areas/social-determinants-health). Lastly, if a clinician has access, it can be advantageous to use Google Scholar to receive alerts when new articles are published about SDOMH and youth needs, these alerts provide an opportunity to stay up to date on research, interventions, evidenced based practice, and methods for addressing SDOMH with youth.

The disparity of adverse and traumatic events that minoritized communities experience is a social justice issue, and actions are needed to address the mental health concerns and aid in transformative care (Gantt et al., 2021). In addition, incorporating the SDOMH framework will allow for the expertise and sensitivities to differences in individual lived experiences to be fully acknowledged and addressed; in counseling settings where many youths might experience increased safety, stability, and access to resources counselors must be advocates for social change.

Implications

The impact of SDOMH must be addressed by mental health and school counselors to meet the ongoing needs of children and adolescents who are most vulnerable. Utilizing the child counseling competencies as a foundation for addressing SDOMH with youth is good practice. For example, to appropriately address sensitive issues, such as SDOMH, it is necessary to engage in advocacy, which is one of the child counseling competencies. Advocacy is important to address the systemic issues that create SDOMH. Mental health and school counselors must form community relationships among stakeholders, families, politicians, and schools for systemic action to prevent the detrimental disparities due to SDOMH. Through community outreach, counselors can build more trust and support for many communities that continuously and historically suffer from social inequities (Teixeira et al., 2021). Counselors working together with stakeholders and other community members would allow for meeting those in need where they are and help develop purposeful preventive outreach programs (McMahon et al., 2020; Teixeira et al., 2021). Programs curated for the collective community allow for individual care through ethical and multiculturally competent practices. Lastly, centering the child counseling competencies in this work allows counselors to be responsive to both individual and community-level needs of youth (Clark et al., 2022)

Conclusion

More than ever, resources are needed to protect youth suffering due to societal factors. Addressing and intervening on SDOMH allows counselors to evolve with the needs of youths as they become apparent (González et al., 2019). Addressing the needs of families and communities to minimize barriers and increase access to quality mental and overall healthcare allows youth to receive adequate and quality care. The SDOMH must be met with deliberate action and awareness as the consequences of ignoring SDOMH challenges create further suffering in society and injustices that lead to illness and oppression (Johnson, 2021).

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.