Homeless Children: What Every Health Care Provider Should Know

1. Homeless Children:What Every Health Care Provider Should Know Catherine Karr, MD Joining Hands. Healing Lives. Health Care for the Homeless Clinicians’ Network

2. Acknowledgements • Prepared in collaboration with the Health Care for the Homeless Clinicians Network - Pediatric Work Group • Work space provided by the Harborview Injury and Prevention Research Center

3. Did you know? • The number of homeless families with children is increasing • The number of unaccompanied homeless adolescents is increasing • Homelessness is an important risk factor for a number of health issues

4. If you care for children…. You are likely to care for children who are homeless or at risk of becoming homeless

5. Contents • Recognizing homelessness • Understanding the specific health problems of homeless children Infectious disease, injury, lead, mental health & behavior problems, nutrition and growth, anemia, dental health, immunizations, asthma, vision, child abuse • Modifying health care plans and prevention strategies • Finding resources for your homeless patients and their families

6. This presentationis designed as a primer. The goals are to help you: • Recognize homelessness and the risks of homelessness in families with children • Understand the specific health problems of homeless children • Modify health care plans and prevention strategies appropriately • Know how to find resources for your homeless patients and their families

7. Recognizing homelessness and the risks of becoming homeless in families with children

8. A legal definition • Stewart B. McKinney Act, 42 U.S.C. § 11301, et seq. (1994) a person who "lacks a fixed, regular, and adequate night-time residence and ... has a primary night time residency that is: (A) a supervised publicly or privately operated shelter designed to provide temporary living accommodations... (B) an institution that provides a temporary residence for individuals intended to be institutionalized, or (C) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings." 42 U.S.C. § 11302(a) The term "'homeless individual' does not include any individual imprisoned or otherwise detained pursuant to an Act of Congress or a state law." 42 U.S.C. § 11302.

9. An operational definitionHomelessness includes: • Camping with no permanent home to return to • Doubling-up temporarily with another family • Having no permanent place to return to after hospitalization • Living out of a car • Living in an emergency or transitional shelter

10. Who is homeless? U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: a 27-city survey. December 2001.

11. What about homeless children? • 41% are under age 5 1 • 85% are in families headed by single mothers 2 1. The Institute for Children and Poverty. Homeless in America: A Children’s Story. Part One. New York. 1999. 2. The Better Homes Fund. Homeless Children: America’s New Outcasts. 1999.

12. How many childrenare homeless in the United States? Modified from Bassuk EL Homeless Families. Scientific American 265:66-74 (1991).

13. Recent estimates suggest that 2% of American children are homeless in the course of one year. Urban Institute. America’s Homeless II: Population & Services. February 2000. (www.urban.org/presentations/AmericasHomelessII/index/htm)

14. What are the trends? • Families with children are among the fastest growing segment of people experiencing homelessness

15. What are the trends? Nationwide, city officials predict: • Requests for emergency shelter by homeless families will increase (Request for shelter by homeless families 2000 - 01 -  22%) • The nation’s weak economy will mean that the number of homeless people will increase U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: a 27-city survey. December 2001.

16. How can I identifyfamilies & children at risk? • Know the important risk factors for homelessness • Know how to ask sensitively about homelessness—homelessness carries a stigma

17. An overview of riskand protective factors that influence family homelessness Public Sector Assistance for Low-Income Families Background Factors Childhood/Distal Risk Factors Proximal Risk Factors Precipitating Risk or Protective Factors Gender Parental Socioeconomic Status Race/Ethnicity 1. Work History 2. Mental Health Status 3. Chronic Health Conditions 4. Educational Attainment 5. Victimization 6. Drug & Alcohol Use 1. Monetary Resources 2. Social Resources 3. Non-cash Benefits 4. Current Health Status 5. Current Substance Use 6. Primary Tenancy 7. Pregnancy 8. Dependent Children 9. Partner Violence Events & conditionsin childhood Homelessness Housing & Job Market Conditions Bassuk EL et al. Homelessness in female-headed families: childhood and adult risk and protective factors. AJPH 87:242-248 (1997).

18. Causes of homelessness: • Lack of affordable housing • Low paying jobs • Substance abuse and lack of needed services • Mental illness and lack of needed services • Domestic violence • Unemployment • Poverty • Prison release • Change/cuts in public assistance U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: a 27-city survey. December 2001.

19. Lack of affordable housing: • The gap between the number of affordable housing units and the number of people who need them is the largest on record — 5.4 million units National Coalition for the Homeless. NCH Fact sheet #1. Why Are People Homeless? June 1999.

20. Domestic Violence:One of the most common reasons for women and their children becoming homeless (p <0.01) (p <0.01) (not stat. sign.) 1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-income Housed Children. Pediatrics 102: 554-562 (1998). 3. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

21. Mental Illness:An important risk factor for homelessness (p <0.01) (not stat. sign.) (p <0.001) 1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 2. Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization. AJPH 82:1547-1550 (1992).

22. Mental Illness:An under-treated problem (p<0.001) Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization. AJPH 82:1547-1550 (1992).

23. Alcohol and drug abuseare associated with homelessness (p<0.05) (p<0.001) (p<0.001) 1. Coll CG et al. The Developmental Status and Adaptive Behavior of Homeless and Low-Income Housed Infants and Toddlers. AJPH 88:1371-1374 (1998). 2. Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization. AJPH 82:1547-1550 (1992). 3. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

24. Substance abuseplays an important role in single parent families (p<0.05) (p<0.05) (not stat. sign.) (not stat. sign.) Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).

25. Homelessnessis a dynamic state • Children are homeless on average 10 months at a time • 25% of homeless children are homeless more than once U.S. Department of Health & Human Services. Bureau of Primary Health Care. No Place to Call Home. April 2001.

26. Understandingthe specific health problems of homeless children

27. How do the health issuesof homeless children differ from housed children? • Data are limited* but suggest an overall increased morbidity • The specific areas of concern and increased morbidity reflect “poverty medicine” in the extreme *most studies are descriptive with small, non-representative samples and often without an appropriate comparison group

28. Overall Health

29. Homeless parents ratetheir children’s health as fair or poor more often (not stat. sign.) (*) (p<0.05) (*) 1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-income Housed Children. Pediatrics 102: 554-562 (1998). 3. Hu DJ et al. Health Care Needs for Children of the Recently Homeless. Journal of Community Health 14:10-7 (1989). 4. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988). 5. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991) 6. Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues in Comprehensive Pediatric Nursing 20: 153-173 (1997). * No statistical comparison reported

30. Hospitalizationis common for homeless children 1. p<0.05 2. No statistical comparison reported

31. Homeless childrenare more likely to be seen in an ED Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

32. Homeless childrenoften have multiple health problems Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001).

33. Clinic visits by homeless childrenunderscore increased acute problems Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

34. Infectious Disease

35. Infectious Disease • Homeless families often live in crowded quarters, which increase the risk of the common infectious diseases of childhood such as upper respiratory infections, ear infections, and diarrhea

36. Infectious Disease (*) (p<0.001) 1. Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992) 2. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). * No statistically significant difference between homeless and housed, no statistical comparison with general population reported.

37. Infectious Disease:Acute Otitis Media (*) The Children’s Health Fund. Still in Crisis: The health status of New York City’s homeless children. 1999. The Children’s Health Fund. The Crisis Continues: The health status of New York City’s homeless children. 2000. * No statistical comparison reported.

38. Infectious Disease:Diarrhea (*) Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). *No statistically significant difference between homeless and housed, no statistical comparison with general population reported.

39. Infectious Disease:Lice & scabies (*) (*) (*) 1. Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992). 2. Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991). 3. Page AJ et al. Homeless Families and their Children’s Health Problems: a Utah Urban Experience. Western Journal of Medicine 158:30-35 (1993). * No statistical comparison reported.

40. Injury

41. Injury • Homeless children live in less structured and less safe environments that may place them at risk of injury

42. Injury (not stat. sign.) (p<0.05) 1. Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998). 3. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

43. Lead

44. Lead • Elevated blood lead levels are associated with poverty • This is related to increased exposure to dust and dilapidated housing • There may also be increased absorption of lead in settings of poor nutrition • Iron and calcium deficiencies increase lead absorption

45. Lead toxicity 1. Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988). 2. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). 3. Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical Pediatrics 32:151-155 (1993). 4. U.S. Department of Health & Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2010: Understanding and Improving Health.

46. Lead screening is inadequate Weinreb L et al. Determinants of Health and Service Use Patternsin Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

47. Mental Health& Behavior Problems

48. Mental Health& Behavior Problems • Homeless children are more likely to come from backgrounds of domestic violence, mental illness, and substance abuse • These and other stresses associated with homelessness and poverty impact psychosocial well-being

49. Mental Health:A chart review of comprehensive care visits at a school-based clinic (p<0.05) Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal Pediatric Health Care 15:244-250 (2001).

50. Depression:A summary of studies reporting performance on the Children’s Depression Inventory - School-Aged Children Percent exceeding the cut-off suggesting further psychiatric evaluation (not stat. sign.) (not stat. sign.) 1. Zima BT et al. Emotional and Behavioral Problems and Severe Academic Delays among Sheltered Homeless Children in Los Angeles County. AJPH 84:260-264 (1994). 2. Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues of Comprehensive Pediatric Nursing 20: 153-173 (1997). 3. Menke EM. The Mental Health of Homeless School-age Children. JCAPN 11:87-98 (1998). 4. Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990).