Homeless Children: What Every Health Care Provider Should Know

1
Homeless ChildrenWhat 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 presentation is 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 Americas 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 Childrens Story. Part
One. New York. 1999. 2. The Better Homes Fund.
Homeless Children Americas New Outcasts. 1999.
12
How many childrenare homeless in the United
States?
Modified from Bassuk EL Homeless Families.
Scientific American 26566-74 (1991).
13
Recent estimates suggest that 2 of American
children are homeless in the course of one year.

Urban Institute. Americas Homeless II
Population Services. February 2000.
(www.urban.org/presentations/AmericasHomelessII/i
ndex/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 nations 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 Americas 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
  homelessnesshomelessness carries a stigma

17
An overview of riskand protective factors that
influence family homelessness
Public Sector Assistance for Low-Income Families
Precipitating Risk or Protective Factors
Childhood/Distal Risk Factors
Background Factors
Proximal Risk Factors
Gender Parental Socioeconomic Status Race/Ethnicit
y
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
1. Work History 2. Mental Health Status 3.
Chronic Health Conditions 4. Educational
Attainment 5. Victimization 6. Drug Alcohol Use
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 87242-248 (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 Americas 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 lt0.01)
(p lt0.01)
(not stat. sign.)
1. Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(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 145520-526 (1991).
21
Mental IllnessAn important risk factor for
homelessness
(p lt0.01)
(not stat. sign.)
(p lt0.001)
1. Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(1990). 2. Weitzman BC et al. Predictors of
Shelter Use Among Low-Income Families
Psychiatric History, Substance Abuse, and
Victimization. AJPH 821547-1550 (1992).
22
Mental Illness An under-treated problem
(plt0.001)
Weitzman BC et al. Predictors of Shelter Use
Among Low-Income Families Psychiatric History,
Substance Abuse, and Victimization. AJPH
821547-1550 (1992).
23
Alcohol and drug abuseare associated with
homelessness
(plt0.05)
(plt0.001)
(plt0.001)
1. Coll CG et al. The Developmental Status and
Adaptive Behavior of Homeless and Low-Income
Housed Infants and Toddlers. AJPH 881371-1374
(1998). 2. Weitzman BC et al. Predictors of
Shelter Use Among Low-Income Families
Psychiatric History, Substance Abuse, and
Victimization. AJPH 821547-1550 (1992). 3.
Parker RM et al. A Survey of the Health of
Homeless Children in Philadelphia Shelters. AJDC
145520-526 (1991).
24
Substance abuseplays an important role in single
parent families
(plt0.05)
(plt0.05)
(not stat. sign.)
(not stat. sign.)
Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(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
Understanding the 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 childrens health as
fair or poor more often
(not stat. sign.)
()
(plt0.05)
()
1. Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(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 1410-7 (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
145520-526 (1991) 6. Menke EM Wagner JD. A
Comparative Study of Homeless, Previously
Homeless, and Never Homeless School-Aged
Childrens Health. Issues in Comprehensive
Pediatric Nursing 20 153-173 (1997). No
statistical comparison reported
30
Hospitalizationis common for homeless children
1. plt0.05 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 15244-250 (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 15244-250 (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
()
(plt0.001)

• 1. Murata J et al. Disease Patterns in Homeless
  Children A Comparison with National Data.
  Journal of
• Pediatric Nursing 7196-204 (1992)
• 2. Wood D et al. Health of Homeless Children and
  Housed Poor Children. Pediatrics 86858-866
  (1990).
• No statistically significant difference between
  homeless and housed, no statistical comparison
  with
• general population reported.

37
Infectious DiseaseAcute Otitis Media
()
The Childrens Health Fund. Still in Crisis The
health status of New York Citys homeless
children. 1999. The Childrens Health Fund. The
Crisis Continues The health status of New York
Citys homeless children. 2000. No statistical
comparison reported.
38
Infectious DiseaseDiarrhea
()
Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(1990). No statistically significant difference
between homeless and housed, no statistical
comparison with general population reported.
39
Infectious DiseaseLice scabies
()
()
()

• 1. Murata J et al. Disease Patterns in Homeless
  Children A Comparison with National Data.
  Journal of Pediatric Nursing 7196-204 (1992).
• 2. Wright JD. Children in and of the Streets.
  AJDC 145516-519 (1991).
• 3. Page AJ et al. Homeless Families and their
  Childrens Health Problems a Utah Urban
  Experience.
• Western Journal of Medicine 15830-35 (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.)
(plt0.05)

• 1. Murata J et al. Disease Patterns in Homeless
  Children A Comparison with National Data.
  Journal of Pediatric Nursing 7196-204 (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
  145520-526 (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
781232-1233 (1988). 2. Parker RM et al. A Survey
of the Health of Homeless Children in
Philadelphia Shelters. AJDC 145520-526
(1991). 3. Fierman AH et al. Status of
Immunization and Iron Nutrition in New York City
Homeless Children. Clinical Pediatrics 32151-155
(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 Patterns in 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
(plt0.05)
Berti LC et al. Comparison of Health Status of
Children Using a School-Based Health Center for
Comprehensive Care. Journal Pediatric Health Care
15244-250 (2001).
50
DepressionA summary of studies reporting
performance on the Childrens 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 84260-264 (1994). 2. Menke EM
Wagner JD. A Comparative Study of Homeless,
Previously Homeless, and Never Homeless
School-Aged Childrens Health. Issues of
Comprehensive Pediatric Nursing 20 153-173
(1997). 3. Menke EM. The Mental Health of
Homeless School-age Children. JCAPN 1187-98
(1998). 4. Bassuk EL et al. Psychosocial
characteristics of homeless children and children
with homes. Pediatrics 85257-261 (1990).
51
Behavior ProblemsChildrens performance on the
Behavior Problems Index
plt0.05
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
Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(1990).
52
Behavior Problems Reported performance on the
Child Behavior Checklist - School-Aged Children
(not stat. sign.)
(not stat. sign.)
(not stat. sign.)
Percent exceeding the cut-off suggesting further
psychiatric evaluation (criteria Tgt60 for 1,2,
Tgt65 for 3)
1. Menke EM Wagner JD. A Comparative Study of
Homeless, Previously Homeless, and Never Homeless
School-Aged Childrens 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 85257-261 (1990). 3.
Rescorla L et al. Ability, Achievement and
Adjustment in Homeless Children. American
Journal of Orthopsychology 61210-220 (1991).
53
Behavior Problems Reported performance on the
Child Behavior Checklist - Homeless School-aged
Children

• 26 met criteria for clinical diagnosis (Tgt70)
• 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 (Tgt70)
• Mean scores were comparable to population means.

Parker RM et al. A Survey of the Health of
Homeless Children in Philadelphia Shelters. AJDC
145520-526 (1991).
Menke EM. The Mental Health of Homeless
School-Age Children. JCAPN 1187-98 (1998).
54
Behavior Problems Reported performance on the
Child Behavior Checklist Pre-School Children

• Homeless, sheltered children compared with poor,
  housed children
• Statistically significant worse scores for total
  problems, externalizing and internalizing
  subgroup scores
• Total T score gt 70 (clinical range)
• Homeless 21
• Housed 5

• Homeless, sheltered children compared with
  normative data
• No statistically significant differences in
  scores
• Total T score gt 70 (clinical range)
• Homeless 20

Rescorla L et al. Ability, Achievement and
Adjustment in Homeless Children. American
Journal of Orthopsychology 61210-220 (1991).
Parker RM et al. A Survey of the Health of
Homeless Children in Philadelphia Shelters. AJDC
145520-526 (1991).
55
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

56
Development
57
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

58
Denver Developmental Screening Test Results

• Reported prevalence of homeless children failing
  at least one sectiona wide range
• 5 percent,1 15 percent,2 54 percent3
• Reported prevalence of homeless children failing
  at least two sections9 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
  childrens 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 86858-866
  (1990).
• 3. Bassuk EL et al. Psychosocial characteristics
  of homeless children and children with homes.
• Pediatrics 85257-261 (1990).

59
Denver Developmental Screening Test Results
(plt0.05)
(plt0.05)
(plt0.05)
(plt0.05)
(plt0.05)
Bassuk EL et al. Psychosocial characteristics of
homeless children and children with homes.
Pediatrics 85257-261 (1990).
60
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.

Parker RM et al. A Survey of the Health of
Homeless Children in Philadelphia Shelters. AJDC
145520-526 (1991).
61
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

Parker RM et al. A Survey of the Health of
Homeless Children in Philadelphia Shelters. AJDC
145520-526 (1991).
62
Nutrition Growth
63
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

64
Obesity and malnutrition
()
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
86858-866 (1990). 3. Alperstein G et al. Health
Problems of Homeless Children in New York City.
AJPH 781232-1233 (1988). No statistical
comparison made.
65
Accessto nutritious food is problematic
(plt0.01)
Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(1990).
66
Accessto adequate amounts of food is problematic
(plt0.01)
(plt0.01)
Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(1990).
67
Evidence of stuntingin homeless children
chronic malnutrition decreases attained height
Percentile Distribution of Height
Fierman AH et al. Growth Delay in Homeless
Children. Pediatrics 88918-925 (1991).
68
Evidence of obesityin poor, housed children
Percentile Distribution of Weight-Height
Fierman AH et al. Growth Delay in Homeless
Children. Pediatrics 88918-925 (1991).
69
Anemia
70
Anemiais another well-known disease of poverty
(plt0.05)
(not stat. sign.)
1. Parker RM et al. A Survey of the Health of
Homeless Children in Philadelphia Shelters. AJDC
145520-526 (1991). 2. Fierman AH et al. Status
of Immunization and Iron Nutrition in New York
City Homeless Children. Clinical Pediatrics
32151-155 (1993). 3. Page AJ et al. Homeless
families and their childrens health problems a
Utah urban experience. Western Journal of
Medicine 158 30-35 (1993).
71
Dental Health
72
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 childrens health problems a Utah urban
experience. Western Journal of Medicine 158
30-35 (1993). 3. Wright JD. Children in and of
the Streets. AJDC 145516-519 (1991).
73
Access to Dental Care
()
Menke EM Wagner JD. A Comparative Study of
Homeless, Previously Homeless, and Never Homeless
School-Aged Childrens Health. Issues in
Comprehensive Pediatric Nursing 20 153-173
(1997). No statistical comparison reported.
74
Immunization Delay
75
Immunization delayis common, particularly in
young children
Percent of children lacking up-to-date
immunizations
(plt0.05)
()
()
1. Fierman AH et al. Status of Immunization and
Iron Nutrition in New York City Homeless
Children. Clinical Pediatrics 32151-155
(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 Childrens Health Fund. Still in
Crisis The health status of New York Citys
homeless children. 1999. 4. Alperstein G et al.
Health Problems of Homeless Children in New York
City. AJPH 781232-1233 (1988). No statistical
comparison reported.
76
Immunization delayin school-aged children
Percent of children lacking up-to-date
immunizations
(not stat. sign.)
()
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 15244-250 (2001). 2. Menke EM Wagner JD.
A Comparative Study of Homeless, Previously
Homeless, and Never Homeless School-Aged
Childrens Health. Issues in Comprehensive
Pediatric Nursing 20 153-173 (1997). no
statistical comparison reported
77
Asthma
78
Asthma ratesincrease with poverty

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

79
Asthma
()
(plt0.05)
(plt0.01)
(not stat. sign.)
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 15244-250 (2001). 2. The Childrens Health
Fund. Still in Crisis The health status of New
York Citys homeless children. 1999. 3. Wood D et
al. Health of Homeless Children and Housed Poor
Children. Pediatrics 86858-866 (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 145520-526 (1991). No
statistical comparison reported.
80
Vision
81
Problems with visionare common among homeless
children
Percent with visual acuity deficits identified
during screening
(plt0.01)
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 15244-250 (2001). 2. Parker RM et al. A
Survey of the Health of Homeless Children in
Philadelphia Shelters. AJDC 145520-526
(1991). 3. Page AJ et al. Homeless families and
their childrens health problems a Utah urban
experience. Western Journal of Medicine 158
30-35 (1993).
82
Child Abuse
83
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

84
Families involvedin child abuse investigation
(plt0.01)
(plt0.05)
(not stat. sign.)
(plt0.01)
1. Wood D et al. Health of Homeless Children and
Housed Poor Children. Pediatrics 86858-866
(1990). 2. Coll CG et al. The Developmental
Status and Adaptive Behavior of Homeless and
Low-Income Housed Infants and Toddlers. AJPH
881371-1374 (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).
85
Families reportingabuse of their children
(not stat. sign.)
1. Parker RM et al. A Survey of the Health of
Homeless Children in Philadelphia Shelters. AJDC
145520-526 (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).
86
Homeless Child Syndrome

• In summary, the typical homeless child problem
  list will include
• poverty-related health problems
• immunization delays
• untreated or under-treated acute and chronic
  problems
• mental health, behavior and academic problems
• child abuse/neglect

87
Modifying health care plans and prevention
strategies
88
Homelessnesscarries a stigma

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

89
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?

90
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

91
Altering your plan of care

• Determine the safety of the living environment
• If it is not safe, provide access to resources

92
Altering your plan of care

• Recognize that homelessness is dynamic
• Reassess potential for homelessness at every
  encounter

93
Altering your plan of care

• Use acute problem visits as a window of
  opportunity
• Provide a thorough medical, developmental and
  psychological history as well as physical exam

94
Altering your plan of care

• 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

95
Altering your plan of care

• Pay particular attention to health care
  maintenance
• Provide immunizations and screening for lead
  toxicity, anemia, visual acuity, and hearing loss
• Monitor growth and nutrition

96
Altering your plan of care

• 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

97
Altering your plan of care

• 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

98
Altering your plan of care

• 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

99
Know how to find resources for your homeless
patients and their families
100
Finding resources

• Web-based information
• Health Care for the Homeless Information
  Resource Center
• www.hchirc.com
• Web site supported by Health Resources Service
  Administration, U.S. Department of Health Human
  Services
• Includes state-based directory of health care for
  the homeless projects
• Links to federal agencies, national and student
  organizations
• Links to hotlines including domestic violence and
  crisis lines

101
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 update
• Includes sections on training, research, public
  policy and advocacy
• Links to other organizations and agencies serving
  homeless populations

102
Finding resources

• Print-based information
• No place to call home Overview of outreach and
  primary health care services for the Homeless
  Childrens Program. 2001. (Health Care for the
  Homeless Information Resource Center phone 1
  888-439-3300)
• Americas Homeless Children New Outcasts. A
  Public Policy Report from The Better Homes Fund.
  1999. (617/964-3834)

103
Homelessness and Children
It is hard to imagine a social environment less
conducive to health or normal maturation and
development. J.D. Wright
104
References used in this presentation
U.S. Conference of Mayors. A Status Report on
Hunger and Homelessness in Americas Cities a
27-city survey. December 2001 The Institute for
Children and Poverty. Homeless in America A
Childrens Story. Part One. New York. 1999. The
Better Homes Fund. Homeless Children Americas
New Outcasts. 1999. Bassuk EL. Homeless
Families. Scientific American 26566-74
(1991). Urban Institute. Americas Homeless II
Population Services. February 2000.
(www.urban.org/presentations/AmericasHomelessII/in
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female-headed families childhood and adult risk
and protective factors. AJPH 87242-248 (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 86858-866
(1990). Weinreb L et al. Determinants of Health
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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 145520-526 (1991). Weitzman BC et
al. Predictors of Shelter Use Among Low-Income
Families Psychiatric History, Substance Abuse,
and Victimization. AJPH 821547-1550 (1992).
Coll CG et al. The Developmental Status and
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105
References used in this presentation
Miller DS et al. Children in Sheltered Homeless
Families Reported Health Status and Use of
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(1988). Menke EM Wagner JD. A Comparative Study
of Homeless, Previously Homeless, and Never
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J et al. Disease Patterns in Homeless Children A
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Childrens Health Fund. Still in Crisis The
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children. 1999. The Childrens Health Fund. The
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Improving Health. Zima BT et al. Emotional and
Behavioral Problems and Severe Academic Delays
among Sheltered Homeless Children in Los Angeles
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Mental Health of Homeless School-Age Children.
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(1990). Rescorla L et al. Ability, Achievement
and Adjustment in Homeless Children. American
Journal of Orthopsychology 61210-220 (1991).
Fierman AH et al. Growth Delay in Homeless
Children. Pediatrics 88918-925 (1991). Wright
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