Socioeconomic position and child mental health: a global systematic review including LMIC evidence

Background

Socioeconomic inequalities in child and adolescent mental health are a global public health priority, yet prior systematic reviews were restricted to high-income countries (HICs) and lacked pre-registered protocols.

Aim

to examine the association between socioeconomic position and mental health across seven outcome domains, stratified by HIC and low-/middle-income country (LMIC).

Methods

Pre-registered systematic review (PROSPERO CRD42024595145), PRISMA 2020, and SWiM guidelines. Seven databases searched (1990–March 2025) for studies examining socioeconomic position (SEP) and validated mental health outcomes in children/adolescents (0–18 years). Primary synthesis: vote-counting based on direction of effect, stratified by income context. Risk of bias was assessed for all included studies.

Results

113 studies met criteria (HIC: 88; LMIC: 21; Mixed: 4), from >40 countries, ∼1.9 million participants (1996–2025). Of 312 direction-classified estimates, 272 (87.2%) were pro-inequality (lower SEP, worse mental health). Gradient dominant across seven domains: externalizing (97%; OR up to 5.00), depression (90%; HR = 5.59), internalizing (89%), anxiety (87%; OR up to 6.38), quality of life (80%; RII=2.07), general mental health (78%), neurodevelopmental (inconclusive). HIC: 87.6% pro-inequality; LMIC: 79.6%. All reverse findings were in high-risk-of-bias studies with identifiable confounds. All 21 LMIC studies were cross-sectional; no longitudinal evidence from LMICs exists.

Conclusions

Lower SEP is consistently associated with worse child mental health across domains, regions, and income settings. Lower LMIC consistency reflects methodological constraints rather than a weaker association. Findings provide a global foundation for prioritizing socioeconomic determinants in child mental health policy. LMIC longitudinal research is the most critical unmet evidence need.

Key messages

• Lower SEP is robustly associated with worse child mental health in 87% of 312 estimates across HIC and LMIC.

• All LMIC studies are cross-sectional; LMIC longitudinal research is the most critical unmet evidence need.