Homeless Children: What Every Health Care Provider Should Know Catherine Karr, MD Joining Hands....

Homeless Children:Homeless Children:What Every Health Care Provider Should KnowWhat Every Health Care Provider Should Know

Catherine Karr, MDCatherine Karr, MD

Joining Hands. Healing Lives.Joining Hands. Healing Lives.Health Care for the Homeless Clinicians’ Health Care for the Homeless Clinicians’ NetworkNetwork

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

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

If you care for children….

You are likely to care for children who are homeless or at risk of becoming homeless

Contents

Recognizing homelessnessUnderstanding the specific health problems of homeless childrenInfectious disease, injury, lead, mental health & behavior problems, nutrition and growth, anemia, dental health, immunizations, asthma, vision, child abuse

Modifying health care plans and prevention strategiesFinding resources for your homeless patients and their families

This presentation is designed as a primer.

The goals are to help you:

Recognize homelessness and the risks of homelessness in families with childrenUnderstand the specific health problems of homeless childrenModify health care plans and prevention strategies appropriatelyKnow how to find resources for your homeless patients and their families

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

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.

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 hospitalizationLiving out of a carLiving in an emergency or transitional shelter

Who is homeless?

40%

4%14%

40%

2%Families with ChildrenUnaccompanied minorsSingle WomenSingle MenNot specified

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

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.

How many childrenare homeless in the United States?

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

Estimates of Annual Number ofHomeless Children

U.S. Department ofEducation (1989)

General AccountingOffice (1989)

National Coalition for theHomeless (1990)

Urban Institute (2000)

National Coalition for theHomeless (2001)

Modified from Bassuk EL Homeless Families. Scientific American 265:66-74 (1991).

Recent estimates suggestthat 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)

What are the trends?

Families with children are among the fastest growing segment of people experiencing homelessness

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


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

An overview of riskand protective factors that influence family homelessness

Bassuk EL et al. Homelessness in female-headed families: childhood and adult risk and protective factors. AJPH 87:242-248 (1997).

Public Sector Assistance forLow-Income Families

Precipitating Risk orProtective Factors

Childhood/DistalRisk Factors

BackgroundFactors

Proximal Risk Factors

Gender

Parental Socioeconomic Status

Race/Ethnicity

Events & conditionsin childhood

1. Monetary Resources2. Social Resources3. Non-cash Benefits4. Current Health Status5. Current Substance Use6. Primary Tenancy7. Pregnancy8. Dependent Children9. Partner Violence

Housing & Job Market Conditions

Homelessness

1. Work History2. Mental Health Status3. Chronic Health Conditions4. Educational Attainment5. Victimization6. Drug & Alcohol Use

Causes of homelessness:

Lack of affordable housingLow paying jobsSubstance abuse and lack of needed servicesMental illness and lack of needed servicesDomestic violenceUnemploymentPovertyPrison releaseChange/cuts in public assistance


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.

Domestic Violence: One of the most common reasons for women and their children becoming homeless

0%

20%

40%

60%

80%

100%

Single momsreporting ever

physical or sexualabuse by mate (1)

Moms in 2 parentfamilies reportingever physical orsexual abuse by

mate (1)

Moms reportingany intimate

violence duringlifetime (2)

Moms reportingbeing battered in

the previousmonth (3)

Homeless, sheltered

Housed, poor

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 HousedChildren. 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).

(p <0.01)

(p <0.01)

(not stat. sign.)

Mental Illness:An important risk factor for homelessness

0%2%4%6%8%

10%12%14%16%

Single moms reportinghistory of

hospitalization for amental healthproblems (1)

Moms in 2-parentfamilies reporting

history ofhospitalization for a

mental health problem(1)

Moms reportinghistory of

hospitalization for amental health problem

(2)

Homeless, sheltered

Housed, poor

(p <0.01)

(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, SubstanceAbuse, and Victimization. AJPH 82:1547-1550 (1992).

(not stat. sign.)

Mental Illness: An under-treated problem

0%

2%

4%

6%

8%

Moms reporting use of prescriptiondrugs for mental health problem

Moms reporting use oftherapist/counselor/mental health

clinic

Homeless, sheltered Housed, poor

(p<0.001)

Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, SubstanceAbuse, and Victimization. AJPH 82:1547-1550 (1992).

Alcohol and drug abuseare associated with homelessness

0%

10%

20%

30%

40%

50%

Substance abuse problems(1)

Substance abuse problems- past 6 mo. (2)

Use of detox center forsubstance abuse (2)

Drug use = "big part" oftheir present problems (3)

Homeless, sheltered mothers Housed, poor mothers

(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, SubstanceAbuse, 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).

Substance abuseplays an important role in single parent families

0%

10%

20%

30%

40%

50%

60%

Single momsreporting

drug/alcoholabuse of mate

Moms in 2 parentfamilies reporting

drug/alcoholabuse of mate

Single momsreporting drug or

alcohol abuse

Moms in 2 parentfamilies reporting

drug or alcoholabuse

Homeless, sheltered Housed, poor(p<0.05)

(p<0.05)

Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).

(not stat. sign.)

(not stat. sign.)

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.

Understanding the specific health problems of homeless children

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

Overall Health

Homeless parents ratetheir children’s health as fair or poor more often

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

1 2 3 4 5 6

Homeless, sheltered

Housed, poor

General population

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 HousedChildren. 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

(not stat. sign.)

(p<0.05)(*)

(*)

Hospitalizationis common for homeless children

Homeless Housed, poor

Hospitalization rate children < 18 years presenting to an ED 2

11.6/1000 7.5/1000 Alperstein et al. Am. J. Pub. Hlth. 78:1232-1233 (1988)

Hospitalized in the previous 12 months 1

11% 5% Weinreb et al. Pediatrics 102:554-562 (1998)

Hospitalized in the previous 12 months 2

12% Parker et al. AJDC 145:520-526 (1991)

Ever hospitalized 2 15% McNamee et al. Iss. Comp. Ped. Nrsg. 17:233-242 (1994)

Ever hospitalized 2 33% 57% Menke et al. Iss. Comp. Ped. Nrsg. 20:153-173 (1997)

1. p<0.05 2. No statistical comparison reported

Homeless childrenare more likely to be seen in an ED

Homeless, sheltered

Housed, poor

Mean ED visits in previous year

1.6 1.0 p<0.01

Percent with 2 ED visits in the last year

38% 20% p<0.001

Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

Homeless childrenoften have multiple health problems

Homeless children compared with their housed schoolmates

Odds Ratio (95% confidence interval)

Children with any health problems vs. none

2.5 (1.4-4.5)

Children with multiple health problems vs. one

6.1 (2.3-16.0)

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).

Clinic visits by homeless childrenunderscore increased acute problems Homeless Housed, poor Acute problem found during comprehensive care visit 1

8% 1% p<0.001

Mean number of clinic visits in the past year 2 5.6 3.8 p<0.001

1. 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).

Infectious Disease

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

Infectious Disease

0%

10%

20%

30%

40%

50%

60%

70%

80%

Clinic visits for communicabledisease (1)

URI symptoms in the last month(2)

Homeless

Housed, poor

General population

(p<0.001)

1. Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal ofPediatric 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.

(*)

Infectious Disease:Acute Otitis Media

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

AOM diagnosed during a clinic visit

Homeless childreninvolved in NYCchildren's health project(1999)

Subset of thesehomeless childrenundergoing behavioralevaluations (2000)

General population

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’shomeless children. 2000.* No statistical comparison reported.

(*)

Infectious Disease:Diarrhea

0%

5%

10%

15%

20%

25%

30%

35%

Diarrhea in the last month

Homeless, sheltered

Housed, poor

General population

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.

(*)

Infectious Disease:Lice & scabies

0%

2%

4%

6%

8%

10%

12%

14%

Lice (1) Scabies (1) Lice orscabies (2)

Lice (3)

Homeless, sheltered

General population

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.

(*)(*)

(*)

Injury

Injury

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

Injury

0%2%4%6%8%

10%12%14%16%18%20%

Proportion ofoutpatient visits

for injury (1)

Accidentsrequiring medicalcare in the past

year (2)

ED visit forinjury/fall in the

past year (3)

Burn in the lastyear causingscarring (3)

Homeless

Housed, poor

General population

(p<0.05)

(not stat. sign.)

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).

Lead

Lead

Elevated blood lead levels are associated with povertyThis is related to increased exposure to dust and dilapidated housingThere may also be increased absorption of lead in settings of poor nutritionIron and calcium deficiencies increase lead absorption

Lead toxicityHomeless Housed, poor Source

Blood lead level > 30mcg/dL

3.8% 1.7% Clinic record review 1

(no statisticalcomparison reported)

Lead poisoning diagnosisin past year

10% Survey results 2

Blood lead level 10-15 mcg/dL 10-15 mcg/dL Children with elevatederythrocyteprotoporphyrin (>35ug/dL) 3

Goal blood lead level 10 mcg/dL 10 mcg/dL National HealthyPeople 2010 4

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. ClinicalPediatrics 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.

Lead screening is inadequate

Homeless Housed, poor

Screened(9 mo. – 6 yr.)

67% 81%

Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

Mental Health& Behavior Problems

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

Mental Health: A chart review of comprehensive care visits at a school-based clinic

0%1%2%3%4%5%6%7%8%9%

Identification of Mental HealthProblems

Homeless students

Housed students

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).

(p<0.05)

Depression:A summary of studies reporting performance on the Children’s Depression Inventory - School-Aged Children

0%

20%

40%

60%

1 2 3 4

Homeless

Housed, poor

Estimated prevalence inschool- age generalpopulation

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).

Behavior Problems:Children’s performance on the Behavior Problems Index

Mean score

Homeless, sheltered 43

Housed, poor 40

p<0.05

Differences were primarily due to aggressive behaviors such as frequently stubborn, sullen or irritable, hitting other children or adults, frequent temper tantrums

There were similar ratings on withdrawal, delinquency, and immaturity dimensions


Behavior Problems: Reported performance on the Child Behavior Checklist - School-Aged Children

0%

5%

10%

15%

20%

25%

30%

35%

40%

1 2 3

HomelessHoused, poor

Percent exceeding the cut-off suggesting further psychiatric evaluation:(criteria T>60 for 1,2, T>65 for 3)

1. 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).2. Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990).3. Rescorla L et al. Ability, Achievement and Adjustment in Homeless Children. American Journal of Orthopsychology 61:210-220 (1991).

(not stat. sign.)(not stat. sign.)

(not stat. sign.)

Behavior Problems: Reported performance on the Child Behavior Checklist - Homeless School-aged Children

26% met criteria for clinical diagnosis (T>70)More problems in males.Compared to normative data:Homeless males had statistically significantly higher scores for total behavior and subcategories of externalizing, uncommunicative, and obsessive-compulsive behavior.

No statistically significant differences for homeless females.

9% met criteria for clinical diagnosis (T>70)Mean scores were comparable to population means.

Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

Menke EM. The Mental Health of Homeless School-Age Children. JCAPN 11:87-98 (1998).

Behavior Problems: Reported performance on the Child Behavior Checklist – Pre-School Children

Homeless, sheltered children compared with poor, housed childrenStatistically significant worse scores for total problems, externalizing and internalizing subgroup scoresTotal T score > 70 (clinical range)Homeless 21%Housed 5%

Homeless, sheltered children compared with normative dataNo statistically significant differences in scoresTotal T score > 70 (clinical range)Homeless 20%

Rescorla L et al. Ability, Achievement and Adjustment in Homeless Children. American Journal of Orthopsychology 61:210-220 (1991).


Behavior Problems: Reported performance on the Simmons Behavior Checklist - Pre-School Children

Homeless, sheltered children compared with housed, poor children

No statistically significant difference in mean score or specific factor scores

Development

Development

Psychosocial and environmental stresses undermine normal development

Developmental screening has identified more developmental lags in homeless pre-school children

Among school-age children, academic problems are common

Denver Developmental Screening Test Results

Reported prevalence of homeless children failing at least one section—a wide range: 5 percent,1 15 percent,2 54 percent3

Reported prevalence of homeless children failing at least two sections—9 percent 2

Most common area of delay reported is speech/language (prevalence reported = 4 percent,1 13 percent,2 42 percent3)

1.Page AJ et al. Homeless families and their children’s health problems: a Utah urban experience. Western Journal of Medicine 158: 30-35 (1993).2. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).3. Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990).

Denver Developmental Screening Test Results

0%

10%

20%

30%

40%

50%

60%

Failed 1 ormore sections

Speech Delay Gross MotorDelay

Fine MotorDelay

Personal/SocialDelay

Homeless, sheltered

Housed, poor

Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990).

(p<0.05)

(p<0.05)

(p<0.05)

(p<0.05)

(p<0.05)

Psychometric testingof pre-school children and toddlers

Homeless, sheltered pre-school children (age 3 - 5 years) performed more than one standard deviation below general population on tests of:

Visual-motor skills (Draw-A-Person)Verbal ability (Binet IV vocabulary)Receptive vocabulary (PPVT-R)Visual-motor skill (Beery VMI)

Homeless, sheltered toddlers (age 2) performed similarly to general population.


Psychometric testingof school-age children

Homeless, sheltered children (age 6 - 12) performed more than one standard deviation below general population on tests of:verbal ability (WISC-revised vocabulary)reading (WRAT-R)

Only 30% of the homeless children were reading at age level


Nutrition & Growth

Nutrition & Growth

Poverty has been associated with both obesity and malnutrition

Obesity reflects a diet containing excessive cheaper, carbohydrate rich foods

Malnutrition reflects caloric deficiency

Obesity and malnutrition

0%

5%

10%

15%

20%

25%

30%

35%

wt/ht > 95th percentile (1) wt/ht > 95th percentile(2) wt < 5th percentile (3)

Homeless

Housed, poor

1. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988).2. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).3. Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988).* No statistical comparison made.

(*)

Accessto nutritious food is problematic

0%

2%

4%

6%

8%

10%

12%

14%

Parents report eating at a fast foodrestaurant or convenience store at least 4

times per week

Homeless, sheltered

Housed, poor

(p<0.01)


Accessto adequate amounts of food is problematic

0%

5%

10%

15%

20%

25%

Parents endorse children arehungry and not enough food fairly

often to always

Parents endorse children arehungry and not enough to eat

because of lack of money for 4 ormore days in past month

Homeless, sheltered Housed, poor

(p<0.01) (p<0.01)


Evidence of stuntingin homeless children: chronic malnutrition decreases attained height

0

10

20

30

40

50

60

70

<5th 5th-24th

25th-49th

50th-74th

75th-95th

>95th

Homeless

Housed, poor

General Population(NCHS)

Fierman AH et al. Growth Delay in Homeless Children. Pediatrics 88:918-925 (1991).

Percentile Distribution of Height

Evidence of obesityin poor, housed children

0

10

20

30

40

50

60

<5th 5th-24th

25th-49th

50th-74th

75th-95th

>95th

Homeless

Housed, poor

General Population(NCHS)

Fierman AH et al. Growth Delay in Homeless Children. Pediatrics 88:918-925 (1991).

Percentile Distribution of Weight-Height

Anemia

Anemiais another well-known disease of poverty

0%

10%

20%

30%

40%

50%

60%

ErythrocyteProtoporphyrin Level

> 35 mcg/dL (1)

ErythrocyteProtoporphyrin Level

> 35 mcg/dL (2)

Hematocrit <33% (2) Anemia - criteria notspecified (3)

Homeless children

Housed, poor children

(p<0.05)

(not stat. sign.)

1. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).2. Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. ClinicalPediatrics 32:151-155 (1993).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).

Dental Health

Dental cariesand lack of dental care is common among the poor

36% of children have dental problems according to homeless families surveyed 1

28% of children have visible caries according to providers of health care for homeless children 2

10 times rate of poor dentition in homeless children compared with general population according to national homeless health care providers 3

1. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988).2. Page AJ et al. Homeless families and their children’s health problems: a Utah urban experience. Western Journal of Medicine 158: 30-35 (1993).3. Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991).

Access to Dental Care

0%5%

10%15%20%25%30%35%40%45%50%

Percent of school aged children who have notseen a dentist in the previous year

Homeless

Previouslyhomeless, poorNever homeless

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.

(*)

Immunization Delay

Immunization delayis common, particularly in young children

0%

10%

20%

30%

40%

50%

60%

70%

6 mo - 6 yr (1) < 6 yr (2) < 3 yr (3) < 5 yr (4)

Homeless

Housed, poor

General population

Percent of children lacking up-to-date immunizations(p<0.05)

(*)

1. Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical Pediatrics 32:151-155 (1993).2. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988).3. The Children’s Health Fund. Still in Crisis: The health status of New York City’s homeless children. 1999. 4. Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988).*No statistical comparison reported.

(*)

Immunization delayin school-aged children

0%

2%

4%

6%

8%

10%

12%

14%

16%

6-12 yr (1) 8-12 yr (2)

Homeless

Housed, poor

Percent of children lacking up-to-date immunizations

1. 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. 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

(not stat. sign.)

(*)

Asthma

Asthma ratesincrease with poverty

Dust mites, cockroaches, rodents, and indoor molds are common asthma triggers found in most shelter housingUpper respiratory infection is common in homeless children and is a well-identified asthma triggerThere is increasing evidence that psychosocial stress may also be an important asthma trigger

Asthma

0%

5%

10%

15%

20%

25%

30%

35%

40%

Asthmadiagnosis (1)

Asthmadiagnosis (2)

Asthmasymptoms in the

past month (3)

Asthmasymptoms in the

past month (4)

Hospitalized forasthma in thepast year (5)

Homeless

Housed, poor

General population

1. 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. The Children’s Health Fund. Still in Crisis: The health status of New York City’s homeless children. 1999.3. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).4. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).5. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).* No statistical comparison reported.

(p<0.05)(*)

(p<0.01)(not stat. sign.)

Vision

Problems with visionare common among homeless children

0%

5%

10%

15%

20%

25%

30%

1 2 3

Homeless

Housed

Percent with visual acuity deficits identified during screening

(p<0.01)

1. 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. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).3. Page AJ et al. Homeless families and their children’s health problems: a Utah urban experience. Western Journalof Medicine 158: 30-35 (1993).

Child Abuse

Child Abuse

It is well known that perpetrators of child abuse are often victims of abuse themselves

As such, it is not surprising that many homeless children are at risk of abuse

Families involvedin child abuse investigation

0%

5%

10%

15%

20%

25%

30%

35%

Single parents (1) Two parents (1) All parents (2) All parents (3)

Homeless, shelteredHoused, poor(p<0.05)

(not stat. sign.) (p<0.01)

(p<0.01)

1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).2. Coll CG et al. The Developmental Status and Adaptive Behavior of Homeless and Low-Income Housed Infants and Toddlers. AJPH 88:1371-1374 (1998).3. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

Families reportingabuse of their children

0%

2%

4%

6%

8%

10%

12%

Physically abused in thepast year (1)

Ever physically orsexually abused (2)

Homeless

Housed, poor

1. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

(not stat. sign.)

Homeless Child Syndrome

In summary, the typical homeless child problem list will include:

poverty-related health problemsimmunization delaysuntreated or under-treated acute and chronic problemsmental health, behavior and academic problemschild abuse/neglect

Modifying health care plans and prevention strategies

Homelessnesscarries a stigma

Determining housing status requires asking questions in a sensitive and non-threatening manner

Suggested assessment questions

Do you have safe and permanent housing?

Where are you staying? How long have you been there?

Have there been any changes in your housing situation since your last visit?

Suggested assessment questions (continued)

Do you have any concerns about your housing?

How many times have you moved in the last year? Homeless mothers living in shelters move an average of three to four times per year

Altering your plan of care

Determine the safety of the living environment

If it is not safe, provide access to resources


Recognize that homelessness is dynamic

Reassess potential for homelessness at every encounter


Use acute problem visits as a “window of opportunity”

Provide a thorough medical, developmental and psychological history as well as physical exam


Be alert to medical conditions that result from lack of access to medical care, preceded homelessness, or occur with homelessness

Prescribing practices should reflect the fact that the child may be living and eating in a shelter or on the street


Pay particular attention to health care maintenance

Provide immunizations and screening for lead toxicity, anemia, visual acuity, and hearing loss

Monitor growth and nutrition


Provide a “medical home”

Include primary pediatric care plus access to subspecialty care, developmental and psychological evaluation/treatment, medication and medical devices, case management, and 24 hr/7day access through an answering service


Address continuity of care limitations

Ensure patient transportation and availability of providers

Ensure means of communication taking into consideration that patients often have limited phone access


Screen parents for depression, substance abuse, and child abuse or neglect

Make appropriate referrals

As a final reality check, ask the parent if there is anything in the plan that will be difficult or impossible to follow

Know how to find resources for your homeless patients and their families

Finding resources

Web-based information

Health Care for the Homeless Information Resource Center

www.hchirc.comWeb site supported by Health Resources & Service Administration, U.S. Department of Health & Human ServicesIncludes state-based directory of health care for the homeless projectsLinks to federal agencies, national and student organizationsLinks to hotlines including domestic violence and crisis lines

Finding resources

Web-based information

National Health Care for the Homeless Council and HCH Clinicians’ Network

www.nhchc.org Web site for membership organization serving health care providers working with homeless people across the U.S.Features numerous publications including Healing Kids: the pediatric interest group updateIncludes sections on training, research, public policy and advocacyLinks to other organizations and agencies serving homeless populations

Finding resources

Print-based informationNo place to call home: Overview of outreach and primary health care services for the Homeless Children’s Program. 2001. (Health Care for the Homeless Information Resource Center; phone 1 888-439-3300)

America’s Homeless Children: New Outcasts. A Public Policy Report from The Better Homes Fund. 1999. (617/964-3834)

Homelessness and Children

“It is hard to imagine a social environment less conducive to health or normal maturation and development.”

—J.D. Wright

References used in this presentation

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

The Institute for Children and Poverty. Homeless in America: A Children’s Story. Part One. New York. 1999.The Better Homes Fund. Homeless Children: America’s New Outcasts. 1999. Bassuk EL. Homeless Families. Scientific American 265:66-74 (1991).Urban Institute. America’s Homeless II: Population & Services. February 2000.

(www.urban.org/presentations/AmericasHomelessII/index/htm) Bassuk EL et al. Homelessness in female-headed families: childhood and adult risk and protective factors.

AJPH 87:242-248 (1997). National Coalition for the Homeless. NCH Fact sheet #1. Why Are People Homeless?June 1999. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed

Children. Pediatrics 102: 554-562 (1998).Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526

(1991).Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance

Abuse, and Victimization. AJPH 82:1547-1550 (1992). Coll CG et al. The Developmental Status and Adaptive Behavior of Homeless and Low-Income Housed Infants

and Toddlers. AJPH 88:1371-1374 (1998).Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526

(1991).U.S. Department of Health & Human Services. Bureau of Primary Health Care. No Place to Call Home. April

2001. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).Hu DJ et al. Health Care Needs for Children of the Recently Homeless. Journal of Community Health 14:10-7

(1989).

References used in this presentation

Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988).

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).

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).

Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992).

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.Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991).Page AJ et al. Homeless Families and their Children’s Health Problems: a Utah Urban Experience. Western

Journal of Medicine 158:30-35 (1993). Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988).Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical

Pediatrics 32:151-155 (1993).U.S. Department of Health & Human Services. Office of Disease Prevention & Health Promotion. Healthy

People 2010: Understanding and Improving Health. 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).Menke EM. The Mental Health of Homeless School-Age Children. JCAPN 11:87-98 (1998).Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics

85:257-261 (1990). Rescorla L et al. Ability, Achievement and Adjustment in Homeless Children. American Journal of

Orthopsychology 61:210-220 (1991). Fierman AH et al. Growth Delay in Homeless Children. Pediatrics 88:918-925 (1991). Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991).

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