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Study Reveals Fourfold Range in Rates of Mental Health Problems Among U.S. Children Based on Relational and Social Risks

Most recent national data, from 2016–2019, also highlight relationship-focused protective factors linked to resilience and school outcomes


A large multi-year study based on 20162019 data found that children facing relational and social risks are more likely to have mental, emotional, or behavioral health problems, but the negative impact of these problems on child resilience, self-regulation and school engagement can be offset by protective factors such as strong caretaker-child connection and family resilience.

The study, led by researchers at Johns Hopkins Bloomberg School of Public Health, also found that children who were facing relational risks only, such as substance abuse among family members, were more likely to have mental, emotional, or behavioral concerns than those who were only facing social risks, such as economic hardship.

The findings are published as the U.S. and other countries face a crisis in children’s mental health exacerbated by the pandemic. The study appears online in the January 2022 issue of Child and Adolescent Psychiatric Clinics of North America.

The study found that, overall, 21.8 percent of U.S. children ages 3 to 17 have one or more of the common mental, emotional, and behavioral health conditions assessed. The prevalence of mental health problems across U.S. children ranged from about 15 to 60 percent, increasing with the type (social, relational, or both) and number of these risks that children had been exposed to.

The analysis, based on survey responses covering nearly 132,000 children ages 3 to 17, examined the complex interplay between common mental health problems among children, social and relational health risks, and protective factors. 

“If we treat children with mental, emotional, and behavioral problems without individually and collectively addressing social and relational health risks, or even assessing them, which is often the case, we are missing some of the biggest factors driving the mental and emotional suffering of our children,” says study leader Christina Bethell, PhD, MPH, MBA, professor in the Department of Population, Family and Reproductive Health and director of the Child and Adolescent Health Measurement Initiative at the Bloomberg School.

Research suggests that both social and relational health risks contribute to mental, emotional, and behavioral health problems in children. Much prior research has focused on individual social and relational health risks. The new study investigated both the individual and combined effects of these factors on U.S. children.

For their analysis, Bethell and her colleagues gathered data from the National Survey of Children’s Health, an annual survey led by the U.S. Health Resources and Services Administration’s Maternal and Child Health Bureau in collaboration with the U.S. Bureau of the Census. The survey, administered to thousands of parents and caregivers each year, provides data on multiple, intersecting aspects of children’s lives—including physical and mental health, access to quality health care, and the child’s family, neighborhood, school, and social context.

The study found that over two-thirds of children with mental health conditions experienced at least one of the eight evidence-based social or relational health risk factors examined in the analysis compared to about half of children without mental health conditions.

Factors examined included economic hardship, food insecurity, unsafe neighborhood, racial discrimination, multiple Adverse Childhood Experiences (ACEs) like substance abuse or domestic violence, poor caregiver mental health, and low levels of caregiver coping or high aggravation with their child.

Relational—versus social health risks—were both more prevalent among children with mental health problems and had a stronger association with these conditions. Nearly one-third of children with mental health problems experienced both types of risks.

A key focus of the study was on identifying opportunities to promote positive outcomes among children with mental, emotional, and behavioral conditions who also experience social and relational health risks, with a focus on their engagement in school and building their own resilience, assessed as the ability to regulate emotions and behavior when facing challenges. 

Researchers found that the chances a child was engaged in school were 77 percent less if they lacked self-regulation. Offering hope, the chances a child with mental health problems demonstrated good self-regulation—a key component of resilience—were 5.73 times greater when children also experienced stronger parent-child connection.  These odds were over 2.25 times greater when their family reported staying hopeful and could identify strengths to draw on during difficult times. Findings were consistent across all levels of social and relational health risks.

Bethell notes that both parent-child connection and family resilience are learned behaviors that can be strengthened through supports to families and skills building. Bethell notes that the American Academy of Pediatrics recommend promoting these factors during routine well-child check-ups, through schools, in mental health treatment, and in the community at large.  

“There is a mental, emotional, and behavioral health crisis for children in our country, but most children with these conditions have risk factors that we can identify and do something about,” says study co-author Tamar Mendelson, PhD, MA, a Bloomberg Professor of American Health in the Bloomberg School’s Department of Mental Health. “Ultimately, we need to address the structural and systemic issues that threaten young people’s well-being; at the same time, there is a lot we can be doing to decrease risk factors for families.”

“Social and Relational Health Risks and Common Mental Health Problems Among U.S. Children: The Mitigating Role of Family Resilience and Connection to Promote Positive Socioemotional and School-Related Outcomes” was written by Christina D. Bethell, Andrew S. Garner, Narangerel Gombojav, Courtney Blackwell, Laurence Heller, and Tamar Mendelson.

This study was funded by the Robert Wood Johnson Foundation.

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