The mental health of children in homeless families and their contact with health, education and social services

Previous research indicates that children in homeless families have a high risk of physical and mental illness. This study reports the initial stage of a longitudinal research programme to measure the prevalence of psychiatric disorders among parents and children in homeless families. A sample of parents in 113 homeless families were interviewed within 2 weeks of admission to seven homeless centres in the City of Birmingham, and compared with a sample of 29 low-income families who were not homeless. Both sets of interviews used the Child Behaviour Checklist (CBCL), the Communication Domain of the Vineland Adaptive Behaviour Scales (VABS), the General Health Questionnaire (GHQ), the Interview Schedule for Social Interaction (ISSI), and height and weight percentiles. A sub-sample of children was also interviewed. The results indicate that 85% of families became homeless because of domestic or neighbourhood violence, that in 54% of families in homelessness coincided with the separation of the partners, and that 49% of mothers had current psychiatric morbidity. Children in homeless families had delayed communication and higher mean scores for mental health problems than the comparison sample. Homeless children were also more likely to have had histories of abuse, and less likely to have attended school or nursery school since becoming homeless. Homeless families had high rates of contact with primary healthcare and social services, but few had been in contact with specialist child and adolescent mental health services. These results indicate a need for a co-ordinated action by housing, social services, education, health services, and the police to prevent families from becoming homeless by protecting victims of domestic and neighbourhood violence from further violence and intimidation. Hence the need to rapidly re-house into permanent accommodation those who do become homeless, to maintain education for their children, and to ensure that such families have access to effective social support and healthcare.     

Why does family homelessness occur? A case-control study.

We compared 49 homeless female-headed families with 81 housed female-headed families in Boston. Most housed families were living in public or private subsidized housing. In both groups the mothers were poor, currently single, had little work experience, and had been on welfare for long periods. Many of their children had serious developmental and emotional problems. Homeless mothers had more frequently been abused as children and battered as adults and their support networks were fragmented; the housed mothers had female relatives and extended family living nearby whom they saw often. The frequency of drug, alcohol, and serious psychiatric problems was greater among the homeless mothers. The homeless mothers may have been more vulnerable to the current housing shortage because they lacked support in time of need. This, in turn, may have been due to their history of family violence. Psychiatric disabilities may have been another contributing factor in the minority of homeless women. The notion that a "culture of poverty" accounts for homelessness was not supported by the data since the homeless were less likely to have grown up in families on welfare. The data suggest that solutions to family homelessness in the current housing market require an increase in the supply of decent affordable housing, income maintenance, and assistance from social welfare agencies focused on rebuilding supportive relationships.     

Making the invisible visible: a Photovoice exploration of homeless women's health and lives in central Auckland

Women and the concept of homelessness are weakly connected in the international discourses on health and housing. This PhotoVoice study gave a sample of homeless women in central Auckland a camera with which to photograph their lives in order to voice their felt health needs as advocates and agents for positive change. Interviews explored the meanings given to street lives captured in the photographs and reveal threats to the women's mental health and worsening addictions. Their tight-knit, resilient community, including dogs, was seen as 'family' who provide support and protection. The women perceived social services as helping them survive and support their health, but not ending their homelessness. Barriers to them getting and staying off the street included a shortage of affordable, secure housing, which has also tended to become overcrowded. They identified their own leaders who could link with state housing services to implement and evaluate new homelessness programmes, such as Housing First.     

Causes of homelessness among older people in Melbourne, Australia

OBJECTIVE: A comparative study of the causes of new episodes of homelessness among people aged 50 years and over has been undertaken in Australia, the United States and England. Semi-structured questionnaires were used to collect information on the circumstances and problems that contributed to homelessness. METHODS: This paper presents the findings from Australia, where information was obtained from 125 older homeless people (aged 50+ years) and their key workers in Melbourne. All three participating nations followed identical research methodologies. RESULTS: The factors most frequently reported by respondents as contributing to their homelessness were problems with people with whom they lived, followed by physical and mental ill-health and problems associated with the housing itself. The most frequently reported factors by case workers were problems with alcohol, followed by physical and mental health factors. CONCLUSIONS: This study demonstrates a significant under-utilisation of housing and support services among recently homeless older people and provides evidence that people who had previously been homeless appear to be more resigned to their homelessness than do those who had not experienced homelessness before. Significant issues relating to depression and gambling were also noted. The findings support the need for more targeted, specialised services to be developed or improved such that older homeless people can readily gain access to them and for improved collaboration or information exchange among housing providers and welfare agencies.     

Drug use and other problems of residents in projects for the young, single homeless

One hundred people who make use of an organization housing the young, single homeless were interviewed using a semi-structured interview. There was a high prevalence of problems, including substance abuse and dependence, other mental health problems, extensive use of health services and extensive experience of crime both as victim and perpetrator. Most people said they had become homeless because they did not get on with their parents. Since becoming homeless, most had not spent more than a month sleeping rough, but most had spent time staying with friends or staying in other hostels for the homeless. It is concluded that most young, single homeless people who seek help have problems beyond a lack of permanent shelter. The extent to which the sample is representative of all homeless people is considered and implications for service provision are discussed.     

Military Sexual Assault and Homeless Women Veterans: Clinical Correlates and Treatment Preferences

BackgroundBoth homeless women and women who have experienced military sexual assault (MSA) are at high risk of serious psychological sequelae. However, little is known about the combined impact of MSA and current homelessness on psychological distress, or about distinctive treatment preferences among homeless female veterans affected by MSA.MethodsThis observational study compared clinical symptoms, pre-military experiences, and treatment preferences among 509 female veterans with and without MSA who enrolled in 11 VA Homeless Women Veterans Programs.ResultsOver one third of participants (41.1%) reported MSA. In multivariate analyses, homeless female veterans who reported MSA endorsed greater severity of PTSD and other psychiatric symptoms. Those who had experienced MSA were more likely to report interest in treatment, and treatment focused on safety was reported as especially attractive.ConclusionsAmong homeless female veterans, MSA is associated with greater mental health symptoms and greater interest in safety-focused treatment. Services targeting the needs of homeless MSA survivors should be encouraged.     

Health and health needs of homeless and runaway youth A position paper of the Society for Adolescent Medicine

The experience of runaway and homeless youth in the United States is not entirely unique and should be viewed in an international context. The youth in this country do have some unique characteristics and needs. Homeless youth in affluent societies such as ours are often on the streets for different reasons than those of their counterparts in developing countries. Nonetheless, life on the streets brings with it hazards for all homeless young people. Homeless youth are at risk for a number of serious physical and mental health problems, some resulting in pain and discomfort, others in disability and death.

Less dramatic, but just as critical, is the role that homelessness plays in disrupting an adolescent's healthy development. Many of the youth who become homeless come from dysfunctional families where physical and sexual abuse, neglect, and substance abuse are common.

Homelessness and the experiences associated with homelessness further negatively impact youths' physical, emotional, psychologic, and social development. As a result, most do not develop a healthy sense of self, nor do they establish healthy, supportive peer relationships. The majority of homeless youth drop out of school during their early teens. Thus, they miss the opportunity to develop the kinds of problem-solving and intellectual skills required for securing and maintaining employment as adults.

Homeless youth involved in alcohol and other drug abuse are even more likely to have significant deficits and may be more irresponsible and emotionally immature. Thus, a vicious cycle is established. Rather than acquiring the types of enriching experiences and skills that would enable them to develop into healthy adults, homeless youth become over time more alienated from society. As a result, many will become chemically dependent and chronically homeless adults.     

Youth at risk of homelessness in an affluent Toronto suburb

BACKGROUND: This study examines the characteristics and needs of 69 youth who are homeless, or at risk of homelessness at Pathway's Home Base Youth Drop-In Centre in the affluent suburb of Richmond Hill, Ontario, Canada. METHODS: A semi-structured interview examined demographics, characteristics, living arrangements, family characteristics, substance use, mental health, criminal activity and educational experiences of the youth in this sample. RESULTS: The majority of youth came from economically advantaged families and were currently residing with their parents, but were substantially more at risk than their mainstream peers in measures related to youth homelessness. The majority of Home Base youth had left home and school prematurely, been arrested in their lifetime, and used at least one illicit drug in the past 12 months. A substantial number of youth had been imprisoned, experienced physical abuse, and exhibited depressive symptomatology and suicidal ideation. CONCLUSION: Although living mainly at home and in a relatively affluent suburb, these youth have many attributes related to homelessness and may progress to homelessness without intervention.     

Nutrition and health services needs among the homeless

This review discusses nutrition and related health problems among homeless Americans, summarizes recent information, and identifies needs for services and future research. The nature of homelessness today provides a context for the discussion. Many homeless persons eat fewer meals per day, lack food more often, and are more likely to have inadequate diets and poorer nutritional status than housed U.S. populations. Yet many homeless people eligible for food stamps do not receive them. While public and private agencies provide nutritious food and meals for homeless persons, availability of the services to homeless persons is limited. Many homeless people lack appropriate health care, and certain nutrition-related health problems are prevalent among them. Compared with housed populations, alcoholism, anemia, and growth problems are more common among homeless persons, and pregnancy rates are higher. The risks vary among homeless persons for malnutrition, nutrition-related health problems, drug and alcohol abuse, and mental illness. For example, among homeless persons, fewer heads of families than single adults are substance abusers, and mental illness varies in prevalence among single men, single women, and parents in homeless families. Homeless persons need improved access to food, nutrition, and health services. More nutrition education needs to be available to them and to service providers. Use of representative samples and validation of self-reported nutrition and health data will help future investigators to clarify the relationships between the characteristics of the homeless and their nutritional status.     

Psychopathology in Young People Experiencing Homelessness: A Systematic Review

Understanding mental health issues faced by young homeless persons is instrumental to the development of successful targeted interventions. No systematic review of recent published literature on psychopathology in this group has been completed.We conducted a systematic review of published research examining the prevalence of psychiatric problems among young homeless people. We examined the temporal relationship between homelessness and psychopathology. We collated 46 articles according to the PRISMA Statement.All studies that used a full psychiatric assessment consistently reported a prevalence of any psychiatric disorder from 48% to 98%. Although there was a lack of longitudinal studies of the temporal relationship between psychiatric disorders and homelessness, findings suggested a reciprocal link. Supporting young people at risk for homelessness could reduce homelessness incidence and improve mental health.PREVIOUS ESTIMATES INDICATE that 1% of Americans have experienced homelessness in any single year and as many as 1.35 million of those people are young people or children.1 Exploring mental health difficulties that are found to be highly prevalent among young people with experiences of homelessness is central to understanding the relationship between psychopathology and youth homelessness. Youth homelessness and the characteristics associated with these phenomena have not been well documented. This is partly because of the transient or sometimes hidden nature of homelessness alongside the often chaotic lifestyles of young people living in temporary accommodation or on the streets. Understanding the role of psychopathology in this area may lead to the development of interventions that could reduce the incidence of debilitating psychiatric disorders. It is important that interventions tailored to the needs of young people could also have an impact on the occurrence of homelessness and improve housing outcomes for those who do become homeless.The prevalence of psychiatric disorders among homeless persons has been shown to be high.2,3 However, research has not always distinguished between psychopathology among young people experiencing homelessness and that of older people. This is important because the causes of homelessness and the type and duration of support required by young people in this situation differ from that among adults. For example, family relationship breakdown, a reliance on insecure forms of accommodation, leaving care, and living with a step-parent have each been shown to be related to youth homelessness.4 By contrast, some of the strongest risk factors for adult homelessness are eviction, loss of employment, and breakdown of relationship with a partner.5 We performed a review to address the gap in the literature and distinguish the psychopathology found among young people with experiences of homelessness. This will aid the development of services for young people, enabling more focused targeting of resources to combat issues particular to young homeless people.The concept of “youth” has been defined by the United Nations as a person aged between 15 and 24 years.6 “Youth” is a period often temporally linked to the age at which a person ceases to be the responsibility of his or her legal guardians, becoming more psychologically and economically autonomous. For some, this period is accompanied by experiences of homelessness.7,8 Periods of homelessness at a young age have been linked to homelessness later in life.9 Mental health difficulties may be central to explaining this link. Mental health can have an impact on the problem-solving skills necessary for coping when homeless, with implications for the ability to move out of homelessness successfully.10Only a very limited number of systematic reviews examining psychopathology among young homeless people have been completed. These have focused on research from 1 country,11 did not specifically focus on mental health,12 have examined the homeless population in general rather than young people in particular,2 or have been completed more than 10 years ago.13Furthermore, researchers studying the etiology of youth homelessness have published their findings across a range of disciplines including public health, psychology, psychiatry, social policy, and human geography. Indeed, because research has been published in a range of journals it is difficult for service providers to gain a clear impression of the extent of the association between experiences of homelessness and psychopathology. This systematic review collates findings providing an overview of recent international research focused on psychiatric disorders prevalent among this group. A second aim was to consider evidence in relation to the direction of effects linking experiences of homelessness and psychopathology. Mental health issues may precede homelessness or, alternatively, symptoms may be exacerbated or elicited by homelessness.     

A family support service for homeless children and parents: users' perspectives and characteristics

The objective of the present study was to establish the psychosocial characteristics and perspectives of 49 consecutive homeless families who received input from a new designated family support worker (FSW) post at a large statutory hostel for homeless parents and children. The FSW provided: assessment of social, educational and health needs; support and parent training; and liaison with and referral to specialist services. Measures included quantitative questionnaires (i.e. the Hospital Anxiety and Depression Scale, the Parenting Daily Hassles Scale, the Eyberg Child Behaviour Inventory, and the Health of the Nation Outcome Scales for Children and Adolescents), and a qualitative (semistructured) interview on service experiences and satisfaction. The psychosocial measures indicated high rates of parenting difficulties, mental health and related needs among children and their parents. Parenting difficulties were associated with child behaviour problems. Parents expressed satisfaction with the service whilst they were residents at the hostel, but they were often not clear about the objectives of agencies and interventions. Family support interventions have a key role in service provision for homeless and other vulnerable families by providing direct parenting interventions and ensuring that specialist agencies are appropriately involved. Family support worker involvement needs to continue when families are re-housed in the community.     

Invited commentary: co-occurring health conditions among women living with profound life challenges

People challenged by homelessness are living with several losses including the loss of a home, employment, economic security, health or well-being, and personal security. Assistance programs for people who are homeless consist of housing, emergency shelter, food services, employment assistance, peer support, medical care, and mental health services. An article by Riley et al. (Am J Epidemiol. 2011;175(5):515-522) appearing in this issue of the Journal examines the relation between basic subsistence needs and health outcomes in a cohort of 129 human immunodeficiency virus-infected women who were recruited from a probability sample of low-income hotels, homeless shelters, and free food programs in San Francisco, California. The results of their study underscore the importance of addressing subsistence needs and providing access to medical and psychological treatment for homeless and unstably housed women. In addition to subsistence needs, more attention should be given to comorbid psychiatric and medical conditions that occur among homeless women, including trauma-related disorders.     

The eating patterns and problems of homeless women

While inadequate nutrition has been identified as a factor affecting the health of the homeless, there has been little research to identify the extent to which inadequate nutrition is a problem. The goal of this paper is to document the eating patterns and problems of single homeless women and to locate the determinants of nutritional adequacy in their diets. Our findings are based on a random sample of 84 single homeless women using hostels and drop-in centers. For 85.5% of the women food was provided primarily by hostels and supplemented by the drop-ins. When their daily food intake was compared to the Canada's Food Guide recommendations, the average number of servings in each of the four food groups was below the recommended. The women in our sample indicated that their problems with food consumption were rooted in their poverty and further analysis indicated that the provision of food by social agencies was an important factor in the nutritional adequacy of their diets. Hostels and drop-in centers not only provide shelter, they have also assumed most of the responsibility for feeding the homeless. It is their poverty which burdens these women and structures their eating patterns.     

Australian homeless persons’ experiences of social connectedness,isolation and loneliness

Both loneliness and a lack of social integration are associated with serious physical and psychological health issues. One population highly susceptible to social isolation and loneliness are individuals who are homeless, who also experience high rates of mental disorder and relationship breakdown. Despite this, little research has explored how social networks, isolation and loneliness are experienced for those with a history of homelessness. In‐depth, semi‐structured interviews were used to get a nuanced understanding of how social networks and isolation are experienced and understood by individuals experiencing homelessness. Sixteen participants who were either homeless (n = 11) or previously homeless (n = 5) in Sydney, Australia, completed one‐off interviews that were audio‐recorded and transcribed. Data were analysed using thematic analysis. Participants constructed their social networks as being both constrained and enabled by marginalisation. They experienced rejection from the non‐homeless: the loss of critical network members, including rejection from family and a lack of companionship, and low quality and precarious relationships within the homeless community. These accounts were best conceptualised through loneliness theory. Participant's accounts signal that the homeless will likely continue feeling isolated if mainstream attitudes towards homelessness remain stigmatising and discriminatory.     

Sleeping at the margins: a qualitative study of homeless drug users who stay in emergency hostels and shelters

A growing social science literature demonstrates that sleep is not merely a personal matter but also a political problem and a public health issue. Taking this as a point of departure, our article presents an analysis of sleeping practices amongst homeless drug users (HDUs) who make use of emergency hostels and night shelters in England. Data generated by way of qualitative interviews undertaken with 29 men and 11 women reveal that, as we might expect, securing sleep for this group is by no means easy. The strategies they pursue to find places to sleep are described, as are the threats and barriers to their sleeping. Emergency hostels and night shelters can afford a lifeline; providing warmth, water, food and access to support services. But if these are inadequately resourced they can be experienced as volatile environments and inimical to sleeping. It is argued here that although sleep is an essential prerequisite for health, for this population it can, somewhat ironically, be experienced as a risky behaviour. Vulnerable to both physical risks (e.g. inclement weather) and social threats (e.g. abuse and violence), falling asleep can exacerbate exposure to such dangers. These vulnerabilities are compounded by the social position of HDUs who live in socially and physically marginal places. It is this marginality that prevents them from being able to secure sleep that is both restful and restorative.     

Engagement with health and social care services: perceptions of homeless young people with mental health problems

The present qualitative study describes and discusses the perspectives and experiences of young homeless people with mental health problems in relation to their interactions with health and social care services. Working in partnership with Streetlink, a supported accommodation assistance programme in Adelaide, Australia, the authors interviewed 10 homeless young people, aged from 16 to 24 years of age, who had experienced mental health problems. In-depth interviews elicited accounts of the best and worst of the participants' experiences of health and social care services. Access to services was not identified as being a significant problem in comparison with the participants' concerns regarding the quality of the services encountered. The central findings stress the importance of a respectful and supportive climate in relation to the qualities of service provision that the young people identified as valuable for their continuing treatment or consultation.