Before I joined the Center for Social Innovation, I worked at a residential treatment program for adolescent girls with behavioral health issues. All had experienced severe or recurring trauma. Most were neglected or abused by a person close to them. For some, their childhood trauma included periods of homelessness. They had spent time on the streets, in shelters, doubled up with friends or family members, and in unstable housing where they were one crisis away from another bout of homelessness.
The youth I worked with were at one end of a spectrum of children who had experienced homelessness and struggled with mental health issues. They had been diagnosed with PTSD, anxiety disorders, depression, psychotic spectrum disorders, bipolar disorders, and personality disorders. They needed therapy, medication, and individualized education plans. However, not all children who experience homelessness have or will develop a mental illness. Studies have documented that there is a “continuum of risk” to which children are exposed. On this continuum, children experiencing homelessness lie furthest out, followed by low-income housed children, then children in the general population. Homeless children are at the greatest risk.
In February, the Center for Social Innovation, led by Dr. Ellen Bassuk, published new research: The Prevalence of Mental Illness in Homeless Children: A Systematic Review and Meta-Analysis (Bassuk, Richard, & Tsertsvadze, 2015). We reviewed the literature from 1990 to 2014 and our results were startling.
In the twelve studies included in our review, 10% to 26% of homeless preschoolers and 24% to 40% of homeless school-aged children had mental health problems requiring clinical evaluation. When we pooled data from the studies that included a comparison group of housed low-income children, the school-aged homeless children were significantly more likely to have a mental health problem than their housed peers. Children who were homeless were more than twice as likely to have internalizing problems, including withdrawn, anxious, and depressed behavior.
Our systematic review confirmed past research on homeless children. Despite methodological differences these studies told a story: these kids need mental health services and support. More recently, the conclusions drawn from our study have been supported by new work by Dr. Mary Haskett and her colleagues. They assessed children in 11 emergency or transitional housing programs in a large metropolitan area in North Carolina and found that 25%, 1 in 4, suffer from mental illness and need treatment.
What causes children experiencing homelessness to develop high rates of mental illness?
Families who are homeless vary in their past and current experiences, but many have risk factors that increase the likelihood of developing mental health issues. These include unhealthy and chaotic living conditions, extreme poverty, and extremely high rates of exposure to traumatic events, such as domestic violence, losing a parent, and the experience of not having a home, living on the streets, or living in a shelter.
A few months ago, a story from Southern California Public Radio described the toll homelessness takes on children. The story included an interview with Yanira Mayora Rodriguez, a teacher who worked with Early Head Start for eight years.
“Anytime a child is moved it can feel to that child like a death because it’s so traumatic.”
She has seen how homelessness impacts the children in her classroom.
“It makes it hard for those children to make connections with other children, because they’re not worried about, 'Are you going to play with me?' They’re worried about, 'Where am I going to sleep?'” Rodriguez said.
Rodriguez also emphasized that being “doubled up,” like many children are, can put as much stress on families as shelters. Living in crowded rooms that don’t belong to you and carry with it the threat of being kicked out at any time undermines a child’s sense of safety and security. Additionally, children experience the adverse consequences of their mothers’ trauma. One study in our review found that 93% of homeless mothers experienced at least one trauma and 81% experienced multiple traumatic events, with violent victimization the most common (Hayes et al., 2013).These experiences profoundly impact a mother’s ability to become residentially stable, find a job that pays a livable wage, and parent successfully.
What can we do?
On the “continuum of risk,” homeless children have the greatest chance of developing mental illness, but a number of factors moderate that risk and facilitate resiliency.
Dr. Ann Masten at the University of Minnesota defines resilience as “the capacity of a dynamic system to withstand or recover from significant challenges that threaten its stability, viability or development” (p. 494). Concluding our review, we looked at the literature on resilience and the kinds of policies, programs, and practices that help children both resist stress and bounce back from the significant challenge of homelessness (Cutuli & Herbers, 2014).
Key recommendations include:
- Routine screening and clinical assessment for all children and referral to treatment for those who need it.
- Programs and policies that promote positive parenting and enhance parent-child relationships, such as family-friendly common spaces in shelters.
- Services such as early intervention programs that foster self-regulation skills and enhance executive functioning.
- Training on trauma for staff at all levels of the organization; training should include understanding trauma’s impact on the brain and body as well as guidance on how to provide trauma-informed care.
- Programs and activities that support school stability and attendance.
- Research that confirms evidence-based mental health interventions for children experiencing homelessness.
This is not an exhaustive list. There are many ways to increase the protective factors for children at risk and facilitate the development of good outcomes. Unfortunately, until the need for support is recognized, we will fail to provide children with the tools they need to grow and thrive. Too often, rather than screening sheltered children, when they are in need and in the position to be referred to services, it is assumed that they will be helped by mainstream healthcare. Many believe that all they need is a roof over their head, and the rest will fall into place. However, mainstream services are often not available to the kids that need help. The same is true for mothers; while the lack of affordable housing is a primary driver of homelessness, subsidies for housing do not guarantee residential stability or positive outcomes (Bassuk et al., 2014). Many families need targeted services to help them stabilize, become economically self-sufficient, resist stress and bounce back.
If young children are assessed and those found to be at moderate risk supported, we can help prevent them from developing diagnosed mental illness. Our review found significant differences between homeless and housed kids once they reached school age, not younger, suggesting the impact of cumulative stress. We can address this problem by early intervention.
The National Center on Family Homelessness reported that 1 in 30 children in the U.S. experienced homelessness in 2013. Nearly 2.5 million. If 25% have a mental health issue in need of treatment, the conservative estimate from our study and a finding confirmed by Dr. Haskett’s study, 625,000 children need clinical evaluation and services.
At my past job, it was clear that these youth needed services in addition to a place to live. With histories of psychiatric hospitalization, arrest, or victimization, few would dispute this fact. My hope is that we can screen for mental health issues early and often, and offer individualized levels of care. It is imperative that we do this before needs intensify, traumas accumulate, and the possibility of bouncing back becomes more difficult to achieve.
May 3rd through 9th is National Children's Mental Health Awareness Week, and Thursday, May 7th is SAMHSA's National Children's Mental Health Awareness Day. These events will highlight the prevalence of mental illness in the general population of children. I urge you to use this opportunity to have conversations about the unique needs of children experiencing homelessness.
Bassuk, E.L., Richard, M., & Tsertsvadze, A. (2015). The prevalence of mental illness in homeless children: A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 54(2), 86—96.e2.
Buckner, J. (2008). Understanding the impact of homelessness on children: Challenges and future research directions. American Behavioral Scientist, 51, 721-736.
Cutuli, J. J., & Herbers, J. E. (2014). Promoting resilience for children who experience family homelessness: Opportunities to encourage developmental competence. Cityscape, 16(1), 113-139.
Haskett, M. E., Armstrong, J. M., & Tisdale, J. (2015). Developmental Status and Social–Emotional Functioning of Young Children Experiencing Homelessness. Early Childhood Education Journal, 1-7.
Hayes, M., Zonneville, M., & Bassuk, E. (2013). The SHIFT Study final report: Service and housing interventions for families in transition. Newton, MA: National Center on Family Homelessness.
Masten, A. S., Miliotis, D., Graham-Bermann, S. A., Ramirez, M., & Neemann, J. (1993). Children in homeless families: Risks to mental health and development. Journal of Consulting and Clinical Psychology, 61, 335-343.
Masten, A.S. (2012). Risk and resilience in the educational success of homeless and highly mobile children. Educational Researcher, 41, 363-365.
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