0021-7557/04/80-02-Suppl/S104

Jornal de Pediatria
Copyright © 2004 by Sociedade Brasileira de Pediatria
REVIEW ARTICLE

Environmental influences on child mental health

Ricardo Halpern1, Amira C. M. Figueiras2

Abstract
Objective: To present an up-to-date review about environmental influences on child mental health, describing major
risk factors and discussing recommendations for intervention by pediatricians.
Sources of data: MEDLINE, PsycLIT and Lilacs, technical books and publications about child development and child
and adolescent mental health problems and health promotion.
Summary of the findings: Children are exposed to multiple risk factors, among them high prevalence of disease,
premature birth, being born from a problematic pregnancy, and living in poverty. This negative chain of events increases
the risk for emotional problems. The negative effects on development and behavior result from the complex interaction
between genetic, biological, psychological and environmental risk factors. The main factors influencing the mental health
of children are the social and psychological environment. The cumulative risk effect is more important in determining
emotional problems in children than the presence of one single stressor, regardless of its magnitude.
Conclusion: Environmental factors play an important role in the etiology of emotional problems in childhood. An
adequate clinical investigation allows pediatricians to identify risk factors for the development of mental health problems
and to ensure early intervention for children at risk.

J Pediatr (Rio J). 2004;80(2 Suppl):S104-S110: Child mental health, risk factors, environment, child development,
early intervention.

Introduction
Pediatricians have shown more interest in children’s performance and pregnancy. 3 Several studies from
mental health in the last few years. This concern mirrors different countries have revealed an equally high
the fact that recent studies have found a prevalence of percentage of preschool and school-aged children with
mental disorders of 10 to 20%, being considered the most emotional disorders.4-6
important cause of childhood problems.1 According to a The improvement in pediatrics leads us to a substantial
recent study, Glied & Cuellar estimate that 11% of U.S. change of paradigm in terms of child and adolescent health
children have a mental disorder of some sort.2 Half of the care. With various therapeutic instruments at hand,
children and adolescents between ten and seventeen pediatricians could divert their attention away from the
years old are affected at least by two risk behaviors, such treatment of acute diseases, based on the hospital-based
as abuse of alcohol and drugs, delinquency, low school model, and provide the population with community-
centered health care. This way, by preventing diseases
and promoting health, the coverage of this treatment
1. PhD. Associate professor, Fundação Federal Faculdade Ciências Médicas could be extended. Synergistically, such measures further
de Porto Alegre and Universidade Luterana do Brasil. Specialist in decreased infant mortality, revealing new problems, which
Development and Behavior of Children and Adolescents, University of were grouped under the name of “new morbidity” or
North Carolina at Chapel Hill.
2. MSc. Assistant professor, Department of Mother-Child Care II, “hidden morbidity,”7 defined in the 1970s as a set of
Universidade Federal do Pará (UFPA), Belém, PA, Brazil. functional situations and environmental factors that affect

S104
Environmental influences on mental health – Halpern R & Figueras ACM Jornal de Pediatria - Vol. 80, No.2(Suppl), 2004 S105

child development.8 The situations that resulted from the continuity of environmental interference and cognitive
decrease in infant mortality submitted children, who were processes. 16-21 Therefore, the negative effects on
previously exposed to the risk of death, to the stress development are produced by the combination of genetic,
caused by unfavorable living conditions, most of which are biological, psychological and environmental risk factors,
the result of increased urbanization, violence, changes in usually involving complex interactions between them.
family structure, and in some specific areas, the result of Social and psychological factors are strongly associated
poor food supply.9 The group of children with this “new with children’s mental health, influencing more than the
morbidity” includes those who experienced childhood individual’s intrinsic characteristics.22-25
abuse, maltreatment, neglect and developmental
disabilities caused by lack of stimuli or inappropriate
stimuli. The etiology of mental disorders in children often
is attributed to these factors, but it is important to assess
the multiple contexts in which these children live from
birth to adolescence and adulthood. Most studies have and social struct
itical ure
focused on individual behavioral processes that determine Pol
m utional community
mental health, leaving aside the fact that the continuity of te In st it

s
ediate community

sy
adverse environmental factors also determines changes in Imm

no
child development.10 Mental disorders in childhood and Family

chro
adolescence have an immediate impact on children and
their families and also are precursors of psychiatric and Child
social problems throughout life.11,12 The present study
discusses the influence of environment on children’s
M icr os yst e m
mental health, the major risk factors involved, and some
early interventions. M e s o sy st e m

Exo syst em
M a c r o sy s t e m
Environmental risk factors and mechanisms of
action
Risk factor is defined as an element that determines an Figure 1 - Ecological theory of development15

increased probability of problem occurrence. It can also be

defined as a factor that increases vulnerability of a person
or group to a certain disease or to health deterioration.13
According to Garbarino,14 we should bear in mind two
types of interactions when we talk about risk: firstly, the
interaction of children as a biological organism with their The several factors involved in the etiology of
immediate social environment, represented by the family developmental and behavioral disorders rely more on the
(microsystem), in which several processes, events and amount than on the nature of risk factors, since different
relationships occur; secondly, the interaction regarding risk factors produce similar results.26 Therefore, we
the relationship of this system with the environment, in its reinforce the importance of multiple risks, whose cumulative
broadest meaning (exosystem or macrosystem) through effect proved to have a great impact on children’s cognitive
time (chronosystem). This model is shown in Figure 1, and socioemotional results.27,28
which describes the relations between several systems The Rochester Longitudinal Study, carried out by
that influence children’s lives, according to Sameroff et al., on the role of the environment in the
Bronfenbrenner’s ecological theory of development.15 determination of mental health followed up children from
The author proposes a model where development occurs the prenatal period to adolescence.23 The main findings of
through processes of reciprocal interaction that are this study regarding the influence of environmental factors
progressively more complex between children and all on mental health were: a) history of maternal mental
levels of environmental influences. disease; b) high level of maternal anxiety; c) limited
Children have different opportunities in their parental perspectives; d) poor interaction between children
development given by their personal attributes (physical and their mothers; e) head of the family without qualified
and mental) and by the social environment in which they occupation; f) low maternal education; g) family of minority
live. As several studies have shown, direct threats to ethnic groups; h) single-parent families; i) presence of
development may occur due to acquired genetic and stressful events; j) families with four or more children. The
biological problems, although this may also occur due to multiple risk effect individually compared with each variable
the absence of expected opportunities. In short, the forms showed that high-risk children (e.g.: those with mental
though which the risk of developmental disorders appear health problems in the family, parent’s low expectation,
may be related to biological substrate, to direct or indirect poor mother/child interaction, low level of maternal
S106 Jornal de Pediatria - Vol. 80, No.2(Suppl), 2004 Environmental influences on mental health – Halpern R & Figueras ACM

education and no family support) had 24 times more hand, poorer children with perinatal problems had a
chances of having a deficiency, compared to low-risk decrease between 19 and 37 points in their IQ,
children. On top of that, the set of variables explained 50% comparatively to poorer children without perinatal
more of the variation in verbal skills than did the variables problems.37 In the 18-year follow-up, the authors found
that were individually assessed. Some of these findings out that adolescents with behavioral developmental
were also obtained by other studies on development, problems lived in poverty at a percentage 10 times higher
although some of them applied different than those who had been exposed to perinatal problems.41
methodologies,28,29 which reinforces their importance. Lipman et al., 34 even without assessing biological risk,
These findings emphasize the need to identify the group showed that children of low-income families have three
of children at higher risk for emotional and behavioral times more chances of having a low school performance
problems. A recent study carried out by Harland et al.30 and social difficulties, compared to those of more privileged
showed a statistically significant association between families. In addition, low maternal education and the
familial characteristics and the risk of emotional and existence of disruptive families had independent effects
behavioral disorders in children, among which parental on the etiology of psychosocial morbidity.
unemployment and recent separation from parents are Besides the importance of being aware of the risks to
the most important factors. which these children are submitted, we should also consider
Several epidemiological studies demonstrated the a person’s ability to adapt to certain types of stress.
relationship between low socioeconomic level and the Anthony45 described the concept of “invulnerability” that
occurrence of mental disorders in children.31-34 These certain children have to certain types of aggression. This
findings are plausible given the higher probability for the adaptation has been called resiliency, which in physics, is
existence of multiple risks in the underprivileged population. the capacity of a material to return to its original shape or
However, it is essential to distinguish between two important position after deformation that does not exceed its elastic
concepts that are strongly associated with the etiology of limit. Applying this example to individuals, it means a
mental health: social causation and social selection.35 The person’s ability to bounce back from potentially negative
first one refers to the interaction between genetic and events. This resiliency, however, is not totally present in
environmental factors in which genetic aspects are latent children, and thus the child may be highly efficient in
until individuals exposed to adverse factors and stress dealing with a stressful situation at school, and extremely
(common in unfavorable socioeconomic situations) develop inefficient in dealing with a situation that involves
mental disease, due to situations that run out of their emotions.46 Thus, living in poverty and in a psychologically
control. The second one refers to a correlation between unfavorable environment are high-risk conditions for
genetic and environmental aspects where susceptible physical and mental disorder, but certain individuals can
individuals are pushed down to the poverty line or cannot develop competences for a good physical and mental
come out of it, causing the environment to increase the development. These resilient people have personal
risk of mental disease. The distinction between these two attributes that act synergistically with the support received
theories is important, since it influences prevention and/ from the family and community.47
or intervention strategies. In a recent study, Costello et al. Nevertheless, the concept of resiliency runs counter to
found that coming out of the poverty line significantly that of vulnerability, according to which certain children,
decreased behavior-related symptoms (oppositional for being exposed to the same stress, develop difficulties
behavior and conduct disorder) in children, but that it did that interfere in their development and behavior. In the
not change other psychiatric symptoms such as anxiety last few years, research about protective factors has
and depression, suggesting the existence of different changed in terms of methodology. While cross-sectional
mechanisms that are not directly related to unfavorable and retrospective studies have provided elements to
socioeconomic conditions.36 define possible risk and protective factors,16 longitudinal
These are also the conclusions of one of the most and prospective studies have been used to document and
important longitudinal studies on children’s development analyze the short- and long-term effects of these factors
and behavior, conducted by Werner et al.,37-42 which has on child’s development and emotional functioning.42,48,49
followed up children since 1955 and revealed that most
individuals exposed to birth-related biological problems
do not develop any kind of adaptive difficulty in adolescence Interventions for mental health promotion in
and adulthood. Perinatal complications, when analyzed childhood
individually, are not predictors of later physical and The studies on the efficacy of early institutionalized
psychological developmental delays, but present an intervention programs for the prevention of behavioral
increased risk only if combined with adverse environmental and/or learning disorders in children have yielded
situations.43,44 According to the two-year follow-up, contradictory results regarding the general population.
wealthier children with perinatal complications had a However, when studying populations with a low
mean IQ score five to seven points lower than wealthier socioeconomic level, there seems to be an agreement on
children without perinatal complications. On the other the benefits that these interventions provide, especially
Environmental influences on mental health – Halpern R & Figueras ACM Jornal de Pediatria - Vol. 80, No.2(Suppl), 2004 S107

those that are maintained for a long period of time.50,51 To be efficient, the programs should include the
The benefits of social and community services for the major groups of children at risk: a) group with an
intervention are characterized by a decrease in intrafamily established diagnosis, for instance, syndromes in which
violence and social misdemeanors, and also cause a delays are a natural part of the course of the disease,
positive effect on the relationship between mothers and would have an intervention for the improvement of
children. The larger impact occurs when interventions are infants and/or children with growth and behavior
initially made in the prenatal period and extend up to the retardation with established disabilities; 67 with regard
first three years of life.52 to the group of children at biological risk, usually related
One of the most important preventive measures that to pregnancy and/or birth conditions, as is the case of
offers benefits in several areas is breastfeeding preterm babies, preventive interventions should be
encouragement. Although no definitive conclusions exist implemented for infants with increased biomedical
as to the role of human milk in cognitive development, risk; 68 finally, the group of children who have social
different studies conducted in different social contexts risks related to unfavorable socioeconomic conditions,
suggest that breastmilk has a positive effect on child poor family structure and inappropriate health care, the
development and on the mother/child relationship.53 If strategy includes preventive interventions for infants
this relationship is sound, it is a good start for the child’s and children with increased environmental risk. 69-71,30
mental health. In a cohort study carried out in Pelotas, It is quite difficult to distinguish the actual impact of
southern Brazil, 1,363 newborn infants were followed up social variables from the impact of biological variables,
during their first year of life and the relationship between since the relationship between them is quite complex, thus
development and breastfeeding, among other variables, hindering the interpretation of results and consequently
was assessed.28 The results showed a dose-response the intervention.
effect regarding the length of breastfeeding: the longer
There are biological and environmental components in
the breastfeeding period, the lower the risk of having a
the etiology of mental disorders that affect the neural
Denver II test with suspected delay. Non-breastfed children
substrate. Brain dysfunctions are not the only etiology of
had an 88% greater risk of having a test with suspected
psychopathology, but also have an impact that depends
delay, compared to those breastfed for longer than six
on the individual’s environmental and social response,
months. In addition to proven nutritional, psychological
thus determining the risk for a negative result.
and immunological advantages,54-56 the evidence that
Environmental conditions such as no physical and social
breastfed children have a better performance in their
stimulus, poverty, stress, and prenatal exposure to drugs,
future cognitive development is another reason for
may compromise brain functions in the presence of
breastfeeding to be encouraged consistently. Breastfeeding
predisposing conditions. 72 The relationship between
is not an innate behavior, but a habit that depends on
genetics and environment is dynamic and also cumulative
learning and on the positive interaction between cultural
in its ability to influence development and change
and social factors.57,58
subsequent behaviors. This combination makes brain
Intervention on the risk factors and mechanisms of function malleable enough to reduce the risk of mental
action that influence children’s mental health goes beyond disorders by changing the environment. For instance, the
the health sector. Joint actions that involve the health neurobiology of processes related to social anxiety shows
sector, education, social assistance, and economics are the clear relationship between neurochemical susceptibility,
increasingly needed, producing jobs and income for the which combined with an unfavorable exposure, causes a
families, infrastructure and leisure. Integrated projects disruption in brain homeostasis.73
aimed at promoting children’s and adolescents’ good
Some theories exist on the neurobiology of drugs of
development have been implemented in different
abuse, suggesting that addiction is strongly associated
communities, especially in the ones with lower
with genetic mutations in neurotransmitters, making
socioeconomic level, showing a high probability of
susceptible individuals abuse the substance in order to
success.59,60
increase the levels of dopamine in their brain.74 An
Even though most developmental and behavioral extensive review on this topic can be found in Gil-Verona
disorders may be recognized still in childhood, disorders et al.74 Research improvements in this area will allow a
such as speech delay, hyperactivity and emotional disorders change in the course of development or at least attenuation
are not commonly diagnosed before the third or fourth of negative results.
years of life.61 In primary care, health professionals often
According to Werner,40 risk factors are not static
do not assess children’s development and mental health
elements and are only valid if they are linked to intervention
as a routine practice.62
programs, where there is a regular follow-up, offering
The positive impact that early intervention programs
health education, rehabilitation and treatment.
have shown in terms of children’s development and later
school performance are a definitive justification for the Despite the fact that early interventions in developing
necessity of early identification of children at risk for such countries may be more difficult, several alternatives
delays.63-66 exist that could promote low-cost and community-
S108 Jornal de Pediatria - Vol. 80, No.2(Suppl), 2004 Environmental influences on mental health – Halpern R & Figueras ACM

based programs, involving children at risk for mental effects on suffering and will improve the quality of life, in
disorders. The type of model depends on the target the medium and long run, reducing school failure, abusive
population. According to Thorburn,75 there are nine use of drugs, violence, crime rate, and development of
available models, ranging from home visits (on which psychiatric disorders in adulthood.
occasion the mother is taught how to stimulate her
child), day care center (as a training center for
caregivers), and school, with teacher’s participation and
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