American Orthopsychiatric Association

Family Homelessness: Mental Health Needs of Children and Families

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Adoption: January 2015

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Introduction

Each year, 1 in 30 American children experiences homelessness (Bassuk, DeCandia, Beach, & Berma, 2014). A recent systematic review and meta-analysis based on the literature to date summarized the mental health needs of homeless children. Approximately 40% of homeless school-aged children have mental health problems requiring clinical evaluation, which is 2 to 4 times the rate for poor children of similar age (Bassuk, Richard, & Tsertsvadze, in press). Unfortunately, adequate mental health responses remain largely absent from homeless services. Mental well-being of families and children who do not have a home is a complex issue and this complexity contributes to fragmentation and lack of coordination among all stakeholders involved. Unlike medical, educational, or criminal systems, homeless facilities have virtually no standards for delivering mental health services. The problem has taken on greater urgency following the economic downturn, as growing unemployment rates and increasing cases of foreclosures have adversely impacted families (Bassuk, 2010). A comprehensive approach is required to address the mental health needs of children and families experiencing homelessness. 

Purpose/Problem Statement

Homeless families account for more than one-third of the overall homeless population (Henry, Cortes, & Morris, 2013). On average, a homeless family consists of a single mothers in her late twenties with two young children (Rog & Buckner, 2007). Most homeless mothers do not have college degrees, and over a third are in poor physical health, with chronic medical problems such as asthma or hypertension (Bassuk et al., 1996). More than 50% of mothers experience a major depressive episode while homeless (Weinreb et al., 2006), and 85% report having had a major depressive episode in the past. To alleviate their distress, 41% have become dependent on alcohol or drugs – a rate twice as high as the general female population (Bassuk et al., 1996).

According to the 2013 Hunger and Homeless Survey conducted by the U.S. Conference of Mayors, the top three contributing factors to family homelessness are poverty, lack of affordable housing, and unemployment. Other causes include mental health issues, addictions, physical health problems, migration, ineffective support structures, changing family demographics, unemployment, lack of education or employment skills, and adverse childhood experiences (Guarino & Volk, 2010). The recent increase in the number of homeless families has been influenced by the economic downturn, which contributed to foreclosures, job layoffs, rising food and fuel prices, and inadequate supplies of low-cost housing (Duffield & Lovell, 2008; Sard, 2009).

Children feel the stress of homelessness: 74% of them worry that they will have no place to live; more than a half (58%) worry that they will have no place to sleep; and a vast majority (87%) worry that something bad will happen to their family (Bassuk et al., 2014). Homelessness also results in a loss of community, routines, possessions, privacy, and security. Within one year, 97% of children experiencing homelessness move, often leaving behind familiar surroundings; 25% have witnessed violence; and 22% have been separated from their families (National Center on Family Homelessness, 1999). This constant stress puts children at risk for developing significant mental health issues (Masi & Cooper, 2006). One third of them express their distress through aggressive behaviors (Anooshian, K. J., 2005; Buckner & Bassuk, 1997).

Families who have experienced homelessness have much higher rates of separation than other low-income families (Culhane, Webb, Grimm, Metraux, & Culhane, 2003). Some separations are dictated by the shelter system. Homeless children are also 7 times more likely than other children to be placed in foster care (22% experience foster care or living with relatives compared to 3% of housed children). The likelihood of foster care placement increases with the child’s age: 9% for infants and toddlers, 19% for 3 to 6 year olds, and 34% among school-agers (National Center on Family Homelessness, 1999). Homelessness is also a barrier to reunification: at least 30% of children in foster care could return if their parents had housing (Doerre & Mihaly, 1996).

Even where supportive services exist, they are not always readily available, used by the people who need them most, or family-centered (DeRosa et al., 1999; Kilmer, Cook, Crusto, Strater, & Haber, 2012). Lack of health insurance is a serious barrier to specialty care for older children and youth ineligible for Medicaid. Other barriers include limited shelter placements, overcrowding, fear of shelters and health care providers, and distrust of structured, rule-bound programs. In addition, language barriers are increasingly becoming a challenge for service providers. Although the McKinney-Vento Act mandates ways to serve homeless children, reports show that the majority of homeless shelters are unfamiliar with the law.

The McKinney-Vento Act has improved access to education significantly; however, obstacles to the enrollment, attendance, and success of homeless children in school persist. One of the largest challenges is limited resources, for example, for preschool programs such as Head Start. Findings from a three-year Head Start Demonstration Project reveal numerous challenges in serving homeless children and their families, including recruiting and enrolling homeless families; retaining homeless families in project services; involving homeless parents; and meeting the unique needs of homeless children and parents (U.S. Department of Health and Human Services, 1999).

Policy/Position Statement

Ortho has long been a supporter and advocate for mental well-being of vulnerable populations, and we are gravely concerned about homelessness and its consequences for children and families. Although a number of federal agencies, non-profit organizations, and leaders work to alleviate the problem, more attention needs to be paid to the mental health needs of children experiencing homelessness. The overall response to homelessness often appears inadequate in terms of promoting basic human rights and ensuring respect for human dignity.

Ortho encourages an interdisciplinary dialogue among mental health professionals, child advocates, service providers, researchers, policymakers, and other stakeholders to develop and promote a more humane approach to addressing the needs of children and families who experience homelessness. Important topics include: safe and stable housing, quality schools, affordable health care, nutritional food, safe neighborhoods, and positive adult role models. Services to address these basic needs include adequate and affordable housing, health care and dentistry services, parenting education and programs, after-school tutoring and other academic programs, and nutritional programs (Hart-Shegos, 1999; Kilmer et al., 2012; Perlman, Cowan, Gewirtz, Haskett, & Stokes, 2012). Because of the trauma that can accompany homelessness and related experiences, some children need more extensive care, services, and supports. Comprehensive, integrated services that promote the well-being of the whole family can protect mental health and prevent prolonged homelessness. These kinds of discussions can identify the mental health needs of homeless children and families and develop resources to help program providers and organizers meet these needs more effectively.

References

Anooshian, K. J. (2005). Violence and aggression in the lives of homeless children. Journal of Family Violence, 20, 373-387.

Bassuk, E. L. (2010). Ending child homelessness in America. American Journal of Orthopsychiatry, 80, 496-504.

Bassuk, E. L., DeCandia, C. J., Beach, C. A., & Berman, F. (2014). America’s youngest outcasts:  A report card on child homelessness. Newton, MA: The National Center on Family Homelessness.

Bassuk, E. L., Richard, M. K., & Tsertsvadze, A. (2014). The prevalence of mental illness in homeless children: A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry. Advance online publication. doi:http://dx.doi.org/10.1016/j.jaac.2014.11.008

Bassuk, E. L., Weinreb, L. F., Buckner, J. C., Browne, A., Salomon, A., & Bassuk, S. S. (1996). The characteristics and needs of sheltered homeless and low-income housed mothers. Journal of American Medical Association, 276, 640-646.

Buckner, J. C., & Bassuk, E. L. (1997). Mental disorders and service utilization among youths from homeless and low-income housed families. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 890-900.

Culhane, J. F., Webb, D., Grimm, S., Metraux, S., & Culhane, D. P. (2003). Prevalence of child welfare services involvement among homeless and low-income mothers:  A five year birth cohort study. Journal of Sociology and Social Welfare, 30, 79-95.

DeRosa C. J., Montgomery S. B., Kipke M. D., Iverson, E., Ma  J. L., & Unger, J. B. (1999). Service utilization among homeless and runaway youth in Los Angeles, California:  Rates and reasons.  Journal of Adolescent Health, 24, 449-458.

Doerre, Y. A., & Mihaly, L. K. (1996). Home sweet home. Washington, DC: Children’s Welfare League of America Press.

Duffield, B., & Lovell, P. (2008). The economic crisis hits home:  The unfolding increase in child & youth homelessness. Washington, DC:  National Association for the Educators of Homeless Children and Youth and First Focus.

Guarino, K., & Volk, K. T. (2010). Child homelessness:  Minimizing the impact, ending the epidemic. Communities & Banking, 21, 10-12.

Hart-Shegos, E. (1999). Homelessness and its effects on children. Minneapolis, MN:  Family Housing Fund.

Henry, M., Cortes, A., & Morris, S. (2013). The 2013 annual homeless assessment report to Congress. Washington, DC: U.S. Department of Housing and Urban Development, Office of Community Planning and Development.

Kilmer, R. P., Cook, J. R., Crusto, C., Strater, K. P., Haber, M. G. (2012). Understanding the ecology and development of children and families experiencing homelessness: Implications for practice, supportive services, and policy. American Journal of Orthopsychiatry, 82, 389-401.

Masi, R., & Cooper, J. (2006). Children’s mental health facts: Facts for policymakers. New York, NY:  National Center for Children in Poverty.

National Center on Family Homelessness. (1999). Homeless Children: America’s New Outcasts. Newton, MA: Author.

National Center on Family Homelessness (2008). The characteristics and need of homeless families experiencing homelessness. Newton, MA: Author.

Perlman, S., Cowan, B., Gewirtz, A., Haskett, M., & Stokes, L. (2012). Promoting positive parenting in the context of homelessness. American Journal of Orthopsychiatry, 82, 402-412.

Rog, D. J., & Buckner, J. C. (2007). Homeless families and children. Retrieved from http://www.huduser.org

Sard, B. (2009). Number of homeless families climbing due to recession. Washington, DC: Center on Budget and Policy Priorities.

U.S. Conference of Mayors. (2013). Hunger and homelessness survey: A status report on hunger and homelessness in America’s cities. Washington, DC: Author.

U.S. Department of Health and Human Services, Head Start Bureau. (1999). Serving homeless families:  Descriptions, effective practices, and lessons learned. Washington, DC: Author.

Weinreb, L., Buckner, J. C., Williams, V., & Nicholson, J. (2006). A comparison of the health and mental health status of homeless mothers in Worcester, Mass: 1993 and 2003. American Journal of Public Health, 96, 1444-1448.