Homeless children: Their evaluation and treatment

Homeless Children: . Their Evaluation and Treatment David

Wood,

MD,

n

MPH

The number of homeless families in the United States is growing at an alarming rate. More families are becoming homeless primarily because of financial and housing problems, such as loss of job and income, loss of welfare benefits, being victims of robbery, and eviction. Many of the homeless families have complex psychosocial and medical problems. Their children have a higher prevalence than the general population of all categories of illness, including acute illnesses such as colds, fevers, and diarrhea; chronic health problems such as epilepsy and asthma; developmental delay; and behavior and mental health problems. Clinical evaluation of the homeless family and child is presented, incorporating their special needs and considerations. J PEDIATR HEALTH CARE. i1989). 3, 194-199.

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he United States faces an epidemic of homelessness. The estimated size of the nation’s homeless population varies nationally from a conservative 350,000 to almost 3,000,OOO persons (U.S. Housing and Urban Development, 1984; National Coalition for the Homeless, 1985). Historically, the homeless population was characterized as aged men, suffering from either alcoholism or mental illness. Even if previously accurate, this depiction no longer holds true. Families represent the fastest-growing segment of the homeless population. A family is here defined as one or more adults living with a dependent minor. This nation’s two largest cities illustrate this national trend. In New York, families are the largest segment of the homeless population. Individuals in families comprise 35% to 50% of the homeless (New York Coalition for the Homeless, 1986). Between 40,000 to 60,000 homeless people live in the Los Angeles area (U.S. Conference of Mayors, 1984, 1986), and approximately 40% of the homeless in Los Angeles are family members. The national increase in family homelessness is primarily a result of two converging economic trends. First, the supply of affordable housing in major cities is rapidly decreasing because of rising costs and the depletion of low-cost housing by inner-city development (Hartman, 1983). The second economic trend is an increase in family poverty. In the past ten years, public assistance grants through Aid to FamDavid Wood is an NCHSR-funded Health Policy Study. Reprint requests: David Wood, St., Santa Monica, CA 90406.

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fellow MD,

at the RAND/UCLA

The Rand Corporation,

Center for 1700 Main

ilies with Dependent Children (AFDC) have decreased by 10% in real dollars (U.S. Congress, 1986). Moreover, the number of underemployed familiesfamilies whose wage earners are able to obtain only minimum wage jobs-has grown dramatically. These factors have caused the number of families in poverty to grow by more than 40% in the last 5 years (U.S. Congress, 1986). There are now more poor families competing forfaver low-cost housing units. n

HOMELESS

FAMILIES: WHO ARE THEY?

Very little is known about families who become homeless. Since 1985, homeless families have been seen at the Venice Family Clinic, under the Homeless Health Care project funded by the Robert Wood Johnson Foundation. To expand the understanding of the population, extensive interviews with 200 homeless families in 10 shelters in the greater Los Angeles area were conducted. The study documents demographics, health needs of the children, and family characteristics.

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here are now more poor families competing for fewer low-cost housing

units.

The boxes on p. 195 list descriptive data on the families interviewed at the shelters. Generally, the families had been homeless for a relatively short time; about 60% had been homeless less than 3 months. Only about 10% had been homeless for more than 1 year. JOURNAL

OF PEDIATRIC

HEALTH

CARE

Journal of Pediatric Health Care

The mothers in homeless families tended to be young, with a median age of 29 and a range from 14 to 50. More than halfgave birth to their first child by age 21, and one fourth became mothers by age 17. The average size of the families was between two and three children. The majority of the families were black (579/o), with 30% white and 7% Latino. The majority of the mothers had graduated from high school or finished some college. Approximately 70% of the families were on welfare when they became homeless, and more than 90% had been on welfare at some time.

M

others in homeless families tended to be young, with a median age of 29.

The majority of families were headed by single women (see box above), but more than half of the women reported that they were involved in a significant relationship with a man. Only 25% of the women were married, and many of the women in relationships were not living with the man. Women in relationships were typically involved with men who had serious problems: alcoholism (42%), physical abusiveness toward women (32%), poor work history (31%), and mental illness (15%). Approximately 42% of the women stated their relationship had none of these problems. The women frequently had backgrounds with complex psychosocial problems. Three fourths of the women reported histories of sexual or physical abuse and 39% of those were abused before 18 years of

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age. More than one quarter of the women (27%) reported having been removed from their own parents to live with other relatives or in a foster home. HEALTH EVALUATION HOMELESS FAMILY

n

OF THE

In evaluating the health of the homeless family, the health care professional must take into consideration the special characteristics and needs of this population. Providers need to understand that a homeless family’s basic hierarchy of needs is different from their own. Once homeless, the family focuses its concerns on day-to-day survival and protection from external threats. The parents are struggling to provide food, shelter, and other necessities for themselves and their children. As a result, many of the children’s needs may be neglected that would, in more secure family situations, be considered essential, such as emotional support, discipline, and health care. In addition, the parents often have feelings of guilt, failure, and self-condemnation. Though the initial parental attitude may range from depressive to arrogant, demanding, or hostile, the practitioner should focus on enabling the parent to feel accepted and openly relay the needs of the family. Subjective Data Base

The practitioner should try to obtain a comprehensive health history on the child and family. Ask the parent to describe his or her reason for coming to the clinic. The parent will usually describe a minor, acute health problem. The practitioner should begin by inquiring about the family’s ability to meet their

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basic needs of shelter, food, clothing, and security. Where have they been staying? With whom? What kind of situation is it? Why did they leave? What are their plans? How can they be contacted for follow up? Do they need assistance with these needs? The family members will not offer this information unless specifically asked. They may not have shelter for the night. Unless the family’s basic needs are met, the parents will find it hard to attend to the health needs of the child or listen to the counsel of the clinician.

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roviders need to understand that a homeless family’s basic hierarchy of needs is different from their own.

This initial visit with a homeless family is often the first time the practitioner has seen them as patients. It is therefore important to do a brief but comprehensive history that includes preventive health care, development, school progress, and medical history. Preventive Health Care

Miller and Lin (1988), and my own experience, indicate that homeless families are seldom current on routine preventive services. Therefore, the practitioner should ask when the child last had a routine physical examination, including screening for anemia, vision, and hearing. If the parents are unsure about these, all preventive services needed to bring the child up-to-date should be performed. Homeless children are at high risk for inadequate nutritional intake, failure to thrive, or delayed growth or obesity; therefore, each child’s height and weight should be plotted on a growth chart. Through obtaining a simple history and conducting screening, the practitioner may detect children with non-organic (or psychosocial) failure to thrive, or others with obesity. Immunizations are usually not current, and the records have often been either lost in the frequent moves or stolen. School enrollment can be delayed for weeks for lack of immunization documentation. Therefore, it is important to immunize children and reopen immunization records. Homeless children should be considered a high-risk group for tuberculosis; they require a PPD annually. The HIB, DPT, OPV, and MMR are given according to the routine guidelines of the American Academy of Pediatrics (Report on Committee on Infectious Disease, 1986).

The family is encouraged to obtain past records, if possible, to augment the current health records. Developmental

Status

Homeless children have three or more times the rate of developmental problems that other poor children do (Bassuk et al., 1986). Thus it is important to perform a brief development screening on all these children. This evaluation may include the parent selfadministered Denver Prescreening Developmental Questionnaire (PDQ) or an abbreviated administration of the Denver Developmental Screening Test (DDST) (Frankenberg, Goldstein, & Camp, 1971; Frankenberg et al., 1986). Children with possible developmental delays should receive a full DDST. All children who fail the DDST may be referred to the local Regional Center for Developmental Disabilities, where a comprehensive developmental evaluation can be performed. School Problems

In school, homeless children experience high rates of absenteeism and failure. In my experience, nearly 30% of children in Los Angeles homeless families are failing in school. Therefore it is important to inquire about school enrollment, achievement, and problems, and encourage the parents to seek the school’s evaluation of the child’s progress. Because of the families’ transience, children with special needs are often missed by the schools and do not receive the appropriate remedial service they are entitled to under the law. A note from the health provider is a powerful stimulus to the school system to perform academic testing. Past Medical Problems

Due to the stresses of their daily lives and the constant struggle for the necessities of life, homeless families often seek medical care only for acute illness, meanwhile neglecting other important health problems.

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omeless children have three or more times the rate of developmental problems that other poor children do.

Therefore, a thorough inquiry into the child’s past medical problems is very important. Use a quick “review of systems” to jog the parent’s memory and improve the reporting of important past medical problems. The author and other clinicians (Wright

lourndl of Pediatric Health

& Weber, 1987) have found higher-than-expected incidence of asthma or recurrent bronchitis, anemia, cerebral palsy, seizure disorders, enuresis, encopresis, urinary tract infections, and other health problems in these children. Because the homeless family has often had poor accessto medical care, these problems may or may not have been diagnosed. A review of systems approach will uncover specific medical symptoms that should be pursued in a diagnostic workup. Behavior Patterns and Family Functioning

When first interacting with the mother, the practitioner should obseve her affect and speech for signs of depression, anger, confusion, ambivalence, or more profound mental illness. Signs in the mother, such as extreme hostility or suspicion, indifference toward the child’s health, or abnormally low body weight, may be signs of drug abuse in the family. Note the interaction of the family as a unit-the amount of communication, expression of affection, discipline, and organization. Ask directly whether all the children are living with the family. If not, inquire as to where they are and whether the Department of Children’s Protective Services has ever removed children from the family’s custody. The behavior of the children is an excellent barometer for family stress in general and level of family functioning in particular. Inquire of the mother and observe the children for destructive behavior, withdrawal, depression, anxiety, regressive behavior (such as bedwetting in a previously toilet-trained child), or more profoundly disturbed behavior (such as rocking and self-mutilation). It is important to be sensitive to the maturity level of the children’s behavior. Homeless children often display “pseudomature” behavior that appears mature on the surface, but may be actually maladaptive. For example, 3-year-old children may be immediately affectionate with strange adults of whom they should be initially suspicious. A 4-year-old may act as the part-time caretaker for a year-old sibling, performing duties such as diapering or feeding. These may be signs of extreme stress on the child and family and call for further evalution by a mental health professional. Objective

Homeless Children

Care

Data Base

As noted above, the child’s initial complaint may not be the most serious medical problem. It is common for a history or physical examination to uncover serious disorders in a child complaining of cold symptoms. In addition to treating the child for the initial complaint, the clinician should also search for other

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acute problems that are common in homeless children. These conditions include: ear infections, colds, tooth decay, lice or scabies, conjunctivitis, allergies, skin infections, diaper rashes, cuts, abrasions, and bruises. Physical Examination

The physical examination should also include a careful inspection for the following chronic problems: visual acuity and/or strabismis, sinus infections with chronic nasal congestion and purulent nasal discharge, hearing problems, heart murmurs, anemia, asthma or bronchitis, constipation and encopresis (with palpable intra-abdominal stool and/or hard stool in the rectum), eczema, and neurologic signs, such as weakness, spasticity, or asymmetry of movements or reflexes.

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he behavior of the children is an excellent barometer for family stress in general and level of family functioning in particular.

Homeless families have high rates of intrafamily violence, and both child and spouse abuse are common (Bassuk et al., 1986; Bassuk & Rosenberg, 1988). Thus, if there is sufficient privacy, every physical examination should include a genital examination for signs of sexual abuse. The skin and extremities also should be carefully inspected for new or old traumatic injury. Explanations by the parents for any findings should be carefully explored. Any questionable or suspicious findings should be first reported to Department of Children’s Protective Services and then referred to a specialist for further examination and an in-depth interview with the family. Screening Tests

I recommend the following examinations be routinely performed: screening for anemia, vision and hearing, and a routine urinalysis. If the child presents with diarrhea, a stool culture is recommended. There have been several outbreaks of shigella in the shelters our clinic serves, and the stool culture is used as much for epidemiologic surveillance and disease control as for clinical management. H ASSESSMENT AND PLAN

An effective health plan for homeless children requires the clinic to develop an extensive outreach and follow-up system. This outreach team should mini-

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mally consist of a public health nurse and a community worker. The box above lists the responsibilities of the nurse and community worker on the outreach team. The outreach team assists families in following medical regimens and accepting services, such as psychiatric counseling, parenting classes, and follow-up health visits.

A n effective

health plan for homeless children requires the clinic to develop an extensive outreach and follow-up system.

The outreach team will be better able than the clinic team to help the family set priorities and incorporate the clinical recommendations into their life in the shelter. Families in such stressful living conditions and with such a wide array of problems, need an advocate outside the clinic who can see their entire situation, follow-up on problems, help the family maintain priorities, and help them make progress toward meeting their health and other basic needs. Case Study Subjective. The mother’s chief concern is that her Smonth-old boy has diarrhea. The diarrhea occurs four times a day and fills the diaper. There is no vomiting, fever, rash, or blood in the stool. The child is mildly irritable, but taking fluids well. The review of his

medical history reveals that he was less than five pounds at birth and remained in the hospital 1 month. He was hospitalized at 2 months of age for a fever. The mother is not quite sure what he had, but he was in the hospital 10 days. The review of systems does not reveal any other problems. The child is behind on his immunizations and has had only one well child health visit in his life. By a quick developmental history, it appears that the child may be delayed: he cannot sit alone. His social skills and upper extremity motor skills appear normal by history. The mother is not with an adult partner, and she has no other children. The mother became homeless because she was recently dropped from welfare for reasons unclear to her. She has no money, food, or plans for shelter for the night. She has been living in a friend’s car, but she does not want to go back to that situation because it is dangerous. Objective. The mother is moderately hostile and appears detached and depressed. On physical examination of the child, he is afebrile, well hydrated and active, and his growth parameters are tenth percentile for his age. The physical examination is normal, except that the neurologic examination shows mild hypertonicity in the lower extremities, and he is unstable in the sitting position. He has a normal grasp and passes objects hand to hand. On a full Denver Developmental Screening Test, he fails the gross motor section and passes the fine motor, personal-social and language sections. A screening hematocrit is 30%.

Journal of Pediatric Health Care

Assessment, by Problem

She 1. Housing/safety/food/transportation. has no place to stay tonight, needs clothes and needs help requalifying for welfare or looking for a job. 2. Diarrhea. The diarrhea appears mild, with no dehydration or fever. 3. Questionable developmental delay. He may have a mild form of spastic diplegia. 4. Anemia. 5. Well child care-immunizations, nutrition, and growth. 6. Question of maternal depression. Plan, by Problem

1. Emergency housing voucher or same-day referral to a shelter. Refer to outreach team for welfare advocacy, food pantry, and clothes distribution agency referral. Bus tokens for transportation. Close follow-up by the outreach team community worker. 2. Stool culture for surveillance. Oral rehydration fluid information and education on transition diet. Give 2-day supply of soy formula. Refer to outreach nurse for next-day follow-up evaluation and education. Notify outreach nurse of pending culture. 3. Refer to the regional center for complete evaluation. The outreach team should encourage the mother to follow through and check on compliance with appointments. 4. Educate the mother about iron-containing foods and a WIC referral. Notify the outreach nurse of the referral. Treat with ferrous sulfate at 3 to 5 milligrams of elemental iron/kg. Inform mother that the hematocrit should be rechecked in one month. 5. Give the DT and OPV immunizations during this visit, despite the mild illness. Withhold the pertussis component until after further developmental and neurologic evaluation. 6. Refer the mother to a local mental health agency in coordination with the outreach team. n

SUMMARY

Often the number and complexity of health problems in a homeless family are overwhelming for the cli-

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Children

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nician, as well as for the family. But when a clinicbased team and an outreach team work together, it becomes a powerful intervention in the lives of the families. Social and medical problems that would only frustrate the clinic-based practitioner become very responsive to a coordinated approach with an outreach team. With this case management approach, many families have responded quite well. They begin to sense a new self-confidence and take control of the children’s health and their very lives. It is rewarding to address complex psychosocial and physical health needs of a family and see the healing, growth, and progress that may result. w REFERENCES Bass&, E., Rubin, L., & Lauriat, A.S. (1986). Characteristics of sheltered homeless families. American Journal ofPublic Health, 76, 1097-1101. Bassuk, E., & Rosenberg, L. (1988). Why does family homelessness occur? A case control study. A&an Journal of Public Health, 78, 783-788. Committee on Infectious Disease, American Academy of Pediatrics. (1986). Repvrt of the Committee on Infectiuus Diseases (20th ed.). American Academy of Pediatrics, Elk Grove Village, IL. Frankenburg, W.K., Goldstein, A.D., &Camp, B.W. (1971). The Revised Denver Developmental Screening Test: its accuracy as a screening instrument. Journal of Pediatrics, 79, 988-995. Frankenburg, W.K., Van Doorninck, W. J., Liddell, T.N., & Dick, N.P. (1986). The Denver Prescreening Developmental Questionnaire (PDQ). Pediukcs, 57, 744-573. Hartman, C. (1983). America’s bowing crisis: What is to be done? Boston: Routledge & Kegan. Miller, D., & Lin, E. (1988). Sheltered homeless families. Pediatrics, 81, 668-674. National Coalition for the Homeless (nd.). Homelessness: National summq and response. New York: Author. New York Coalition for the Homeless (1986). HUNJ~ children and Mr. Cuomu: Time fw a&m. New York: Author. U.S. Conference of Mayors. (1984). Homeless in America. Washington, DC: Government Printing O&e. U.S. Conference of Mayors. (1986). The continuedgrowth of bunger, homelessness, and poverty in America’s cities: 1986. Washington, DC: Government Printing Office. U.S. Congress. House of Representatives. (1986). Safq netproyams: Are they reaching children? Hearings before the Select Committee on Children, Youth and Families, Washington, DC: Government Printing Office. U.S. Department of Housing and Urban Development. (1984). A report to the Secvetaly on the homeless and emeyency sheltws. Washington, DC: DHUD. Wright, J.D., & Weber, E. (1987). Homekwzess and health. Washington, DC: McGraw-Hill.

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