Prevalence, characteristics, and associated health and health care of family homelessness among fifth-grade students

Annual Research Review: The power of predictability - patterns of signals in early life shape neurodevelopment and mental health trajectories

The global burden of early life adversity (ELA) is profound. The World Health Organization has estimated that ELA accounts for almost 30% of all psychiatric cases. Yet, our ability to identify which individuals exposed to ELA will develop mental illness remains poor and there is a critical need to identify underlying pathways and mechanisms. This review proposes unpredictability as an understudied aspect of ELA that is tractable and presents a conceptual model that includes biologically plausible mechanistic pathways by which unpredictability impacts the developing brain. The model is supported by a synthesis of published and new data illustrating the significant impacts of patterns of signals on child development. We begin with an overview of the existing unpredictability literature, which has focused primarily on longer patterns of unpredictability (e.g. years, months, and days). We then describe our work testing the impact of patterns of parental signals on a moment-to-moment timescale, providing evidence that patterns of these signals during sensitive windows of development influence neurocircuit formation across species and thus may be an evolutionarily conserved process that shapes the developing brain. Next, attention is drawn to emerging themes which provide a framework for future directions of research including the evaluation of functions, such as effortful control, that may be particularly vulnerable to unpredictability, sensitive periods, sex differences, cross-cultural investigations, addressing causality, and unpredictability as a pathway by which other forms of ELA impact development. Finally, we provide suggestions for prevention and intervention, including the introduction of a screening instrument for the identification of children exposed to unpredictable experiences.

Longitudinal patterns of childhood homelessness and early adolescent trajectories of internalising and externalising behaviour

BACKGROUND

Child homelessness has been associated with elevated mental health problems during early adolescence, a period of onset for psychiatric problems. Prior literature has relied on cross-sectional studies, limiting the understanding of temporality and trajectories of psychopathology. We extend prior literature by examining associations between child homelessness and internalising and externalising symptom trajectories in early adolescence, with consideration of timing and persistence of homelessness.

METHODS

Using population-based longitudinal data from the Avon Longitudinal Study of Parents and Children, we used multilevel models to examine the effects of homelessness prior to age 9, the timing of homelessness (eg, early vs middle childhood) and cumulative exposure to homelessness on internalising and externalising trajectories across ages <0-9 years. We also tested for sex differences in these associations.

RESULTS

Of the 8391 participants, 5.5% reported exposure to homelessness at least once before age 9. Children who experienced homelessness had elevated internalising and externalising symptoms compared with their consistently housed peers, with excess risk evident among children who first experienced homelessness in middle childhood (relative to early childhood) and children who experienced recurrent homelessness. We did not observe changes in symptom trajectories over the course of 4 years. Men who experienced homelessness displayed a more pronounced risk of internalising symptoms relative to women and men who did not experience homelessness.

CONCLUSION

Childhood homelessness is associated with persistently elevated internalising and externalising symptoms across early adolescence compared with their consistently housed peers. Interventions and policies to address family homelessness may lead to better mental health among adolescents.

Striving for Structure and Stability in Cincinnati's Family Homeless Shelters: A Community-Based Participatory Research Approach

Experiencing homelessness negatively impacts child health, development, and emotional-behavioral functioning, but there is limited knowledge regarding specific service priorities, as articulated by families themselves, to prevent or address these adverse sequelae. Thus, to elicit the service needs perspective of families in shelter and to translate these findings into real-world action, we undertook a community-based participatory research effort using Group-Level Assessment, a focus group methodology. An action-based participatory needs assessment called a Group-Level Assessment (GLA) was conducted in collaboration with parents currently experiencing homelessness. A total of 53 parents from 3 Cincinnati homeless shelters participated by responding to 17 to 20 open-ended prompts regarding their child's medical, developmental, learning, social, and behavioral needs. Using GLA methodology, we found that the needs expressed by families residing in shelters coalesced around the following themes: job and housing stability, education and skill development, emotional support, and improving shelter life. The GLA findings were then shared with shelter and community leaders, leading to a number of policy and practice enhancements in the shelters. This study demonstrates the power of the GLA approach to affect community action as a direct result of priorities generated by families experiencing homelessness.

When a house is never a home: Housing instability among youth affected by parental drug abuse

BACKGROUND

The negative consequences of parental substance abuse are significant and longstanding for children. Among other risks, these youth are more likely to experience housing instability. The most common predictor of a child not living with their biological parent is parental substance use. Research shows that these youth are at higher risks of housing instability; however, little is known about their housing experiences, from their perspective. This study explored the housing experiences of youth affected by parental substance abuse.

PARTICIPANTS AND SETTING

Fourteen African American young adults ages 18 to 24 years old who identified having at least one biological parent with a history of substance use participated in this study. The study is based in Baltimore, MD, USA; an urban city with one of the highest rates of drug overdose and substantial disadvantage.

METHODS

In-depth interviews were conducted among fourteen young adults (18-24) affected by parental drug use to discuss their housing experiences throughout childhood and adolescence. Five research team members developed a codebook, double coded all transcripts and analyzed inductively using a qualitative content analytic approach.

RESULTS

Three themes emerged to characterize housing experiences: frequent housing transitions, repeated trauma exposures related to housing instability, and the lasting effects of housing instability.

CONCLUSION

The residual impacts of parental substance use have caused youth to experience the toxic stress and trauma associated with housing instability. It is important that young people have safe, stable and reliable housing to promote child health and normative development.

Physical illnesses associated with childhood homelessness: a literature review

BACKGROUND

Childhood homelessness is a growing concern in Ireland [1] creating a paediatric subpopulation at increased risk of physical illnesses, many with life-long consequences [2].

AIM

Our aim was to identify and categorize the physical morbidities prevalent in homeless children.

METHODS

A review of the English-language literature on physical morbidities affecting homeless children (defined as ≤ 18 years of age) published from 1999 to 2019 was conducted.

RESULTS

Respiratory issues were the most commonly cited illnesses affecting homeless children, including asthma, upper respiratory tract infections, and chronic cough [3]. Homeless children were described as being at increased risk for contracting infectious diseases, with many studies placing emphasis on the risks of sexually transmitted infections (STIs) and HIV/AIDS transmission [4, 5]. Dermatologic concerns for this population comprised of scabies and head lice infestation, dermatitis, and abrasions [3, 6]. Malnutrition manifested as a range of physical morbidities, including childhood obesity [7], iron deficiency anemia [4], and stunted growth [8]. Studies demonstrated a higher prevalence of poor dental [7] and ocular health [9] in this population as well. Many articles also commented on the risk factors predisposing homeless children to these physical health concerns, which can broadly be categorized as limited access to health care, poor living conditions, and lack of education [3, 10].

CONCLUSION

This literature review summarized the physical illnesses prevalent among homeless children and the contributing factors leading to them. Gaps in the literature were also identified and included a dearth of studies focusing on younger children compared with adolescents. Further research into prevention and intervention programs for this vulnerable population is urgently needed.

Forty Years of Research on Predictors of Homelessness

Homelessness is a chronic public health issue in the U.S. This paper reviews the endurance and evolution of individual, youth, and family homelessness over the past 40-plus years. Thematic findings detail research on predictors of homelessness among adolescents, runaway youth, veterans, older adults, sheltered families, and female-headed families. Results provide a summary of contributors to homelessness, including issues related to family instability, unemployment and poverty, mental illness, substance use, unstable living arrangements, child maltreatment, social support, crime, and violence. Findings highlight key and persistent predictors of homelessness found across decades, as well as more recently identified and nuanced precursors to individual or family displacement. The goal of this work was to summarize what is known about predictors of homelessness to inform targeted research, practice, and policies.

Health Risks and Outcomes of Homelessness in School-Age Children and Youth: A Scoping Review of the Literature

Despite reports that over 1.3 million school-age children (ages 5-18) were homeless in 2019, little is known about the effects of homelessness on their overall health and well-being. To better understand where gaps exist, a scoping review of the literature was conducted to identify studies of the physical, mental, and behavioral health risks and outcomes of school-age children experiencing homelessness or housing instability. Following the Joanna Briggs Institute framework and Preferred Reporting Items (PRISMA) guidelines, seven electronic databases were searched using key words: homelessness, children, health, and well-being. Of the 4,372 records, 23 articles met inclusion criteria. Most examined mental health and high-risk activities or behavioral risks related to school achievement. Few studies tracked the long-term health outcomes of homeless school-age children. Findings have implications for school nurses who have contact with children experiencing homelessness and are in position to intervene to prevent negative health sequelae in this vulnerable population.

Brief CBT group therapy for Mexican homeless girls

Homeless girls suffer labour and sexual exploitation, abuse, discrimination and social exclusion at a higher rate than the rest of the population. However, worldwide information on homeless girls and intervention programmes for this group are scarce. This study examined the preliminary efficacy of a brief cognitive behavioural group therapy tailored to Mexican homeless girls. The intervention targeted subjective well-being and these determinants: symptoms of anxiety, symptoms of depression, assertive behaviours and functional emotion regulation skills. Results revealed statistically significant differences in symptoms of anxiety and depression, assertiveness, emotion regulation strategies and subjective well-being with treatment effects that ranged from moderate to large. Symptoms of anxiety and depression, and dysfunctional emotion regulation strategies decreased. Assertive skills, functional emotion regulation strategies, and subjective well-being increased. Outcomes were clinically relevant. At 2-month follow-up, participants showed improvement from pre-treatment on all measures. The current study provides unique findings in terms of a promising preliminary intervention that helps restore homeless girls to a healthier social/emotional developmental path especially in the context of Latin American cities. As a result, the clinical implications of this research highlight the urgent need to design effective interventions based on the observed characteristics and identified needs among homeless girls.

Characteristics of child physical and sexual abuse as predictors of psychopathology

Childhood physical and sexual abuse victims are at increased risk for developing depression, anxiety, and post-traumatic stress disorder (PTSD) in adulthood. Prior findings suggest abuse onset, duration, and severity moderate relationships between victimization and psychopathology. However, because these abuse characteristics are highly intercorrelated, their unique, individual effects on mental health outcomes remain unclear. To address this gap, the present study examined relationships between physical and sexual abuse characteristics and mental health outcomes and whether these relationships differed by sex. A diverse community sample of late adolescents and emerging adults (N = 1270; mean age = 19.68; 51% female) self-reported the onset, duration, and severity of physical and sexual abuse, as well as their depressive, anxiety, and PTSD symptoms. Results of a multivariate regression model (simultaneously evaluating all physical and sexual abuse characteristics) indicated that physical abuse onset in middle childhood and sexual abuse onset in middle childhood or adolescence were associated with all forms of psychopathology; and physical abuse onset at any time was uniquely linked with PTSD. Duration and severity of physical or sexual abuse did not predict psychopathology after accounting for time of onset. Multigroup analyses indicated that adolescence-onset and duration of sexual abuse respectively predicted anxiety and PTSD in females but not males, whereas sexual abuse severity predicted fewer PTSD symptoms in males but not females. Overall, results suggested that abuse occurring after age 5 may have the most deleterious impact on mental health.

Acute Alcohol Use, History of Homelessness, and Intent of Injury Among a Sample of Adult Emergency Department Patients

BACKGROUND

The literature is clear that adults who are currently homeless also have higher rates of intentional injuries, such as assault and suicide attempts. No study has assessed whether intentional injuries are exacerbated because of substance use among adults with a history of homelessness.

METHODS

Data were obtained from a cohort of adults admitted to 3 urban emergency departments (EDs) in Texas from 2007 to 2010 (N = 596). Logistic regression analyses were used to determine whether a history of homelessness was associated with alcohol use at time of injury in intentional violent injuries (gunshot, stabbing, or injury consistent with assault).

RESULTS

39% adults with a history of homelessness who were treated at trauma centers for a violent injury. Bivariate analyses indicated that adults who had ever experienced homelessness have 1.67 increased odds, 95% confidence interval (CI) [1.11, 2.50], of any intentional violent injury and 1.95 increased odds (95% CI [1.12, 3.40]) of a stabbing injury than adults with no history of homelessness.

CONCLUSIONS

Adults who experienced homelessness in their lifetime were more likely to visit EDs for violencerelated injuries. Given our limited knowledge of the injuries that prompt ED use by currently homeless populations, future studies are needed to understand the etiology of injuries, and substance-related injuries specifically, among adults with a history of homelessness.

Reproductive health rights and survival: The voices of mothers experiencing homelessness

Women experiencing homelessness report higher rates of reproductive health-related traumas, including unplanned pregnancy, miscarriage, and abortion than their non-homeless peers. Using phenomenological hermeneutic methods, we sought to understand the reproductive health histories of women currently experiencing homelessness (N = 20, 25-61 years old, Mage = 38.33, SDage = 9.33) analyzing data collected between June 2014 and July 2015 in north central Texas. Three key themes highlight the essence of the women's experiences: (1) unexpected pregnancy-pregnancy just happened, (2) loss of reproductive health rights-I was broken, and (3) resilience-giving back and looking forward to good things. Many of the women became mothers through unexpected pregnancies, and overnight found that their lives were transformed irrevocably. Often unexpected pregnancy was the result or cause of a lack of ownership over their reproductive health and led to prolonged health-related traumas. Over time, though, many of the women whom we interviewed re-expressed resilience through social support, housing assistance, and a sense of giving back to society. Results indicate that reproductive health care providers require training to identify the relationship among unexpected pregnancy, reproductive health-related traumas, and housing insecurity. Providers can help preserve women's reproductive health rights through education and empowerment.

In Their Own Words: Exploring Family Pathways to Housing Instability

Housing instability threatens the health and well-being of millions of families across the United States, yet little is known about the characteristics or housing trajectories of at-risk families. To address this gap in our understanding of family risk for housing instability and homelessness, we undertook a qualitative descriptive study utilizing a convenience sample of 16 mothers recruited from a housing service agency living in Detroit and receiving emergency services to avoid homelessness. Participants completed the Brief Patient Health Questionnaire (PHQ), then narrated their life events and reasons for housing instability and disclosed desired interventions for homelessness prevention. Data analysis reveals that women experienced high rates of previously undisclosed trauma, broken family relationships, early parenting responsibilities, social isolation, and system failures that contributed to recurrent episodes of housing instability. We argue that housing instability is a symptom of multiple chronic underlying issues that need more than a temporary financial patch.

Quality Health Care for Homeless Children: Achieving the AAP Recommendations for Care of Homeless Children and Youth

BACKGROUND

We assessed whether and how health care organizations serving homeless pediatric patients meet recommendations issued by the American Academy of Pediatrics (AAP).

METHODS

We conducted a web-based survey of Health Care for the Homeless (HCH) Program grantees serving children.

RESULTS

Of 169 grantees, 77 (46%) responded. All organizations reported connecting patients to specialty services. Nearly all reported screening for homelessness (90%), facilitating Medicaid enrollment (90%), connecting patients to benefits (94%), addressing underlying causes of homelessness (83%), assisting with transportation (83%), and knowing about the causes of homelessness (76%). Fewer reported integrating comprehensive care into acute visits (61%) or having medical-legal partnerships (57%). Federally qualified health center status was associated with meeting more recommendations. We described barriers and facilitators to meeting recommendations.

DISCUSSION

Health care organizations serving homeless children largely meet AAP recommendations, but integrating comprehensive care into acute visits remains an area for improvement. Disseminating best practices may support guideline adherence.

The Association Between Familial Homelessness, Aggression, and Victimization Among Children

PURPOSE

The purpose of this study was to evaluate the relationship between the number of periods children were exposed to familial homelessness and childhood aggression and victimization.

METHODS

Survey data were obtained from 4,297 fifth-grade children and their caregivers in three U.S. cities. Children and primary caregivers were surveyed longitudinally in 7th and 10th grades. Family homelessness, measured at each wave as unstable housing, was self-reported by the caregiver. Children were categorized into four mutually exclusive groups: victim only, aggressor only, victim-aggressor, and neither victim nor aggressor at each time point using validated measures. Multinomial, multilevel mixed models were used to evaluate the relationship among periods of homelessness and longitudinal victimization, aggression, and victim aggression compared to children who were nonvictims and nonaggressors.

RESULTS

Results suggest that children who experienced family homelessness were more likely than domiciled children to report aggression and victim aggression but not victimization only. Multivariate analyses suggested that even brief periods of homelessness were positively associated with aggression and victim aggression (relative to neither) compared to children who were never homeless. Furthermore, childhood victimization and victim aggression significantly decreased from 5th grade to 10th grade while aggression significantly increased in 10th grade.

CONCLUSIONS

Children who experienced family homelessness for brief periods of time were significantly more likely to be a victim-aggressor or aggressor compared to those who were never homeless. Prevention efforts should target housing security and other important factors that may reduce children's likelihood of aggression and associated victimization.

"It's a struggle but I can do it. I'm doing it for me and my kids": the psychosocial characteristics and life experiences of at-risk homeless parents in transitional housing

Families experiencing homelessness face a number of risks to their psychosocial health and well-being, yet few studies have examined the topic of parenting among homeless families. The purpose of this multimethod, descriptive study was to acquire a better understanding of the psychosocial status and life experiences of homeless parents residing in transitional housing. Quantitative data were collected from 69 parents and primary caregivers living in a transitional housing community, with a cohort of 24 participants also contributing qualitative data. The quantitative results suggest risk associated with depression, parenting stress, and negative parenting practices. The qualitative findings highlight five themes that convey both the challenges faced by homeless parents as well as the resilience they display in spite of such adversity. These results extend current scholarship on homeless families with children and can better inform how couple and family therapists work with this at-risk population.

Life shocks and homelessness

We exploited an exogenous health shock-namely, the birth of a child with a severe health condition-to investigate the effect of a life shock on homelessness in large cities in the United States as well as the interactive effects of the shock with housing market characteristics. We considered a traditional measure of homelessness, two measures of housing instability thought to be precursors to homelessness, and a combined measure that approximates the broadened conceptualization of homelessness under the 2009 Homeless Emergency Assistance and Rapid Transition to Housing Act (2010). We found that the shock substantially increases the likelihood of family homelessness, particularly in cities with high housing costs. The findings are consistent with the economic theory of homelessness, which posits that homelessness results from a conjunction of adverse circumstances in which housing markets and individual characteristics collide.

Asthma, tobacco smoke and the indoor environment: a qualitative study of sheltered homeless families

OBJECTIVE

Asthma is common in homeless children with an incidence of 28-40%. There are few published studies investigating asthma in homeless children. This study examines the perspectives of both caregivers and shelter staff regarding challenges and opportunities of caring for children with asthma.

METHODS

A focus group of sheltered parents (n = 10) with children who have asthma was conducted to identify barriers to optimal asthma management. Key informant interviews (n = 6) were conducted with shelter staff to discuss the shelter systems and policies to address childhood asthma. Data were audio-recorded and transcribed. A representative analysis team performed qualitative theme analysis.

RESULTS

Key themes across 5 domains were identified: asthma education, access to asthma medication and equipment, asthma action plans, structural barriers to asthma management and environmental triggers. Parents identified multiple asthma triggers present in the shelter environment but cited lack of control as a barrier to remediation. Shelter staff desired elimination of asthma triggers but refer to the lack of resources as the primary barrier. Shelter staff favored a smoking ban on shelter property but named challenges to policy implementation. Both parents and staff identified asthma education and increased access to medications would be helpful.

CONCLUSIONS

Policies to reduce environmental exposures, such as a smoking ban, to asthma triggers has the potential to improve the health of sheltered children with asthma.

Analysis of the health status of the homeless clients utilizing a free clinic

The purpose of this study is to evaluate the health status of the homeless population who utilize a free clinic. The study specifically aims to compare the prevalence of asthma, diabetes, tuberculosis, mental health disorders, sexually transmitted diseases, sinus problems, and hepatitis among the homeless population. Investigators collected data from paper medical records during patient visits from 2004 to 2009. Diagnosed health conditions among the homeless population were compared to the general clinic users using logistic regression. There were several similarities between the general clinic and homeless population, however, the homeless population had statistically significant (p < 0.05) outcomes for diagnosed cases of tuberculosis, hepatitis, anxiety, and bipolar disorders. Prevalence of diabetes, sinus problems, asthma, diabetes, and depression were similar among both populations. The odds ratios among hepatitis, tuberculosis, STDs, bipolar disorder and anxiety disorder indicated the homeless had a significantly greater risk of developing hepatitis, tuberculosis, and bipolar disorder. This study adds to the literature by illustrating the characteristics of the homeless population who utilize the free health clinic and their medical conditions. Previous studies have shown the free clinic clients have a lower level of health than the general population. This study finds that the homeless clients of a free clinic have an even worse level of health than the general clinic clients. This research can contribute to the improvement of the healthcare delivery system in providing access to needed health care services for the homeless population.

Unmet eye care needs among U.S. 5th-grade students

BACKGROUND

There is substantial evidence of a disparity in access to eye care services among adults in the U.S.; however, little is known about health disparities for children's eye care.

PURPOSE

The goal of the study was to assess the prevalence of and risk factors for 5th-grade students' unmet eye care needs.

METHODS

Data were collected from 5147 5th-grade students (aged 10-11 years) and their parents and primary caregivers (hereafter "parents") participating in the Healthy Passages study between fall 2004 and summer 2006 (analyzed in 2011). Logistic regression estimated the probability of inability to afford needed eyeglasses and absence of vision insurance coverage.

RESULTS

1794 5th-grade students wore eyeglasses or were told that they need eyeglasses; 13.7% of their parents were unable to afford needed eyeglasses (new prescription or replacement) for their children; 27.4% of their parents reported no vision insurance coverage for eye examinations and eyeglasses. After controlling for confounders, parents without general children's health insurance were more likely to report being unable to afford eyeglasses than those with health insurance (Medicaid, SCHIP, private/other insurance; adjusted percentages: 22.5% vs 10.9%, 9.6%, 12.5%; all p<0.05). Parents with lower income were more likely to report being unable to afford children's eyeglasses even after controlling for all other factors (17.6% with income <$15,000 vs 2.7% with income ≥$70,000; p<0.001).

CONCLUSIONS

SES and health insurance status are strongly associated with 5th-grade students' unmet eye care needs. Policies targeting socioeconomically disadvantaged groups and those without insurance may be needed to reduce disparities in access to appropriate eye care.