Katie Mack

How does Family Homelessness affect Children’s health?

Children and young people living in homeless families are one of the most ‘at risk’ groups of children and young people and often lie at the extreme end of a continuum of poverty and material deprivation. As such they face many similar issues to other low socioeconomic status families, in addition to a number of unique struggles that the reality of homelessness brings.

The ‘United Nations Convention on the rights of the child’ (UNCRC) was formally adopted as a basis for policy making by the Welsh Government in 2004. Their report: ‘Children and Young People: Rights to Action’, sets out 7 core aims which underpin national and local government policy making for children and young people to support them to reach their full potential and enjoy all of their human rights. Articles 24 and 27 of the UNCRC describe the rights to ‘the enjoyment of the highest attainable standard of health’ (United Nations 1990 p.7) and to ‘a standard of living adequate for the child’s physical, mental, spiritual, moral and social development’ (United Nations 1990 p.8) which are human rights that may not be attained by children in the context of homelessness due to the accommodation and the situations in which they live and the consequences of these on their health. 1,655 households in Wales were accepted as homeless during the January to March quarter of 2011, 635 of which contained dependent children (Statswales 2011). While the numbers of households accepted as homeless has generally been falling since 2006, these figures show that homelessness is still a significant problem in Wales and that a considerable number of children are coming into contact with homelessness.

Homeless families should never be roofless. According to the Housing Act 1996 there is a statutory duty for local authorities to provide support to people who are unintentionally homeless, eligible for assistance and who fall within a priority need category, which includes households with dependent children (The National Archives 1996). Although not as extreme as rooflessness, life in a hostel or other form of temporary accommodation poses a multitude of challenges for children and young people. These very often include issues such as a lack of play opportunities, nowhere to do homework, sometimes sharing a kitchen or living space, material deprivation, depression and anxiety, association with substance misusers, violence, aggression and threatening behaviour and many other high stress situations that threaten personal safety. There is no guarantee that hostel accommodation will be in the same area as a family’s previous residence and therefore family members including children can find it hard to access their social and support networks as well as services including GP surgeries and schools. Homeless families can also find it hard to access health services with a temporary address and can find themselves subject to discrimination. The compounded impact of these and many other consequences of homelessness on children and young people therefore extends much further than just changes to their immediate surroundings; it can profoundly affect both their physical and mental health, which can in turn affect nearly every other aspect of their lives. Children and young people in families fleeing domestic violence often find themselves living in a context of homelessness and have a high level of need, not necessarily confined to the consequences of homelessness (Webb et al 2001) but also as a result of the domestic violence. Other groups of homeless children and young people may also have particular needs related to the cause of their homelessness. These include children of homeless asylum seekers, refugees and Gypsys & Travellers, children and young people leaving care and a number of other groups of children and young people. Although it is essential to consider these particular needs they will not be described here. However, many of the issues pertaining to homeless children and young people will be real for all of these ‘specialist’ vulnerable groups. A number of researchers have found that the prevalence of asthma is higher among homeless children. Weinreb et al (1998) found that there were significant differences in the incidence of ‘bronchitis/ wheezing/ asthma attack’ between homeless and low-income housed children. In 3 homeless shelters homeless children were found to have a higher prevalence of asthma than any other documented paediatric population (Grant et al 2007). In this study only children with symptoms consistent with ‘moderate to severe’ asthma were included in the study population and so the actual prevalence of asthma may have been even higher. High prevalence of asthma in homeless children was also found in studies by McLean et al (2004) and Cutuli et al (2010) ,

Katie Mack

finding a prevalence of 39.8% and 27.9% respectively. This high prevalence could be due conditions in hostels and temporary accommodation which can include multiple asthma triggers. It is not just asthma to which homeless children have been found to be at a higher risk; there have been significant differences found in the prevalence of some infections between homeless and low-income housed children (Raoult et al 2001, Weinreb et al 1998). 30% of homeless children compared with 19% of low-income housed children suffered with an ear infection during 1 year, and when asked about the previous month 37% of homeless children reported having a fever, compared with 27% of low-income housed children (Weinreb et al 1998). Another study found that homeless children were 30% more likely to be hospitalised with a urinary tract infection and 25% more likely to have an upper respiratory tract infection than a low socioeconomic status comparison group (Frencher et al 2010). Victor et al (1989) also found that homeless children were more likely to present to hospital with an infection than local children, a finding which was highly statistically significant. In a study of 78 children living in one homeless shelter in Massachusetts 8 children were found to be carrying the Giardia lamblia pathogen asymptomatically and 1 child was found to be suffering acutely with Giardia enteritis which causes diarrhoea and malabsorption (Bass et al 1990). This pathogen is spread via the faecal-oral route; so the increased incidences could be consequence to communal shelter living conditions and possible poor hygiene practices. Homeless children could be at an increased risk of infectious and other diseases due to having incomplete vaccinations, as found in 15% of homeless children in a study by Bass et al (1990). Similarly 27.2% of 265 homeless children attending a paediatric clinic in New York had delayed vaccinations compared with only 8% of the housed children in the same clinic (Alperstein et al 1988). Uptakes of immunisation was also found to be low in children living in refuges for women victims of domestic violence, a subgroup of homeless children (Webb et al 2001). In a study of 25,312 children aged 0.1-9 by Frencher et al (2010) it was found that homeless children were significantly more likely to be hospitalised due to injury than low socioeconomic status children and numbers of unintentional injury were 13% higher in homeless children. In the same study homeless toddlers aged 3 and 4 were found to be at an increased risk of hospitalisation due to falls from furniture, which may be a reflection of the difficulty parenting in the context of homelessness. In a study of 5439 children by Coker et al (2009) homeless children were significantly more likely to have had a serious injury in the last 12 months. Richman et al (1991) found no difference between the accident rate of homeless and housed children, however the types of accidents did vary between the groups- with homeless children having more than twice the rate of burns and scald injuries and housed children more likely to present with bruises, sprains or fractures; which may be why the higher hospitalisation rates of homeless children were found in the study by Frencher et al (2010). Contrastingly, in a study of 627 children the number of accidents during 1 year requiring medical care was found to be equal when comparing homeless to low-income housed children (Weinreb et al 1998). Interestingly, the number of homeless children who had 2 or more visits to A&E during the year was 39.7% compared to 19.5% of the low-income housed children, which was highly significant, signifying that in this sample homeless children were using A&E more often than housed children, even though they were not experiencing more accidents, suggesting that they were experiencing greater numbers of other medical emergencies. An interesting study from the USA looked at how negative life events and other risk factors in extreme childhood poverty affected morning cortisol levels in homeless 4 to 7 year olds. Cortisol is a hormone found in the body which helps regulate glucose levels, can suppress the immune system and can also help the body react to stress. Cortisol is usually found in the body at higher levels in the morning, falling throughout the day and can also be released in response to stress, but usually falls back to baseline level soon afterward. Chronic childhood stress has been shown to interfere with the normal regulation of cortisol, with some children displaying elevated baseline levels. A chronic overproduction of cortisol has been linked to a range of poor mental and physical health outcomes. In the study by Cutuli (2010) children with higher numbers of negative lifetime events were shown to have higher morning cortisol levels, however, there was no significant difference in the morning cortisol levels when comparing the socioeconomic risk of the children. This suggests that having limited family resources alone does not cause homeless children to have an elevated cortisol level, whereas exposure to negative life events such as violence in the home, substance misuse of the caregiver or separation from the caregiver had a significant effect of increasing the morning cortisol level.

Katie Mack

Therefore, rather than all homeless children being more likely to have elevated cortisol levels, it seems that homelessness puts children at an increased risk of being exposed to negative life events which in turn cause cortisol elevation. The increased cortisol levels could cause a decrease in immune function (McEwen 1998) which could explain some of the results discussed earlier, such as increased infection rates in homeless children. These results show that some of the health outcomes found in homeless children may not be due to the impact of homelessness per se, but due to the impact of the factors that led to homelessness. Distinguishing between these factors is a huge challenge for researchers. The stresses of homelessness potentially affect children’s neurodevelopment (Kagan 2004) including delaying rational frontal lobe activity and increasing other brain activity, leading to emotional reactions, constant hyper-arousal and irritability. Some evidence has been found that homeless children are more cognitively impaired than housed children from comparable backgrounds (Parks et al 2007). However a study of 33 homeless children identified no deficits of visual motor, visual perception or motor coordination skills (Schultz-Krohn and Richardson 2002). Yu (2008) found verbal cognitive scores to be significantly higher in housed children than homeless children, however non-verbal skills were equivalent in both groups. In terms of all developmental delay, from a group of 81 homeless children almost half were found to have at least 1 developmental delay and 33% had 2 or more (Bassuk et al 1986). The most prevalent developmental delays were language acquisition and personal and social growth. Another study by Bassuk and Rosenberg (1990) showed similar results with 54% of the homeless children studied showing 1 or more developmental delay. A different study found no differences between the two groups, a finding that was surprising to the researchers (Garcia-Coll Et al 1998). The lack of difference could be due to the homeless and low-income housed children sharing many risk factors other than housing status such as having single parents, parental substance abuse and exposure to violence. These are again risk factors which could cause an increase in the background cortisol levels, which can lead to negative health outcomes. Weinreb Et al (2002) have shown that homeless children are more likely to be hungry than low-income housed children. Hunger can have a damaging effect on both the physical and mental health of children. In the study of 308 children, those with severe hunger had higher rates of chronic illness and psychiatric distress. The parents of children in families with ‘severe hunger’ had anxiety scores which were over double the score of parents of children with no hunger, and this increased anxiety may also detrimentally affect the care of their children. In another study of homeless children it was found that there were significantly higher rates of disordered weight behaviours such as fasting (24.9% versus 10.2% in the housed comparison group) and diet pill use (12.6% versus 4.1%).This could be due to the fact that these behaviours give some sense of control over food for children who often do not have control over their sources of food (Fournier et al 2009) and other aspects of their lives. A study by Fierman et al (1991) showed that homeless children displayed a pattern of stunting, where children are underdeveloped in height but preserve normal weight-height ratio, indicating that they were subject to chronic moderate nutritional stress. They did not however display wasting, a low weight with a normal height, which can indicate acute malnutrition. These findings were sustained even when the effects of multiple factors including birth weight, chronic illness in the child, gender, ethnicity, maternal age and history of maternal drug use were controlled for. When these children were compared to low-income housed children it was found that homeless children had significantly lower weight-height percentiles, a trend that may be explained by the tendency of low-income housed children to lie within the ‘obese’ category; a trend which was not mirrored in the homeless group. Poor nutrition can lead on to a number of health problems including iron deficiency anaemia, with the prevalence having been reported as high as 50% (Wiecha et al 1991). This figure would show that anaemia is almost twice as prevalent amongst homeless children as housed comparison groups or the standard reference populations (The Committee on Community Health Services 1996). Another impact of poor diet is decay of the teeth. A study by DiMarco et al (2009) found 31% of their cohort over 3 years old had obvious dental cavities on examination. In the study more than half of the school-aged children were found to have oral caries, which will lead to cavities if not treated. This high prevalence could be due to hypocalcification of tooth enamel, which is common in low income populations, a high intake of sugary foods and being significantly less likely to have seen the dentist in the previous 12 months when compared with previously homeless or never homeless children (Menke and Wagner 1997).

Katie Mack

The effects of homelessness extend further than detriment to physical health, into poor mental health outcomes also. Several studies use the Child Behaviour Check List (CBCL) to determine whether a child needs further clinical intervention for challenging behaviour. In some studies homeless children are reported as more likely to display externalising behaviours, such as aggression, rule breaking and attention deficit. Menke (1998) found that homeless boys were significantly more likely to have externalising scores in the clinical range than a normative sample. Another sample found that children had normal levels of externalising behaviours but were more likely to have higher levels of internalising behaviours such as depression, anxiety and withdrawal (Buckner et al 1999). Other studies concluded that homeless children had a higher prevalence of both internalising and externalising behaviours (Cumella et al 1998, Masten et al 1993). Masten et al (1993) found the number of homeless children with CBCL total scores in the clinical range was 200% higher than the expected normative value. Yu (2008) found that homeless children showed 4 times the prevalence of disruptive behaviour disorders as compared to housed children. These behaviours could be due to the child reacting to the stresses of homelessness and any emotional distress that homelessness is causing their caregiver, which is hard to disguise. It is also conceivable that difficult characteristics of the child may have been present before the family became homeless, which could have increased demand on the parent and contributed to the family becoming homeless in itself (Haber and Toro 2004). Depression has been found to affect homeless children more frequently than housed children: In a study by Menke (1998) 13% of the children met the criteria for clinical depression, which is higher than the 1-9% expected in the normative population. Menke and Wagner (1997) also observed that the proportion of homeless and previously homeless children scoring in the clinical range for depression was significantly higher than the normative population. In another study by Bassuk et al (1986), based on the Children’s Depression Inventory (CDI) 54% of the children needed further psychiatric evaluation. Bebbington et al (2004) suggest that children who experience victimising experiences, which could include homelessness, may be at a higher risk of developing psychosis, a loss of contact with reality, in later life. With regard to coping with stressors, it has been shown that homeless children have different coping strategies than previously homeless and never homeless children, with significantly less homeless children identifying social support as a coping strategy. Of those who did say they used social support only 49% of homeless children said they could talk to their parents about their problems, compared to 100% of those never homeless (Menke 2000). Masten et al (1993) found that significantly fewer homeless children said they had a close friend. Interestingly Harpaz-Rotem et al (2006) found that children’s emotional problems were not significantly associated with the housing status of the mother, suggesting that homelessness is probably not the root cause of children’s emotional problems; more likely the issues that have contributed to the homelessness are also sources of emotional distress for the child. Not every study showed homelessness to be detrimental to children’s behaviour. Bassuk et al (1986) found that in their sample of homeless children there were less than average numbers of sleep problems, speech difficulties and fear of new things. Masten et al (1993) concluded that overall when comparing the behaviour of homeless children and housed low-income children there were few differences, suggesting an underlying continuum of risk for those in poverty, with homeless children being at the furthest end of that continuum. In conclusion, homeless children are at an increased risk of having negative physical and mental health outcomes compared to normative samples, and in many cases when compared to low income housed children. However this has been demonstrated to not always be the case and that homeless children lie at the farthest end of continuum of risk that exists for all children living in a context of poverty. Negative health outcomes include asthma, respiratory tract infections, urinary tract infections, iron deficiency anaemia and dental cavities. Significant delays in vaccination may contribute to this risk. Homeless children were more likely to be hospitalised due to serious injuries including burns and scalds and had more A&E visits than housed comparison groups. Whilst sizeable diversity exists, homelessness appears to increase the risk of exposure to negative life events, which can potentially affect neurodevelopment leading to developmental delays and increased levels of externalising and internalising behaviours such as aggression or depression. Some of the health problems facing homeless children may be avoided by good preventative healthcare, whereas many seem to be consequence not just to homelessness but to other negative risk factors

Katie Mack

associated with child poverty; meaning that in order to avoid many of the health problems which currently face homeless children attention should be focused on lifting these children and their families out of poverty. Article produced by Katie Mack, Cardiff University, School of Medicine References

Alperstein, G. Et al. 1988. Health problems of homeless children in New York City. American Journal of Public Health 78 (9) pp. 1232-1233.

Bass, J.L. et al. 1990. Pediatric problems in a suburban shelter for homeless families. Pediatrics 85 (1) pp. 33-37.

Bassuk, E.L. and Rosenberg, L. 1990. Psychological characteristics of homeless children and children with homes. Pediatrics 85 (3) pp 257-261.

Bassuk, E.L. et al.1986.Characteristics of sheltered homeless families. American Journal of Public Health 76 (9) pp. 1097-1101.

Bebbington, P.E. et al. 2004. Psychosis, victimisation and childhood disadvantage: Evidence from the second British National Survey of Psychiatric Morbidity. The British Journal of Psychiatry 185 pp. 220-226.

Buckner, J.C. Et al. 1999. Homelessness and its relation to the mental health and behaviour of low income school-age children. Developmental Psychology 35 (1) pp.246-257.

Coker, T.R. et al. 2009. Prevalence, characteristics, and associated health and health care of family homelessness among fifth-grade students. American Journal of Public Health 99 (8) pp. 1446-1452

Committee on Community Health Services. 1996. Health needs of homeless children and families. Pediatrics 98 pp.789-791

Cumella, S. Et al. 1998. The mental health of children in homeless families and their contact with health, education and social services. Health and Social Care in the Community 6 (5) pp. 331-342.

Cutuli, J.J. 2010. Asthma and behaviour in homeless 4 to 7-year olds. Pediatrics 125 (1) pp. 145-151. Cutuli, J.J.2010.Cortisol function among early school-aged homeless children.

Psychoneuroendocrinology 35 pp.833-845. DiMarco, M.A. et al. 2009.The pediatric nurse practitioner’s role in reducing oral health disparities in

homeless children. Journal of Pediatric Health Care pp.109-116. Fierman, A.H. et al. 1991. Growth delay in homeless children. Pediatrics 88 (5)pp. 918-925. Fournier, M.E. et al. 2009. A comparison of weight-related behaviours among high school students

who are homeless and non- homeless. Journal of School Health 79 (10) pp. 466-473. Frencher, S.K. et al. 2010. A comparative analysis of serious injury and illness among homeless and

housed low income residents of New York City. Journal of Trauma, Injury, Infection and Critical Care 69 (4) pp 191-199.

Garcia- Coll, C. Et al. 1998. The developmental status and adaptive behaviour of homeless and low-income housed infants and toddlers. American Journal of Public Health 88 (9) pp. 1371-1374.

Grant, R. et al. 2007. Asthma among homeless children in New York City: An update. American Journal of Public Health 97 (3) pp.448-450

Haber, M.G. and Toro, P.A. 2004. Homelessness among families, children and adolescents: An ecological- developmental perspective. Clinical Child and Family Psychology Review 7 (3) pp. 123-163.

Harpaz-Rotem, H. Et al. 2006. The mental health of children exposed to maternal mental illness and homelessness. Community Mental Health Journal 42 (5) PP. 437-448.

Kagan,R. 2004. Rebuilding attachments with traumatised children: Healing from losses, violence, abuse and neglect. The Haworth Maltreatment and Trauma Press.

Masten, A.S. et al. 1993. Children in homeless families: Risks to mental health and development. Journal of Consulting and Clinical Psychology 61 (2) pp. 335-343.

Menke, E.M. 1998. The mental health of homeless school-aged children. Journal of Child and Adolescent Psychiatric Nursing 11 (3) pp. 87-98.

Katie Mack

Menke, E.M. 2000. Comparison of the stressors and coping behaviours of homeless, previously homeless and never homeless poor children. Issues in Mental Health Nursing 21. Pp. 691-710.

Menke, E. M. And Wagner, J.D. 1997. A comparative study of homeless, previously homeless and never homeless school-aged children’s health. Issues in Comprehensive Pediatric Nursing 20 pp.153-173.

McEwen, B.S. 1998. Seminars in Medicine of the Beth Israel Deaconess Medical Center: Protective and Damaging Effects of Stress Mediators. The New England Journal of Medicine 338 (3) pp. 171-179.

Parks, R. et al. 2007. A systematic review of cognition in homeless children and adolescents. Journal of the Royal Society of Medicine 100 pp.46-50

Raoult, D. Et al. 2001. Infections in the homeless. The Lancet Infectious Diseases 1 pp.77-84. Richman, S. Et al. 1991. Use of acute hospital services by homeless children. Public Health 105

pp.297-302 Schultz-Krohn, W. and Richardson, P.K. 2002. Visual motor skills in homeless children. Occupational

Therapy in Healthcare 16 (4) pp.15-28. The National Archives. 1996. Housing Act 1996 [Online] Available at:

http://www.legislation.gov.uk/ukpga/1996/52/contents [Accessed 10th June 2011]. United Nations. 1990. Convention on the Rights of the Child. Office of the United Nations High

Commissioner for Human Rights. Victor, C.R. et al. 1989. Use of hospital services by homeless families in an inner London health

district. British Medical Journal 299 pp. 725-727. Weinreb, L. Et al. 1998. Determinants of health and service use patterns in homeless and low income

housed children. Pediatrics 102 (3) pp. 554-562. Welsh Assembly Government. 2004. Children and Young People: Rights to Action. Welsh Assembly

Government. Statswales. 2011. Acceptances by Priority Need [Online] Available at:

http://www.statswales.wales.gov.uk/ TableViewer/tableView.aspx? ReportId=30652 [Accessed 23rd June 2011].

Webb, E. et al. 2001. The health of children in refuges for women victims of domestic violence: cross sectional descriptive survey. British Medical Journal 323 (7306) pp. 210-213.

Wiecha, J.L. et al. 1991. Nutrition and health services needs among the homeless. Public Health Reports 106 (4) pp.364- 374.

Yu, M. 2008. A comparison study of psychiatric and behaviour disorders and cognitive ability among homeless and housed children. Community Mental Health Journal 44 (1) pp.1-10.

Ziesemer, C. Et al. 1994. Homeless children: Are they different from other low-income children? Social Work 39 (6) pp. 658-668.