A family was encountered by a pediatrician at a local daycare center that provided temporary and emergency childcare for families who were homeless, involved with domestic violence or the foster care system. The family had moved from another state after they had lost jobs and were living in a shelter. There were two adult sisters, one of whom was pregnant, one sister’s husband, and 4 children under age 5. One adult had secured employment and the other two were searching for work and permanent housing. The one mother stated, “It’s so nice that you have that table of free clothes. We need so much.”
The diagnosis of a homeless family with multiple needs was made. The pediatrician inquired to the center director how the center interacted with other agencies to help support families. The center director discussed how they worked with the state’s human services department, the homeless shelter, the domestic violence program, several local food programs, early childhood education programs and school district, clothing agencies and local programs for free or reduced cost for medical care. The center director noted that she had helped the one sister obtain prenatal care on the second day the children had come to the center, and the children were seen in a clinic down the street within a week of coming to the center. The center director also explained that the childcare center was able to function itself through the generosity of a local church that provided the space for the center, local food programs that provided meals and snacks, and agencies that provided transportation between the shelters and domestic violence programs.
The United States Federal definition of a person considered homeless is one 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.” About 3.5 million people of which are 1.35 million children are likely to experience homelessness in a given year. Note that homelessness is not permanent but persons are likely to move into and out of a homeless state over time. The average period of homelessness is 10 months and 25% of children are homeless more than once during childhood. Children < 18 years accounted for 39% of the homeless population with 42% of these children being under the age of five in 2003. Unaccompanied minors (including runaways) were 5% of the urban homeless. Rural populations have an increased risk of homelessness than urban populations. Families with children are among the fastest growing homeless populations, with a 2007 study, finding families with children comprising 23% of the homeless population in urban areas.
As much as 25% of homeless persons are employed but are not making adequate income. One study stated that “…in the median state a minimum-wage worker would have to work 89 hours each week to afford a two-bedroom apartment at 30% of his or her income, which is the federal definition of affordable housing.” Racial and ethnic variations in homelessness depend on geographical location. Other groups with higher rates of homelessness include domestic violence victims, persons with mental illness or addiction disorders and veterans.
Opportunities to assess adequate housing during a medical encounter include:
- Patient registration – confirming an address, noting numerous changes in address or other contact information or insurance, and single mother headed households
- Reviewing immunization records – having no records, inadequate records, or multiple sources of immunization administration
- Interactions with health care professionals – asking about situations that may influence the doctor or nursing plans such as family stress, problems with travel, a sick relative, a housing change, etc. This can be done when the patient is placed into the room and at other points of contact such as immunization administration.
- Reviewing and re-taking social histories may give clues including history of frequent changes of child care, schools or employment, and having little family, friends or other support available.
- Responding to parental communication such as inquiring about sample medication availability, coverage of medication/health services by insurance, requests for supplies such as diapers, formula, snacks or food, or requests for transportation vouchers, etc.
Children who are homeless or inadequately housed have higher rates of many health problems. These rates are beyond those of children who live in poverty but are adequately housed.
Children who are homeless experience a higher rate of:
- Overall health is poorer – homeless children have more health problems, more severe health problems and more multiple health problems.
- Child abuse and neglect – domestic violence is common among homeless mothers and families. Children are often witnesses to abuse or are victimized themselves. Child abuse investigation prevalence with homeless children is 24-35%. Children are often witnesses to abuse or are victimized.
- Dental – poor dentitia and caries
- Developmental delays – speech and language is the most common delay in younger children. Any developmental area can be affected though. School age children have more problems with verbal skills, vocabulary and reading. They also have more grade repetition and overall below-average school performance.
- Mental health and behavior problems – especially depression
- Immunization – under- and over-immunization for age occurs because of inconsistent health care
- Infant mortality
- Infectious disease
- Ear infections
- HIV and AIDS
- Wound and skin infections
- Upper respiratory tract infections
- Injuries – shelters and temporary housing are less structured and generally less safe so injuries are common
- Lead – although there is a small amount of data, multiple risk factors make homeless children a high-risk group
- Nutrition – obesity, malnutrition, growth stunting and anemia
- Respiratory diseases – asthma, bronchitis, pneumonia
- Substance abuse
- Visual acuity problems
Questions for Further Discussion
1. What resources are available locally to assist for homeless children and families?
2. How does your practice assist homeless families so they can receive adequate healthcare?
3. How can you adapt your practice to provide improved care for homeless families?
4. How can health care providers advocate for their homeless families?
Homeless Health Concerns
Health Maintenance and Disease Prevention
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Homeless Health Concerns
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Karr C, Kline S. Homeless children: what every clinician should know. Pediatr Rev. 2004 Jul;25(7):235-41.
American Academy of Pediatrics Policy Statement. Providing Care For Immigrant, Homeless, and Migrant Children. Pediatrics Vol. 115 No. 4 April 2005, pp. 1095-1100.
Grant R, Shapiro A, Joseph S, Goldsmith S, Rigual-Lynch L, Redlener I. The health of homeless children revisited. Adv Pediatr. 2007;54:173-87.
National Coalition for the Homeless. How Many People Experience Homelessness? Available from the Internet at http://www.nationalhomeless.org/publications/facts/How_Many.html (rev. June 2008, cited 2/5/09).
National Coalition for the Homeless. Who is Homeless? Available from the Internet at http://www.nationalhomeless.org/publications/facts/who.html (rev. June 2008, cited 2/5/09).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital