Cheryl Zlotnick RN DrPH

1
Preventing Adulthood Homelessness with Mental
Physical Health Services The Link to Childhood
History of Foster Care

• Cheryl Zlotnick RN DrPH
• Center for the Vulnerable Child
• Childrens Hospital Research Center Oakland

2
Outline of Presentation
I The Framework of Life Course Epidemiology II
Associations Between Homelessness and Foster Care
throughout the life course III Barriers to and
Opportunities for Intervention IV Discussion
3
The Framework of Life Course Epidemiology
Precepts of Life Course Epidemiology

• Some childhood events are related to adulthood
  sequelae.

• There are critical periods in life when an event
  has a greater impact.

• Intergenerational transmission of risk from
  childhood to adulthood is possible.

Ben-Shlomo, Y. and D. Kuh (2002). "A life course
approach to chronic disease epidemiology
conceptual models, empirical challenges and
interdisciplinary perspectives." International
Journal of Epidemiology 31 285-293.
4
The Framework of Life Course Epidemiology
Adverse childhood events1
Adulthood smoking, obesity, mental health,
substance abuse
Familys socioeconomic status
Adult health status, morbidity and mortality
Felitti et al. (1998). "Relationship of childhood
abuse and household dysfunction to many of the
leading causes of death in adults. The Adverse
Childhood Experiences (ACE) study." American
Journal of Preventive Medicine 14(4)
245-258. Kuh et al. (2002). "Mortality in adults
aged 26-54 years related to socioeconomic
conditions in childhood and adulthood post war
birth cohort study." British Medical Journal 325
1076-1080. Langenberg et al. (2006). "Social
circumstances and education life course origins
of social inequalities in metabolic risk in a
prospective national birth cohort." American
Journal of Public Health 96(12) 2216-2221.
1 Childhood history of sexual or physical abuse
5
Associations Between Homelessness and Foster Care
Children living in out-of-home and foster
placements
Homeless parents with Substance Abuse and/or
Mental Health Problems

• An estimated 44-72 of homeless mothers have
  children in out of home placements (Burt et al.,
  1999 Cowal et al., 2002).
• Approximately, 24 of homeless mothers have
  children in foster care (Park et al., 2004
  Zlotnick et al., 2007).

Burt et al. (1999). Homelessness programs and
the people they serve findings of the National
Survey of Homeless Assistance Providers and
Clients. . Washington, D.C., Urban
Institute. Cowal et al. (2002). "Mother-child
separations among homeless and housed families
receiving public assistance in New York City."
American Journal of Community Psychology 30(5)
711-30. Park, J. M., S. Metraux, et al. (2004).
"Child welfare involvement among children in
homeless families." Child Welfare 83(5)
423-436. Zlotnick et al. (2007). "Adulthood
Trauma, Separation from One's Children and
Homeless Mothers." Community Mental Health
Journal 43(1) 20-33.
6
Associations Between Homelessness and Foster Care
Foster Care or Group Home Teens
Runaway/Homeless Youth
Among runaway/homeless youth, twice as many have
histories of living in foster care/group homes.
Tyler, K. A. (2006). "A qualitative study of
early family histories and transitions of
homeless youth." Journal of Interpersonal
Violence 21(10) 1385-1393. Thompson, S. J. and
D. E. Pollio (2006). "Adolescent runaway
episodes application of an estrangement model
of recidivism." Social Work Research 30(4)
245-251.
7
Homeless Adults with Histories of Childhood
Foster Care
Associations Between Homelessness and Foster Care
Percent
8
Association Between Homelessness and Foster Care
Foster Care
Homeless Adults
Homeless Children
Homeless/Runaway Youth
9
Foster Care
In a random sample of young children entering a
Countys foster care program, 48.7 of birth the
parents were homeless.
Zlotnick, C., D. Kronstadt, et al. (1998).
"Foster care children and family homelessness."
American Journal of Public Health 88(9)
1368-1370.
10
Foster Care
15-22 of children aging-out of foster care
experience homelessness within one year
Pecora et al. (2006). "Educational and
employment outcomes of adults formerly placed in
foster care results from the Northwest Foster
Care Alumni Study." Children Youth Services
Review 28 1459-1481. Kushel et al. (2007).
"Homelessness and health care access after
emancipation results from the Midwest Evaluation
of Adult Functioning of Former Foster Youth."
Archives-of-Pediatrics-and-Adolescent-Medicine
161(10) 986-93.
11
Foster Care
Adults with versus without histories of childhood
foster care were significantly more likely to
experience adulthood mental health problems, poor
physical health and problems with daily
functionand homelessness (men).
United Kingdom 1,a US (CA) 2,a Mental
health 1.7 - males 1.71a Health
Status 1.6 - males 1.53b 1.8 -
females Daily Function 1.50
Homelessness 2.0 - males
a Odds Ratios, significant plt0.05 b Adjusted
for gender
1 Viner, R. M., Taylor, B. (2005). Adult health
and social outcomes of children who have been in
public care population-based study. Pediatrics,
115(4), 894-899. 2Zlotnick C. Tam, T. (2007) .
Will positive interventions on our foster care
system decrease adulthood mental illness and
transiency? 135th Annual American Public Health
Association Meeting, Washington, DC.
12
Association Between Foster Care and Homelessness
Homelessness
Foster Care Children
Foster Care effects Into Adulthood???
Foster Care Youth
13
Foster Care
What is the association between having a history
of childhood foster care and adulthood morbidity
in a general population of adults?
Mental Illness, Poor Health or Substance Abuse
Childhood Foster Care
Homelessness in Adulthood
14
Barriers to and Opportunities for Intervention
Mental health problems are related to having a
childhood history of foster care, and to poor
health status. Could this be the link to
adulthood homelessness?
15
Barriers to and Opportunities for Intervention
Children living in foster care or homelessness
have

• Limited access to health care and may not know
  about existing health problems.
• Suffered from the trauma of transitions.

• Have few opportunities to obtain family-focused
  interventions that include needed case
  management.
• Are hard to follow and so consistent services are
  problematic.

16
Ethnic/Racial Disparities Foster Care
Barriers to and Opportunities for Intervention

• Disproportionately higher prevalence rates of
  homelessness in families who self-identify as
  ethnic/racial minorities
• Disproportionately higher prevalence rate of
  foster care placement for children who come from
  families who self-identify as ethnic/racial
  minorities.
• Disproportionately lower prevalence rate of
  reunification after foster care placement among
  children who were removed from families who
  self-identify as ethnic/racial minorities.

17
Opportunities and Barriers to Intervention
Chaffee Foster Care Independence Program (CFCIP)
- In FY 2006, approximately 280.0 million was
available for the more than 105,000 foster care
children who qualify Transitional Living Program
- In FY 2006, 36.0 million was to provide
long-term, supportive assistance to homeless
youth, ages 16 to 21, who cant return to their
families but are not yet equipped to live on
their own
18
Discussion
Administrative - Interventions
An integrated primary care system with mental
health screening may improve identification of
individuals with need and improve access to
mental health services and reduce morbidity.
History of childhood foster care may be
functioning as a sentinel event identify
individuals who are at risk.
19
Discussion
Clinician Interventions

• Screen children living in transitioning families
  (children living in homelessness or in the foster
  care system) for mental health needs and
  identifying resources to provide treatment.
• During the history portion of a comprehensive
  health examination, the practitioner needs to
  inquire if the child/youth/adult has had a
  childhood history of foster care.

20
Discussion
Limitations
These associations DO NOT mean that all
individuals who experienced childhood foster care
are doomed to have problems it means that
individuals with histories of childhood foster,
compared to those without, have a greater odds of
experiencing problems later in life.
21
Thank You!
Cheryl Zlotnick RN DrPH Center for the Vulnerable
Child Childrens Hospital Research Center
Oakland 747 52nd Street Oakland, CA
94609-1809 czlotnick_at_mail.cho.org
Contact Information
22
References AFCARS Report FY2005 Estimates
(2008) Administration on Children, Youth and
Families, Childrens Bureau. http//www.acf.hhs.go
v/programs/cb/stats_research/afcars/tar/report13.p
df - retrieved 1/5/08 Bassuk et al. (1997).
Homelessness in female-headed families childhood
and adult risk and protective factors. American
Journal of Public Health, 87(2), 241-248. Becker
et al. (2006). Behavioral health services use and
costs among children in foster care. Child
Welfare 85(3), 633-647. Ben-Shlomo, Y. and D.
Kuh (2002). A life course approach to chronic
disease epidemiology conceptual models,
empirical challenges and interdisciplinary
perspectives. International Journal of
Epidemiology 31, 285-293. Burt et al. (1999).
Homelessness programs and the people they serve
findings of the National Survey of Homeless
Assistance Providers and Clients. Washington,
D.C., Urban Institute. Cowal et al. (2002).
Mother-child separations among homeless and
housed families receiving public assistance in
New York City. American Journal of Community
Psychology 30(5), 711-30. Felitti et al. (1998).
"Relationship of childhood abuse and household
dysfunction to many of the leading causes of
death in adults. The Adverse Childhood
Experiences (ACE) study." American Journal of
Preventive Medicine 14(4), 245-258. Halfon et
al. (1995). Health status of children in foster
care. Archive of Pediatric and Adolescent
Medicine 149, 386-392. Koegel, P., Melamid, E.,
Burnam, M. A. (1995). Childhood risk factors
for homelessness among homeless adults. American
Journal of Public Health, 85(12), 1642-1649. Kuh
et al. (2002). "Mortality in adults aged 26-54
years related to socioeconomic conditions in
childhood and adulthood post war birth cohort
study." British Medical Journal 325,
1076-1080. Kushel et al. (2007). Homelessness
and health care access after emancipation
results from the Midwest Evaluation of Adult
Functioning of Former Foster Youth. Archives-of-
pediatrics-and-adolescent-medicine 161(10),
986-93. Langenberg et al. (2006). "Social
circumstances and education life course origins
of social inequalities in metabolic risk in a
prospective national birth cohort." American
Journal of Public Health 96(12), 2216-2221.
23
References Park et al. (2004). Child welfare
involvement among children in homeless families.
Child Welfare 83(5), 423-436. Pecora et al.
(2006). Educational and employment outcomes of
adults formerly placed in foster care results
from the Northwest Foster Care Alumni Study.
Children Youth Services Review 28,
1459-1481. Piliavin et al. (1993). The duration
of homeless careers an exploratory study. Social
Service Review, December, 577-598. Reed, D. F.
K. Karpilow (2002). Understanding the child
welfare system in California A primer for
service providers and policymakers. Berkeley,
California Center for Research on Women and
Families, Public Health Institute. Susser et al.
(1991). Childhood antecedents of homelessness in
psychiatric patients. American Journal of
Psychiatry, 148(8), 1026-1030. Thompson, S. J.
D. E. Pollio (2006). Adolescent runaway episodes
application of an estrangement model of
recidivism. Social Work Research 30(4),
245-251. Tyler, K. A. (2006). A qualitative
study of early family histories and transitions
of homeless youth. Journal of Interpersonal
Violence 21(10), 1385-1393. Viner, R. M.,
Taylor, B. (2005). Adult health and social
outcomes of children who have been in public
care population-based study. Pediatrics,
115(4), 894-899. Zlotnick, C., Kronstadt, D.,
Klee, L. (1998). Foster care children and family
homelessness. American Journal of Public Health
88(9), 1368-1370. Zlotnick, C., Tam, T.,
Bradley, K. (2007). Adulthood Trauma, Separation
from One's Children and Homeless Mothers.
Community Mental Health Journal 43(1),
20-33. Zlotnick C. Tam, T. (2007) . Will
positive interventions on our foster care system
decrease adulthood mental illness and transiency?
135th Annual American Public Health Association
Meeting, Washington, DC. Zlotnick, C.,
Robertson, M. J., Wright, M. (1999). The impact
of childhood foster care and other out-of-home
placement on homeless women and their children.
Child Abuse and Neglect, 23(11), 1057-1068.