Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness

HOMELESS FAMILIES RESEARCH BRIEF

OPRE Report No. 2018-61

August 2018

Marybeth Shinn, Daniel Gubits, and Lauren Dunton

1Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness

About the Family Options StudyThis research brief takes advantage of data collected for the Family Options Study, sponsored by the U.S. Department of Housing and Ur-ban Development. The study involves 2,282 homeless families with children who entered shelter between late 2010 and early 2012 in one of twelve communities across the country chosen based on will-ingness to participate and ability to provide a sufficient sample size and range of interventions: Alameda County, CA; Atlanta, GA; Balti-more, MD; Boston, MA; Bridgeport and New Haven, CT; Denver, CO; Honolulu, HI; Kansas City, MO; Louisville, KY; Minneapolis, MN; Phoenix, AZ; and Salt Lake City, UT. At the time they were recruited to participate in the study, each family had spent at least a week in an emergency shelter. The Family Options Study’s main purpose is to determine whether the offer of a particular type of housing pro-gram—a short-term rent subsidy, a long-term rent subsidy, or a stay in a facility-based transitional program with intensive services—helps a homeless family achieve housing stability and other positive outcomes for family well-being. To provide the strongest possible evidence of the effects of the housing and services interventions, the study uses an experimental research design with random assignment of families to one of the types of housing programs or to a control group of “usual care” families that were left to find their own way out of shelter. For more information, see Gubits et al. (2015), Gubits et al. (2016), and Gubits et al. (2018).

The study collected data from the families at the time they were recruited in emergency shelters, revealing that these are very poor families with significant levels of housing instability, weak work histories, and disabilities affecting both parents and children. The median age of the adults who responded to the survey was 29. Most had either one or two children with them in shelter. Seventy percent included only one adult, almost always the mother.

While the Family Options Study sample is not nationally representa-tive, it has broad geographic coverage; and study families are similar in age and gender of parents, number and ages of children, and race and ethnicity to nationally representative samples of sheltered homeless families. Therefore, it is a good sample for studying the experience of families that have an episode of homelessness.

The study followed the families over the next 37 months and surveyed them again 20 and 37 months after random assignment, collecting a rich set of information about changes to the family’s composition, sources of income, use of benefit programs, and further episodes of homelessness. The 20- and 37-month surveys also mea-sured indicators of well-being such as the health and mental health of adults and children.

This is the ninth in a series of research briefs commissioned by the Department of Health and Human Services (HHS) that draws on the Family Options Study to inform HHS and HHS grantees as they carry out their special responsibilities for preventing and ending the homelessness of families, children, and youth. Topics of briefs already published include connections of homeless families to social service programs, the well-being of young children and adolescents following an episode of sheltered homelessness, and family transi-tions during and after a stay in shelter.

The analysis conducted for this brief does not use the experimental design of the Family Options Study. Instead, it explores the behavioral health of mothers and fathers in families during and after a stay in emergency shelter, regardless of the intervention to which their families were randomly assigned. The analysis includes 1,866 mothers and 154 fathers who responded to either the 20-month survey or the 37-month survey. For families with two adults, the analysis includes information only on the mother’s behavioral health problems. The study interviewed the mother by preference in the baseline and both follow-up surveys because the study included parent reports on children, and children are more likely to stay with mothers if parents become separated.

Highlights:• Parents in homeless shelters reported that they had

high levels of behavioral health problems, including psychological distress, alcohol dependence, drug abuse, and symptoms of post-traumatic stress disorder (PTSD).

• All of these problems diminished over the next 37 months, with the exception of PTSD symptoms, which were unchanged.

• Family characteristics and experiences prior to entering shelters were associated with both initial levels of behavioral health problems and changes over time, with parents with the greatest levels of distress at the time they were in emergency shelters experiencing the largest improvements over time.

• Parents who had been in foster care as children or had experienced intimate partner violence as adults had greater psychological distress at the time of shelter entry than parents without those characteristics.

• Over the next 37 months, the behavioral health of parents who had attained housing stability improved more than the behavioral health of parents who had continued experiences of homelessness or doubling up.

2 Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness

IntroductionStudies of behavioral health among parents of families experiencing homelessness typically interview mothers at the time of the homeless episode and find that homeless mothers exhibit elevated levels of psychological distress, post-traumatic stress disorder (PTSD), and substance abuse problems compared to all mothers of minor children (Bassuk, Buckner, Perloff, & Bassuk, 1998; Chambers et al., 2014; Schuster, Park, & Frisman, 2011; Weinreb, Buckner, Williams, & Nicholson, 2006; Zima, Wells, Benjamin, & Duan, 1996). However, studies that compare mothers experiencing homelessness just with other deeply poor mothers are less consistent. Some find strong evidence that mothers experiencing homelessness have higher levels of behavioral health problems than deeply poor mothers who are housed (Banyard & Graham-Bermann, 1998; Park, Metraux, & Culhane 2010), while other studies find differences that are more modest or not significant (Bassuk et al., 1998; Bogard, McConnell, Gerstel, & Schwartz, 1999; Shinn et al., 1998).1 Little information is available on fathers who are homeless with their children.

A few studies have followed the behavioral health of parents after a period of homelessness and suggest that problems improve. For example, one study concluded that adults in families may go to shelters during a behavioral health crisis, with shelter stays replacing hospital stays (Culhane, Park, & Metraux, 2011). Similarly, a study of families in which the mother had a diagnosable mental illness showed that mothers’ mental health improved as families returned to housing after a shelter stay (Samuels, Fowler, Ault-Brutus, Tang, & Marcal, 2015). However, these studies were confined to small samples or a single city, making it difficult to extrapolate to larger groups of parents experiencing homelessness.

This brief builds on previous research by describing the behavioral health problems reported by 2,020 parents—including some fathers—at the outset of a shelter stay with their children and the association of these problems with parents’ prior experiences. For the purposes of this brief, behavioral health includes psychological distress, alcohol dependence, drug abuse, and symptoms of post-traumatic stress disorder (PTSD).The brief then looks at changes in the parents’ behavioral health problems over the next 37 months and how those changes were related to housing stability following the episode of homelessness.

Parents have high levels of behavioral health problems while in emergency sheltersAfter spending a week in an emergency shelter, 22 percent of mothers and 13 percent of fathers2,3 in the study were experiencing serious psychological distress compared to 9 percent of adults with incomes below the federal poverty level and with 4 percent of mothers and 3 percent of fathers overall in the U.S. across all income levels.4 In addition, 11 percent of the parents in shelter reported current alcohol dependence, 13 percent had current drug abuse, and 23 percent reported PTSD symptoms.5

Parents who had been in foster care as children and who had experienced intimate partner violence at any time in adulthood had higher levels of psychological distress when they entered emergency shelters.6

Parents’ behavioral health improves as they exit homelessness Behavioral health problems for both mothers and fathers decreased steadily over time, as shown in Exhibit 1.7 Among mothers, the percentage showing evidence of drug abuse decreased by more than 75 percent between the shelter stay and 37 months later, from 12 percent to 3 percent.8 The proportion of mothers with serious psychological distress dropped by almost a quarter over the 37-month period, from 22 percent to 17 percent,9 and the proportion of mothers showing evidence of alcohol dependence declined from 11 percent to 9 percent. The slight decline in the percentage of mothers who reported symptoms of PTSD was not statistically significant.

1 Behavioral health patterns of adults in homeless families are very different from those of single adults who experience homelessness. Mothers in families who experience homelessness have lower levels of substance abuse and psychotic symptoms but more depressive symptoms than single adults who experience homelessness (Rog, Holupka, & Patton, 2007). Mothers in homeless families have less substance abuse than childless women who are homeless (Chambers et al., 2014).

2 For families with two adults, we have information only on the mother’s behavioral health problems. We interviewed the mother by preference in the baseline and both follow-up surveys.

3 We use mother and father to refer to the female and male caregivers in the family, who were most often the biological parents of children.4 These benchmarks are from the National Health Interview Survey (Weissman, Pratt, Miller, & Parker, 2015). Psychological distress is a score of 13 or higher

on the Kessler 6 (K6) scale, (Kessler et al., 2003). 5 Alcohol dependence is measured with the Rapid Alcohol Problems Screen (RAPS-4) (Cherpitel, 2000). Drug abuse is measured with 6 items from the Drug

Abuse Screening Test (DAST-10) (Skinner, 1982). The Posttraumatic Stress Diagnostic Scale (PDS) measures the presence of PTSD symptoms. All measures are self-reports.

6 All measures here are self-reports. There is little reason to expect that any tendency for respondents to minimize reports of their behavioral health challenges would increase over time. At the outset, families were seeking admission to housing and service programs, some of which required sobriety. The likelihood of parents’ underreporting problems would most likely be highest at the start of the study.

7 Exhibit 1 shows the percentage of parents who met criteria for serious psychological distress, that is, scoring 13 or higher on the Kessler 6 scale. When examining associations of parental characteristics with distress and with changes in distress later in this brief, we use continuous scores.

8 The proportion of mothers showing evidence of drug abuse decreased from 12.4 percent to 2.6 percent, resulting in an actual reduction of 79 percent.9 The proportion of mothers with serious psychological distress decreased from 22.0 percent to 16.8 percent over three years, resulting in an actual reduction of

24 percent.

3Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness

Sample sizes: Mothers N=1,866. Fathers N=154.Notes: The exhibit shows fitted values. Serious Psychological Distress is measured with the Kessler-6 scale with value of 13 or greater. Posttraumatic stress disorder (PTSD) symptoms is measured using Posttraumatic Stress Diagnostic Scale (PDS) assessment; alcohol dependence is measured with Rapid Alcohol Problems Screen; drug abuse is measured with 6 items from the Drug Abuse Screening test (DAST-10).For mothers, changes over time for serious psychological distress, alcohol dependence, and drug abuse are statistically different from 0 at the .01 level. Change over time for PTSD symptoms is not statistically different from 0 at the .05 level. For fathers, the smaller sample size provides lower statistical power: only the change for drug abuse is statistically different from 0 at the .01 level. The other three changes for fathers are not statistically different from 0 at the .05 level.The baseline prevalence of serious psychological distress for fathers is statistically significantly lower than for mothers (at the .01 level). Baseline prevalence of PTSD symptoms, alcohol dependence, and drug abuse do not statistically significantly differ between fathers and mothers (at the .05 level). Slopes do not statistically significantly differ between fathers and mothers for any of the four measures (at the .05 level).

EXHIBIT 1: CHANGES IN BEHAVIORAL HEALTH PROBLEMS FOR MOTHERS AND FATHERS DURING THE 37 MONTHS FOLLOWING A SHELTER STAY

Fathers showed significantly lower levels of psychological distress than did mothers at the time of the shelter stay. This finding is consistent with the greater prevalence of psychological distress (Pratt, Dey, & Cohen, 2007) experienced by women compared to men in the general population. Fathers’ levels of alcohol dependence and drug abuse were higher than those of mothers, although the differences between mothers and fathers were not statistically significant. Changes in behavioral health and substance abuse over time were similar for mothers and fathers. In the remainder of this brief we describe these changes for all parents rather than for fathers and mothers separately.

0

5

10

15

20

25

Duringshelter

stay

20 months

later

37 months

later

Per

cent

of

Mo

ther

s

0

5

10

15

20

25

Duringshelter

stay

20 months

later

37 months

later

Per

cent

of

Fath

ers

PTSD symptoms Serious Psychological Distress

Alcohol dependence Drug abuse

4 Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness

Parents reporting behavioral health problems while in shelter or a history of intimate partner violence had larger reductions in psychological distress Parents who reported a behavioral health problem in response to an open-ended question about health problems at the start of a shelter stay had higher levels of psychological distress both during the shelter stay and over the next 37 months.10 However, they also showed greater reductions in psychological distress over time (Exhibit 2).

Similarly, the 49 percent of parents who had experienced intimate partner violence at some point as an adult saw greater reductions in their levels of psychological distress over the 37-month period following their initial shelter stay than parents who had not had such an experience. Psychological distress levels remained higher at 20 and 37 months following the shelter stay for parents who had experienced intimate partner violence, but these parents had sharper declines in levels of distress than other parents.

Housing stability was associated with improvements in behavioral health problems over time, but substance use problems may complicate efforts to attain stabilityFamilies who reported stable housing 37 months after the initial shelter stay showed dramatic reductions in psychological distress, while those who returned to homelessness or doubled up with other households because they could not find or afford a place of their own continued to have high levels of psychological distress (see Exhibit 4). Interestingly, psychological distress while the parent was in shelter was not related to whether the family had stable housing 37 months later. Although PTSD was weakly correlated with housing stability, PTSD symptoms did not improve significantly over time as families stabilized.11

10 When reporting on their health, parents were asked an open-ended question on their medical conditions “Do you have any of the following medical conditions?”. Open-ended responses such as ADD/ADHD, Depression, and Bipolar Disorder were post-coded with a behavioral health code. Of the 2,020 parents included in the analysis, 140 (7 percent) reported a behavioral health problem. The level of psychological distress is based on a continuous measure of parent scores on the Kessler 6 scale rather than whether the parent exceeded a cutoff for serious psychological distress.

11 The phi coefficients between PTSD and housing stability at 20 and 37 months after the shelter stay are .10 and .08, respectively.

EXHIBIT 2: CHANGE IN AVERAGE LEVEL OF PSYCHOLOGICAL DISTRESS FOR PARENTS WITH AND WITHOUT BEHAVIORAL

HEALTH PROBLEMS IN SHELTER

Sample sizes: Identified behavioral health problems N=140. No behavioral health problems N=1,880.Notes: The exhibit shows fitted values of actual distress scores on the K6 inventory rather than whether the respondent exceeded the cutoff defining serious psychological distress. The measure of behavioral health problems at shelter entry presented in the exhibit is based on the coded responses to an open-ended question at shelter entry asking about medical conditions. N = 2,020, the number of family heads who responded to either the 20 month survey or 37 month survey. The exhibit combines mothers and fathers, but is dominated by the much larger number of mothers. The difference in slopes between those with and without behavioral problems at shelter entry is statistically significant at the .01 level.

EXHIBIT 3: CHANGE IN PSYCHOLOGICAL DISTRESS FOR PARENTS WITH AND WITHOUT EXPERIENCE OF

INTIMATE PARTNER VIOLENCE SINCE AGE 18

Sample sizes: Did not experience housing instability three years after shelter stay, N=1,198. Experienced housing instability three years after shelter stay, N=584.Notes: Alcohol dependence and drug abuse were measured for a six-month reference period at baseline and at the 37-month survey. Housing instability is measured as either (1) emergency shelter stay in the 12 months before 37-month survey month or (2) self-reported homelessness or doubling up in the 6 months before the 37-month survey. The correlation between alcohol dependence/drug abuse and housing instability at 37 months (controlling for baseline alcohol dependence/drug abuse) is statistically significant at the .01 level.

During shelter stay

Identified behavioral health problem at shelter entry

20 months later 37 months later

Psy

cho

log

ical

Dis

tres

s (K

6 s

cale

)

0

2

4

6

8

10

12

14

No behavioral health problem at shelter entry

13.2

11.6

10

7.67.1

6.5

During shelter stay

Did not experience intimate partner violence since age 18

20 months later 37 months later

Psy

cho

log

ical

Dis

tres

s (K

6 s

cale

)

0

2

4

6

8

10

12

14

Experienced intimate partner violence since age 18

9.4 8.57.7

6.76.3 5.9

5Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness

The relationship between substance abuse, including alcohol dependence or drug use, and housing stability is more complex.

As discussed earlier, drug use or alcohol dependence decreased overall for parents 37 months after a stay in emergency shelter. However, as Exhibit 5 shows, those who experienced continued housing instability 37 months after an initial shelter stay were more likely to have reported drug or alcohol problems both during that shelter stay and 37 months later than families who were more stably housed at that subsequent point in time.12 While we cannot definitively conclude that there is a causal relationship, it is at least plausible that substance problems and housing instability might influence each other.

ConclusionMost studies of families experiencing homelessness look at families while they are in emergency shelter, during what is a very stressful period in their lives. Psychological distress is also associated with other adverse experiences such as foster care and intimate partner violence that are all too common in the lives of families who experience homelessness. Whether because families regain their equilibrium over time, their housing circumstances improve, or they receive behavioral health services, many parents in homeless families show considerable improvements in mental health and substance use challenges over time. Improvements in psychological distress are greater for families who attain housing stability than for those who do not.

Homelessness for most families is a temporary state (Culhane, Metraux, Park, Schretzman, & Valente, 2007; Shinn, 1997). The findings from this analysis suggest that, similarly, some of the behavioral health problems that families experience during the crisis of homelessness may also be temporary, and helping families to attain stable housing may be an important mental health intervention. Findings here are consistent with previous research showing that housing stability and behavioral health outcomes can be related. The experimental analysis of these families who were offered a long-term rental subsidy has also shown that such a subsidy reduces these behavioral health problems (Gubits et al., 2015, 2016, 2018), and entering housing from homelessness has been associated with a reduction in depressive symptoms over time (Wong & Piliavin, 2001).

There is little evidence in this study that psychological distress causes housing problems. Families who started with higher levels of distress were no less likely to become stably housed over time. The picture for substance abuse is more complicated. Substance abuse decreased for all families, and was halved for those who attained housing stability, but families with substance abuse when they entered shelters were also less likely to be stably housed 37 months later.

The study has important implications for policy and practice. Programs that provide stable housing to families experiencing homelessness will have the additional advantage of likely reducing levels of psychological distress. Programs that seek to reduce substance abuse for families who experience homelessness may help families to attain or maintain housing stability.12 The association between baseline substance problems and housing instability at 37 months after shelter stay is statistically significant at the .01 level.

Sample sizes: Did not experience housing instability in period prior to 37-month survey N=1,198. Experiencing housing instability in period prior to 37-month survey N=584.Notes: Housing instability is measured as either (1) emergency shelter stay in the 12 months before the 37-month survey or (2) self-reported homelessness or doubling up in the 6 months before the 37-month survey. The correlation between serious psychological distress (scores of 13 or higher on the Kessler 6 scale) and housing instability at 37 months, controlling for baseline levels of psychological distress) is statistically significant at the .001 level.

Did not experience housing instability three years after shelter stay

Experienced housing instability three years

after shelter stay

0

5

10

15

20

25

30

Percent of family heads that experienced serious psychological distress

37 months laterAt shelter entry

21.5 22.1

14.7

20.3

EXHIBIT 4: SEVERE PSYCHOLOGICAL DISTRESS, BY CONTINUED HOUSING INSTABILITY

Did not experience housing instability three years after shelter stay

Experienced housing instability three years

after shelter stay

0

5

10

15

20

25

30

18.3

8.6

17.2

37 months laterAt shelter entry

25.5

Percent of family heads that experienced alcohol dependence or drug abuse

EXHIBIT 5: FAMILIES EXPERIENCING ALCOHOL DEPENDENCE OR DRUG ABUSE,

BY CONTINUED HOUSING INSTABILITY

Sample sizes: Did not experience housing instability three years after shelter stay, N=1,198. Experienced housing instability three years after shelter stay, N=584.Notes: Alcohol dependence and drug abuse were measured for a six-month reference period at baseline and at the 37-month survey. Housing instability is measured as either (1) emergency shelter stay in the 12 months before 37-month survey month or (2) self-reported homelessness or doubling up in the 6 months before the 37-month survey. The correlation between alcohol dependence/drug abuse and housing instability at 37 months (controlling for baseline alcohol dependence/drug abuse) is statistically significant at the .01 level.

6 Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness

However, housing stability does not guarantee decreases in psychological distress or substance problems for all families, and decreases in PTSD over time were not statistically significant. PTSD, by definition, is a reaction to a previous trauma suggesting support beyond housing assistance is needed to create substantial improvements. Additional research on the relationship between behavioral health and homelessness among families could help service providers better design and tailor interventions.

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