After completing this article, readers should be able to:
Recognize homelessness and the risk of becoming homeless for children who reside with their families.
Describe the specific health problems that affect homeless children.
Determine how to modify health care plans and prevention strategies appropriately for homeless children.
Find additional resources for homeless patients and their families.
Most clinicians who care for children encounter patients who are homeless or at risk of becoming homeless. This reflects the growing number of homeless families that include children and that homelessness increases the risk of a number of health problems.
This article helps the clinician to recognize patient homelessness and create effective, appropriate health care plans. Of note, the information provided relates to homeless children who are part of families and does not address unaccompanied youth who have somewhat different and unique issues.
The Magnitude of the Problem
Approximately 2% of American children are homeless in the course of 1 year, and trends suggest that the number of homeless children will increase. Homeless families are the fastest growing segment of people experiencing homelessness and currently represent 40% of the homeless population. The numbers of families requesting emergency shelter increased by 15% from 2002 to 2003.
Defining the Population of Homeless Children
Homeless children tend to be young (41% younger than age 5 y) and in families headed by single mothers (85%). Homelessness is dynamic; 25% of homeless children are homeless more than once during their childhood, and their average period of homelessness is 10 months.
Definitions of homelessness can be found in federal legislation such as the Stewart B. McKinney Act and in the missions and goals of local and nonprofit agencies. These different definitions are designed to determine the types and distribution of specific services. For clinicians, an operational definition includes a continuum of living situations from living on the street to staying temporarily at a campground or at a friend’s home to entering an emergency shelter or a transitional housing program.
Important Health Issues
Once a clinician determines that a child is homeless, he or she can consider how this factor modifies the usual focus of health issues and the ultimate plan of care.
Published studies on the health of homeless children are limited. Most are descriptive, with small, nonrepresentative samples and often without an appropriate comparison group. Nonetheless, the data generally suggest overall increased morbidity, and the specific areas of concern parallel “poverty medicine” in the extreme.
Homeless parents are more likely to rank their child’s health as being poor. Consistently across surveys, approximately 13% of homeless parents rate their children’s health as fair or poor compared with approximately 4% of poor families or the general population.
Data demonstrate that per year, homeless children experience increased hospitalization rates (11% versus 5%), more outpatient visits (means of 5.6 versus 3.8), and more use of the emergency department (mean visits of 1.6 versus 1.1) compared with low-income children. In a comparison of homeless and housed children who used a school-based health center, homeless children were 2.5 times more likely to have any health problems, 3 times more likely to have severe health problems, and 6 times more likely to have multiple health problems.
Homeless families often live in crowded conditions, which increases the risk of acquiring the common infectious diseases of childhood, such as upper respiratory tract infections, ear infections, and diarrhea. Lice and scabies infestations are particularly high in this population, with observed prevalences of approximately 10% compared with less than 1% among children seen in routine primary care practices.
Homeless children live in less structured and less safe environments that may place them at risk of injury. In one survey of homeless sheltered mothers, 19% reported taking their child to an emergency department for an injury in the previous year, and 13% had children who received a burn with significant scarring in the last year. No comparison group data were provided.
Published data on blood lead levels among homeless children are inadequate, but given the known risk factors of poverty, poor nutrition, dilapidated housing, and dusty environments, homeless children should be considered a high-risk group.
Nutrition and Growth
Poverty is associated with both obesity and malnutrition. Obesity reflects a diet containing excessive amounts of cheaper, carbohydrate-rich foods; malnutrition reflects caloric deficiency. Some 14% of parents in homeless shelters report eating at a fast food restaurant or convenience store at least four times a week compared with 5% of their poor housed counterparts. Approximately 23% endorse the statement that their children are hungry and there never or frequently is not enough food compared with 4% of housed poor parents.
The lack of access to adequate amounts of nutritious food may explain the evidence of stunting observed in a comparison of the growth of homeless children and poor children. Homeless children are disproportionally represented in lower percentiles of height compared with both poor housed children and National Center for Health Statistics standards.
Anemia is another well-known disease of poverty, although the published data lack adequate documentation in homeless children. Nonetheless, due to known nutritional risk factors, homeless children should be considered a high-risk group for anemia.
According to National Health Care for Homeless Providers, the rates of poor dentition and caries are approximately 10 times greater among homeless children than among the general population, although specific data are not provided.
Incomplete immunization rates of 27% to 70% have been reported among homeless preschool children, and delay rates of 5% to 16% are given for school-age children. These rates are two to three times greater than those observed in comparison populations of the general population or poor housed children.
Asthma is more prevalent among homeless school-age children compared with their poor housed schoolmates, as is increased reporting of recent symptoms among homeless sheltered children compared with poor housed children. Asthma rates increase with poverty and homelessness for a number of reasons. Dust mites, cockroaches, rodents, and indoor molds are common triggers found in most shelter housing. Upper respiratory tract infection is a well-identified trigger common in homeless children. Lastly, there is increasing evidence that psychosocial stress is an important factor in asthma.
Problems with vision are common among homeless children. In one study, a significantly increased prevalence of visual acuity problems was identified among screened homeless children compared with their poor housed schoolmates.
Domestic violence is common among homeless mothers. Not surprisingly, many homeless children are at risk for abuse. Surveys report a prevalence of involvement in child abuse investigations to be 24% to 35%.
The psychosocial and environmental stresses of homelessness undermine normal development. When the Denver Developmental Screening Test is used to compare homeless children with poor housed children, increased failure rates for all sections are reported, with speech/language the most commonly failed section. Overall, 54% of the homeless children screened failed at least one section compared with 16% of the housed poor.
Academic problems are common among school-age children. Psychometric testing reveals homeless children to have deficits in verbal skills, vocabulary, and reading. Data suggest that only 30% of homeless children read at their chronologic age level. These deficits reflect the impact of unstable living environments and inconsistent school attendance.
Mental Health and Behavior
Homeless children are likely to come from backgrounds of domestic violence, mental illness, and substance abuse. These and other stresses associated with homelessness and poverty affect psychosocial well-being. A chart review of homeless and housed poor students revealed depression among 9% and 3%, respectively. Other studies of school-age homeless children that have used the Children’s Depression Inventory indicate that 46% to 57% of children exceed the cut-off point used to refer for further psychiatric evaluation.
Determination of Housing Status
It is important to recognize that simply asking, “Are you homeless?” is not an effective method of determining a child’s living situation. Many children and their families perceive the stigma and shame associated with being homeless and deny it. Some children deny being homeless because they do not perceive themselves as such when they are living with their parents and moving around to relatives’ homes.
Table 1 suggests potential assessment opportunities, the questions that can be posed, and possible responses. Essential to this process is evaluating the family’s housing status without making prior assumptions.
|Opportunity for Assessment||Suggested Questions and Responses|
|Registration of the Patient|
|Placement of the Patient in the Examination Room|
|Immunization Review and Administration|
Addressing the Barriers Associated With Homelessness
The key to providing appropriate and adequate health services for homeless patients is understanding and overcoming the potential barriers specific to this population. Examples of barriers and suggested approaches are provided in Table 2.
Homelessness frequently demands that parents concern themselves with issues of survival; they may rate health needs below needs for safety, housing, and food. The stresses of homelessness can alter a parent’s ability to serve as the best historian of the child’s health. Others working with the family, such as child care practitioners, teachers, or case managers, can provide important information. By collaborating with others, clinicians may provide parents with the information and support they need to prioritize a child’s health needs appropriately.
Homelessness raises many unique barriers to treatment compliance and access to care. Many homeless children do not have a medical home. Therefore, evaluating their entire health status, including physical, behavioral, and developmental, during an acute-care visit may be the only opportunity to recognize and address health concerns. Given its prevalence, screening for domestic violence always should be included. Providing practical solutions to transportation and communication barriers also is critical (Table 2).
Informing case managers about a child’s chronic health condition or a serious acute illness can give a family priority status for emergency, transitional, or subsidized permanent housing.
Knowledge of state laws regarding parental rights and homelessness can provide access to funds and services for patients and families. Some states have laws that prohibit children from being removed from the home solely because the family is homeless. Laws also may obligate agencies to assist homeless families.
Numerous resources are available to assist those unfamiliar with homelessness. Table 3 lists organizations that clinicians can access to educate themselves about local, state, and national resources that they can use to serve children enduring homelessness.
|National Health Care for the Homeless Council www.nhchc.org||Membership organization of clinicians and health care organizations providing health care services to homeless individuals. Resources for those providing health care to people who are homeless.|
|The Bureau of Primary Health Care http://bphc.hrsa.gov/||United States Department of Health and Human Services program that supports health care for the homeless through grants. Can locate a Health Care for the Homeless grantee through the site’s “Find a Health Center.”|
|National Coalition for the Homeless www.nationalhomeless.org||Advocacy organization for people dealing with homelessness. Organized by state and provides directory of local and state resources.|
|National Center for Homeless Education www.serve.org/nche/||Advocacy organization that supports the equal educational opportunities of children and youth enduring homelessness. Directory of state coordinators for homeless education.|
|National Association for the Education of Homeless Children and Youth www.naehcy.org||A professional association that addresses educational issues that affect students in homeless situations.|
Making a Difference
Clinicians serving children who are homeless can affect not only their health needs, but the stability of their families. Clinicians partnering with parents can influence children’s well-being and may interrupt the cycle of homelessness by identifying patients and their families who are enduring homelessness, offering appropriate health care services, and advocating for them within the community.
Homeless in America: A Children’s Story. Part One. New York, NY: The Institute for Children and Poverty;1999
Miller DS, Lin EH. Children in sheltered homeless families: reported health status and use of health services. Pediatrics.1988;81 :668– 673
Stewart B. McKinney Act, 42 U.S.C. § 11301, et seq. (1994)
United States Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: A 27 City Survey. Washington, DC: United States Conference of Mayors;2001
United States Department of Health and Human Services. Bureau of Primary Health Care. No Place to Call Home. Washington, DC: United States Department of Health and Human Services;2001
Weinreb L, Goldberg R, Bassuk E, Perloff J. Determinants of health and service use patterns in homeless and low-income housed children. Pediatrics.1998;102 :554– 562
Wood DL, Valdez RB, Hayashi T, Shen A. Health of homeless children and housed poor children. Pediatrics.1990;86 :858– 866
- Copyright © 2004 by the American Academy of Pediatrics