Child Well Being: Health

Many homeless families use emergency rooms as their primary source of health care, seeking assistance only when problems become severe and urgent.

Homelessness can cause health problems and exacerbate existing ones. The impact of poor health on children is profound. Poor health can lead to more absences in school, fewer opportunities for exercise and recreation, and costly emergency care for acute and chronic illnesses that go untreated. Health is defined broadly in the Report Card, and includes physical, mental, and dental health. Health scores were combined with education and hunger scores to create the overall child well-being score.

i. General Health

What We Know from the Report Card

More than one in seven homeless children have moderate to severe health conditions. In comparison, less than one in sixteen middle-class children report these health conditions.⁵¹

Homelessness itself can make children sick. Losing one’s home can cause illness and aggravate existing health conditions for homeless children who tend to be in poorer health than their housed counterparts.⁴⁰

• Poor health for homeless children begins at birth. They have lower birth weights and more often need specialty care immediately after birth as compared with housed children.⁴¹
• From infancy through childhood, homeless children have significantly higher levels of acute and chronic illness.⁴²
• Predictably, homeless children have poorer access to both medical and dental care.⁴³

Health disparities are an integral part of the health status of homeless families and children. Often explained as consequences of a “perfect storm” of poverty, unemployment, and racism, health disparities reflect a complex relationship among economic and social factors, environmental conditions, access to health services, and quality of care. Significant health disparities persist between poor and non-poor households, and between Whites and members of various racial/ethnic minority groups. Of all Americans, people of color, those living below the poverty level, and those with the least education face the worst health outcomes, including higher rates of disease, disability, and premature death.⁴⁴ Even when income and health insurance are accounted for, persons from racial/ethnic minority groups are more likely to have poorer health outcomes.⁴⁵

The same health disparities that affect the broader population touch low-income and homeless children as well. Black and Hispanic children are twice as likely as White children not to be in “excellent or very good health.” Within these groups, Black children fare worse than Hispanic and White children. For example, Black children are 49% more likely than White children to have asthma and 21% more likely to have a limitation in activity.⁴⁶ In contrast, Hispanic children are less likely to have asthma or describe a limitation in activity. Despite their medical needs, both Hispanic and Black children must cope with limited access to ongoing health and dental care, with Hispanic children having the poorest access of all. With the exception of asthma, many of the differences in health status and access to care between White and non-White children were not markedly reduced until family income fell below 200% of the poverty level.⁴⁷

As far as health condition and medical care are concerned, children are prisoners of their socioeconomic and insurance status. To address adequately the health of low-income and homeless children, the social and environmental determinants of disease must be integrated into a more holistic approach. As long as disparities persist among minority groups related to housing, income, education, and employment, so too will health disparities remain. To ensure equal health outcomes among all children, not only must the individual and family be treated, but neighborhood and community factors must be considered as well.

With the exception of the United States, almost all industrialized countries in the world provide guaranteed health insurance for children. Yet, nine million American children under age 18 were uninsured in 2007 and therefore less likely to receive routine and preventive health care.⁴⁸ They are almost five times as likely to go two years without medical care compared to children with insurance. Public programs such as Medicaid and the State Children’s Health Insurance Program (SCHIP) provide health coverage for about half of America’s low-income children.⁴⁹ Nevertheless, low-income and homeless children’s access to health care is limited by participation of physicians in these public insurance programs as well as their uneven geographic distribution.

More than one in ten homeless children report that they have not seen a doctor in the past year. Many homeless families use emergency rooms (ER) as their primary source of health care, seeking assistance only when problems become severe and urgent. Primary and preventive care, which keep children healthy, are largely absent. This leaves various medical problems unrecognized or poorly treated, which, in turn, lead to repeated ER visits, unnecessary and costly treatment, and higher rates of hospitalization.⁵⁰

Top and Bottom 10: Moderate to Severe Health Conditions

ii. Asthma

What We Know from the Report Card

Almost one out of nine homeless children experienced one or more asthma-related health conditions. In comparison, less than one in 15 middle-class children experienced asthma-related health conditions.

Asthma has become a hallmark of poor health among homeless children. The most common chronic childhood illness, it is aggravated by the difficult living conditions often experienced by children without homes. It keeps children from going to and participating in school; interferes with a child’s ability to play; and places an undue burden on the family. For families headed by women alone, who cannot afford child care and may have jobs with inflexible hours, caring for a child with asthma can contribute to the slide into homelessness. Statistics describing the prevalence of asthma confirm its association with poverty and environmental conditions that challenge respiratory health.

• In 2000, asthma accounted for 152,000 or 7.4% of all hospital admissions for children and adolescents, with more than half billed to Medicaid, which is the health insurance most often used by homeless children.⁵²
• Asthma is more common among those living below the Federal Poverty Level (10.3%) compared to those at or above the poverty level (6.4% to 7.9%). It is also more common among African Americans (9.2%) compared to Whites (6.9%), and those of Puerto Rican descent (14.5%) compared to those of Mexican origin (3.9%).⁵³
• African-American and Hispanic children have more severe asthma, miss more school days, and have poorer health status as compared to white children with similar demographic and insurance status.⁵⁴

The profile of children who suffer from asthma is magnified for homeless children, a disproportionate number of whom are African-American. High rates of asthma among homeless children are strongly associated with old, dilapidated housing, exposure to smoke and other environmental allergens, crowded shelters that facilitate the spread of infections, stress, and poor access to health care.

Asthma-Related Health Conditions in Homeless and Middle-Income Children

iii. Dental Care

What We Know from the Kaiser Commission on Medicaid and the Uninsured⁵⁷

*Dental health outcomes are included within the General Health indicator described earlier.

• Although homeless children are likely to have more dental caries (i.e., tooth decay, cavities) as well as more severe decay at any age, they are twice as likely to have untreated caries in their primary teeth.
• One in three poor children had no dental care in the prior year, compared to one in five children in households above the poverty line.
• Low-income children had 12 times as many restricted activity days due to dental disease, compared to their higher income counterparts.
• Within the same income groups, there is also evidence of racial/ethnic disparities. Children of color are more likely to have tooth decay, but less likely to have visited a dentist in the prior year compared to White children in the same income bracket.

Homeless children are at increased risk for tooth decay—the most common unmet health need among all children.⁵⁵ Five times more common than asthma, it has the potential of adversely affecting every aspect of a child’s life. With the tragic death of two children in 2007 due to complications from untreated dental disease, more attention has been focused on this problem.

Insurance coverage often determines the extent of preventive dental care.⁵⁶ Children’s dental woes outweigh even their general medical needs. The American Academy of Pediatric Dentistry recommends that children visit a dentist at least once before age one and bi-annually afterwards. Follow-through may depend to a large extent on adequate dental insurance. According to the National Survey of Children’s Health:

• Over 16 million children are not covered for dental services, more than two and one-half times the number of children without medical coverage.
• About half of all low-income children receive their medical and dental coverage through Medicaid and SCHIP.
• In 2006, almost 75% of children aged 2-17 with public coverage visited a dentist in the past year, compared to only 48% of uninsured children.

Limited participation of dentists in these public insurance plans, an inadequate number of dentists, as well as uneven geographic distribution, all contribute to poor access.

iv. Traumatic Stress and Violence

What We Know from the Report Card

• More than three times as many homeless children are in households where adults “hit or throw things” compared to middle-class children.

Stress and trauma are all too common experiences in the lives of homeless children. They encounter interpersonal and random violence both in their homes and neighborhoods. Not only do homeless children commonly witness severe conflict and violence between their parents or parenting figures, they are routinely victims of physical and sexual abuse. In a five-city study of assaults on women, children were found to be present in more than three-quarters of the households where domestic violence was reported to the police. Most of the households were headed by women with low incomes.⁵⁸

The effects of traumatic stress and violence on children can be profound and long-lasting. Witnessing violence can be as shattering as being directly involved in violent altercations. Many children who witness violence develop a range of emotional and behavioral problems including: high levels of depression and anxiety; increased fearful and inhibited behavior; more frequent aggressive outbursts and antisocial behavior; and greater acceptance of violence as a way of resolving conflict. There is little doubt these experiences interfere with a child’s capacity to learn and to perform adequately in school. In fact, childhood trauma can lead to damaging changes to brain structures and functions.⁵⁹ Violent experiences also may result in difficulties forming sustained relationships and feeling safe in the world.

Researchers have documented a strong link between domestic violence and homelessness. Almost 40% of cities surveyed by the U.S. Conference of Mayors identified domestic violence as a primary cause of homelessness.⁶⁰ A multi-year, longitudinal study of homeless families in a medium-sized Massachusetts city found that approximately two-thirds of homeless mothers had been severely physically assaulted by an intimate partner as adults – almost one-third by their current or most recent partner. More than one-quarter of these women needed or required medical treatment because of the assault.⁶¹ Despite the strong association between homelessness and domestic violence, many programs for homeless children and families have not integrated trauma-informed services into their routine care.

v. Mental Health

What We Know from the Report Card

• One in six homeless children have emotional disturbances. This rate is twice that experienced by middle-class children.

For children to grow, learn, and master the developmental tasks of childhood, they must be physically and emotionally healthy. For all children, the consequences of untreated mental health disorders are devastating and may include school failure and dropping out, substance abuse, violence, and even suicide.⁶² Sadly, young children are not immune; among children ages five to 14 years old, suicide is the sixth leading cause of death.

• One in five young people have a mental health problem.⁶³
• At least one in ten, or about six million children, has an emotional disturbance that is serious enough to disrupt daily functioning in home, school, or the community.⁶⁴
• Mental health disorders may begin as early as 7-11 years old and often persist into adulthood.⁶⁵
• More than three-quarters of these children do not receive adequate treatment.⁶⁶

Low-income children are at increased risk for mental health problems – not surprising given the high levels of stress and trauma they experience. More than one in five low-income children ages six to 17 have mental health problems. Many more have serious emotional disturbances. Approximately 57% of these low-income children come from families that live at or below the poverty level.⁶⁷

Many homeless children describe worries and fears about having no place to live or sleep or about something bad happening to their family. They also fear guns and violence.⁶⁹ They are also the most vulnerable of all to mental health problems. By age eight, one out of three children experiencing homelessness will have a diagnosable mental disorder that interferes with daily activity – compared to nearly one out of five other school-age children. Almost half suffer from anxiety and depression, while one-third express their distress through aggressive or delinquent behaviors.⁶⁸

The health and well-being of a parent is inextricably linked to the health and well-being of their children. Mental health issues, such as the high rates of depression seen in homeless mothers, significantly impede a parent’s ability to bond with her child. The quality of the parent/child relationship has a profound impact on a child’s awareness of self and others, social and emotional development, and school adjustment.⁷⁰ The absence of a predictable and supportive parent is a threat to a child’s emotional and physical well-being and may impact all aspects of a child’s functioning, beginning at the most fundamental, neurobiological level. Research suggests that “relationships children have with their caregivers play critical roles in regulating stress hormone production during the early years of life.”⁷¹ Experiences such as abuse, neglect, and maternal depression can lead to elevated levels of stress hormones that may impact brain development and future coping skills. In addition, research has shown that children who have a parent with a mental health problem are at greater risk of developing psychiatric diagnoses, developmental delays, and psychosocial and academic problems.⁷²

Children with mental health needs are sometimes faced with a bleak future. Even with health insurance, more than three-quarters do not receive much needed mental health services. For those without health insurance and those with the most intense needs, prospects are even worse. As with other healthcare disparities, culture, race, and ethnicity have a strong impact on mental health.⁷⁸ For example, only 12% of Latino children receive adequate mental health services. Furthermore, if the mental health problem is complicated by substance abuse, the likelihood of receiving treatment is minimal.⁷⁹ The barriers to receiving adequate mental health treatment while homeless are overwhelming.

Emotional Disturbances in Homeless and Middle-Income Children