Psychosocial Functioning of Homeless Children PANOS VOSTANIS, M.D., ELEANOR GRATTAN, B.A., STUART CUMELLA, PH.D., AND CAROLINE WINCHESTER, B.Se.
ObJective: To investigate the' psychosocial characteristics of homeless children and their parents. Method: Homeless families were assessed within 2 weeks of admission to seven hostels and were compared with a group of housed families matched for socioeconomic status. Measures included a semistructured interview, the General Health Questionnaire (GHQ). the Interview Schedule for Social Interaction, the Child Behavior Checklist (CBCl), the Communication domain of the Vineland Adaptive Behavior Scales, and height and weight percentiles. The sample consisted of 113 homeless families (249 children aged 2 through 16 years) and 29 comparison families (83 children). Results: Homeless families primarily consisted of single mothers and an average of two children, who had become homeless because of domestic violence (56%) or violence from neighbors (29%). Homeless mothers reported high rates of previous abuse (45%) and current psychiatric morbidity (49% caseness on the GHQ) and poor social support networks compared with housed controls. Homeless children were more likely to have histories of abuse, living in care, and being on the at-risk child protection register and less likely to have attended school or a preschool/day-care center since admission to the hostel. They also had delayed communication and higher CBCl scores. Maternal GHQ scores best predicted CBCl caseness. Conclusions: Homeless mothers and children have high rates of psychosocial morbidity, which are related to multiple risk factors and chronic adversities. Their complex needs should be best met by specialized and coordinated health, social, and educational services. J. Am. Acad. Child Ado/esc. Psychiatry, 1997, 36(7):881-889. Key Words: homeless, children, families, psychosocial, development.
AcupudJanuary 31. 1997. From tht Dtpartmmt of Child and Adoltscmt Psychiatry. Unit'mity of Birmingham. UK Dr. Vostanis is Smior Ltcturtr in Child and Adoltscmt Psychiatry. Ms. Grattan is a Rtuarch Associau. Dr. CumtlIA is Smior Rtuarch Ftllow. and Ms. Winchtsur is a Rrstarch Associau. This work was supporttd by tht NUffitld Foundation. Tht authors art grauftl to all[amilits and staffwho participaud and to tht Housing Dtpartmmt of tht Birmingham City Councilftr thtir htlp. Rtprint rrqutsts to Dr. Vostanis. Univmity ofBirmingham. Parkvitw Clinic. Qutmsbridgt Road. Moulty. Birmingham B/5 8QE. UK; t-mail: [email protected]
0890-8567/97/3607-0881/$O.300/0© 1997 by the American Academy of Child and Adolescent Psychiatry.
tute at least 65% of homeless people (Bachrach, 1992; Victor, 1992) and that homeless families are the most rapidly expanding group within the total homeless population (Wright, 1993). It is estimated that every night 100,000 American children go to sleep homeless (Mihaly, 1991). At anyone time, more than 60,000 households in England are defined as homeless by local authorities, while between 140,000 and 170,000 households are statutorily accepted as being homeless every year (Connelly and Crown, 1994; Leff, 1993). To this population, we need to add homeless young people aged 13 through 18 years (estimated at half a million annually in the United States [Robertson, 1991]). It has been documented that homeless children have high rates of a variety of acute and chronic health problems (Miller and Lin, 1988). More specifically, they are more likely to have a history of low birth weight (Conway, 1988), anemia, dental decay, impaired vision, delayed immunizations (Page et al., 1993), lead toxicity (Alperstein et al., 1988), lower height percentiles, and greater degree of nutritional stress (Fierman et al., 1991). They are also more likely to suffer accidents, in-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 36:7. JULY 1997
Recent years have seen a major increase in the number of people in North America and Western Europe who become homeless and a significant rise in public anxiety about homelessness and mental illness. There have been, however, few systematic studies of the prevalence of mental illness among the homeless outside the United States, and there have been no outcome studies (Shanks, 1988; Victor, 1992). Most research has concerned the problems of single homeless people, despite evidence that mothers with dependent children consti-
VOSTANIS ET AL.
juries, and burns (Parker et aI., 1991). Some studies have found a longer duration of homelessness to be related to more child health problems (Hu et aI., 1989), but this is not a consistent finding. Homeless children's development also is often delayed, i.e., they have either been found to develop more slowly than the general population or housed children (Bassuk and Rosenberg, 1990; Conway, 1988; Rescorla et aI., 1991) or to have specific developmental delays, such as in receptive and expressive language (Fox et aI., 1990), visual-motor skills (Parker et aI., 1991), and reading skills (Finkelstein and Parker, 1993). Rafferty (1991) found that 30% of homeless children did not attend school, and only 42% were reading above grade level. Mental healrh problems of homeless children have been less systematically researched, and the findings are not as conclusive. The prevalence of such mental health-related problems was 38% in a report by Fox et aI. (1990). Many of these problems were confirmed, even after comparing homeless children with poor housed controls (Masten et aI., 1993). Behavioral problems such as sleep disturbance, eating problems, aggression, and overactivity were also described in homeless under-five children in the United Kingdom (Conway, 1988). Even more serious mental health disorders, such as depression and suicide attempts, alcohol and drug abuse, and vulnerability to sexually transmitted diseases, including acquired immunodeficiency syndrome, have been established in adolescent street youths (Robertson, 1991; Sherman, 1992). Mental health problems in children and parents are often interrelated. It was not surprising, therefore, £0 find a high prevalence of psychiatric morbidity in homeless mothers (45% in Connelly and Crown, 1994; 72% in Zima et aI., 1996), mainly depression (28% in Fox et aI., 1990) and substance abuse (Parker et aI., 1991). Many of the mental health problems experienced by homeless families are common among deprived families. The main differences between homeless and poor housed families occur in the characteristics and experiences of the parents. Although the population of homeless families is diverse, certain patterns and characteristics have been established. Some authors distinguish, for example, between episodic and long-term homelessness among families (Page et aI., 1993). Overall, histories of abuse and neglect have been widely reported among these families, both in children and mothers (Alperstein et aI., 1988). Homeless families are
more likely to be headed by a single parent and to have young children (Connelly and Crown, 1994). They also have a high incidence of exposure to domestic violence (Mihaly, 1991). Homeless families are often less likely than parents of low-income controls to have stable and supportive relationships (Bassuk et al., 1986). This suggests that homeless families are downwardly mobile, compared with low-income families who have developed supportive networks that have enabled them to adjust to a life in poverty. In a preliminary study of 19 homeless families with 50 children, we established similar patterns of multiproblem family histories and high rates of psychosocial morbidity, with 47% of the mothers and 62% of the children indicating psychiatric caseness (Vostanis et al., 1996). The aims of the study presented in this article were to (1) investigate the psychosocial characteristics of homeless families in a more representative sample, (2) control for socioeconomic deprivation by comparing homeless families with housed controls, and (3) identify predictors of psychiatric morbidity among homeless families. It was hypothesized that homeless parents and children would have higher rates of psychiatric morbidity, which would be predicted by housing-related factors.
METHOD Subjects The survey population comprised homeless families with children aged berween 2 and 16 years who had applied for rehousing (Q the Ciry of Birmingham Housing Departmem. This is the largest municipal housing aurhoriry in the United Kingdom with a policy to house homeless families in secure tenancies where possible. Each year, more than 1,500 families emer homeless cemers in the Ciry of Birmingham. Consecutive families were selected from seven hostels. The nature of the population is represemative of Other areas in the United Kingdom because of similar admission criteria, e.g., Women's Aid refuges and cemers run by the volumary sector or housing associations. A comrol group of families was selected from rwo primary schools in Birmingham. Families were housed and of social class V (Office of Population Censuses and Surveys, 1980) and were selected by stratified quasi-randomization. Measures were administered to homeless families within 2 weeks of application for rehousing. The length of time waiting for rehousing varied from a few days (Q 3 momhs.
Parent Measures A semistructured interview was conducted with the mother (or father if sole parem) concerning circumstances leading (Q homelessness, previous family life, peer and family relationships, and behavioral and developmemal problems among the children (some items are included in Tables 1 and 2). The interview had been pilot-tested in the preliminary study (Vostanis et al., 1996). Because of the
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MENTAL HEALTH OF HOMELESS CHILDREN
number of measures used, particularly in relation to each individual child. no other measure of family functioning was included. Gmeral Health Questionnaire. The General Health Questionnaire (GHQ) (Goldberg, 1978) is a self-administered, standardized screening instrument for the detection of psychiatric morbidity in the general population and in community settings. Its 28-item version was completed by parents. with a simple Likert method of scoring (0 through 3), according to which a total score of more than 39/40 strongly indicates the presence of psychiatric disorder. The GHQ consists of four scales, i.e., Somatic Symptoms, Anxiety. Social Dysfunction, and Depression. Interview Schedule fOr Social Interaction. The Interview Schedule for Social Interaction (ISS I) (Henderson et aI" 1981) is a standardized measure of people's social network. It includes scales of availability of attachment, perceived adequacy of attachment, availability of social integration, perceived adequacy of social integration, number of close friends or relatives with whom the respondent recently had arguments or unpleasant interactions, and number of facets of attachment relationships that the respondent says he or she has not got but can do without.
Child Measures Child Behavior Checklist. The Child Behavior Checklist (CBCL) (Achenbach, 1991a) was completed by the principal caregiver (usually the mother) for each child. The widely used and standardized CBCL measures internalizing and externalizing problems and social competence. T scores greater than 63 have been found to be in the clinical range for both the internalizing and externalizing dimensions. The CBCL/2-3 (Achenbach. 1992) was used for preschool children. This includes the same behavioral dimensions but no social competence scales. Children aged 11 through 16 years completed the equivalent Youth Self-Report (Achenbach. 1991 b). For children who had been attending school. teachers were asked to complete the Teacher's Repon Form (TRF) (Achenbach, 199Ic), which is the teacher version of the CBCL. Communication Domain ofthe Vineland Adaptive Behavior Scales. The Vineland Adaptive Behavior Scales (VABS) (Sparrow et a!', 1984) is a semistructured. standardized interview with the mother that measures the development of child receptive, expressive, and written communication. It produces raw scores, which can be converted to standard scores. These compare the performance of the identified child with those of children of the same chronological age. Standard scores are grouped into groups of ability: 20 through 69, low; 70 through 84. moderately low; 85 through liS. average; 116 through 130, moderately high; and 131 and above, high. Measuremmt ofHeight and Weight. Height and age were measured and were convened to age-appropriate centiles (Tanner and Whitehouse, 1975).
RESULTS Composition of the Families
One hundred thirceen homeless families with 249 children aged 2 through 16 years were interviewed. Of 191 consecutively admitted families with at least one child older than 2 years, 23 (12%) were excluded because of being rehoused within the second week, and three because of being physically unwell (one mother had given birth before admission, and two were expected to give birch shortly). Eight families (4.2%) could not be contacted despite repeated attempts, and 44 (23%) refused to parcicipate. The acceptance rate compares well with those of previous studies with similar mobile populations (e.g., 62% in Masten et al., 1993). The comparison group consisted of 29 housed families with 83 children. The relatively small sample was selected because of the expected "homogeneity" (i.e., low variance) of family and social factors in this group. The percentages given on each variable throughout the "Results" section vary, as these were estimated on available data rather than on the total sample. The family characteristics and demographic data are presented in Table 1. As most homeless parents living with the children were single mothers (n = 96, or 85%), the analysis was confined to mothers and children. The ethnic distribution was not significantly different in the housed comparison group (X 2 = 6.9, df= 1 5, P = .23). The family constitution was significantly different from that of housed controls, with more control mothers living with their parcner (X 2 = 24.0, df= 3, P = .000). There were no single fathers in the comparison sample. Reasons for Becoming Homeless and Recent History of Housing
The two groups were compared on CBCL, GHQ, ISSI, and VABS scores by nonparametric tests (Mann-Whitney U test). The association between CBCL and GHQ scales was tested by Spearman correlation test. To assess which variables predicted the presence of caseness in children. a stepwise forward logistic regression analysis was used. The CBCL dichotomy (above or below the cutoff score that indicates psychiatric morbidity) was entered as the dependent variable. Similar analyses were performed with mothers' psychiatric caseness or children's school attendance as the dependent variables.
Most families (82.3%) had moved to the hostel from rented accommodations (Table 2). The most frequently reported reasons were domestic violence (55.8%) and violence from neighbors (29.1 %). Sixty-four families (56.6%) had lived at the same residence for at least 1 year. The rest had lived in at least one more rented accommodation (36), at an owned property (5), in another homeless facility (5), or with friends or relatives (3). Again, the families who had moved at least once more during the previous year reported that domestic violence (22) and violence from neighbors (8) were the most frequent reasons. Six comparison families (20.7%)
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:7. JULY 1997
VOSTANIS ET AL.
owned the home property, and the remaining 23 (79.3%) lived in rented accommodations. One comparison family had moved from their previous residence because of domestic violence, and one had moved because of violence from the neighbors. Mothers
Most homeless mothers (n = 102, or 93.6%) were unemployed but had completed secondary school education (n = 97), with an average school-leaving age of 15.8 years (II through 19), which was similar to the controls (mean 16.0, 14 through 19). The most significant characteristic in their previous history was the high rate of having suffered previous sexual abuse (45%) (Table 3). The two groups did not differ significantly on history of having lived in care and having been homeless as a child or on history of drinking and offenses. The majority of homeless mothers described a poor relationship with their partner, with domestic violence occurring in 41 families (Table 3). The reverse pattern was established in housed families, with 18 mothers (or 90% of those who had a partner) describing their relationship as supportive and confiding (X 2 = 39.1, df = 4,p = .000). As in our preliminary study, half of the mothers who
completed the GHQ (n = 52, or 49.1 %) reported scores that indicate psychiatric morbidity. A similar rate, using the same instrument, has recently been found in a hostel for single homeless women in London (Adams et al., 1996). In contrast, none of the control mothers presented with significant psychiatric problems, although this is an underestimate of morbidity in the general population (up to 20% for women of this age group in the United Kingdom [Goldberg and Huxley, 1992]). The two groups differed significantly on all four GHQ scales (Mann-Whitney test): Somatic Symptoms, z = -4.5, P = .000; Anxiety, z = -5.9, P = .000; Social Dysfunction, z = - 3.2, P = .001; Depression, z = -5.1,p = .000. There were significant differences between the two groups on all scales of the ISS I. Homeless mothers had fewer availability attachment relationships (z = - 3.1, P = .002), lower perceived adequacy of attachment relationships (z = -7.4, P = .000), lower availability of social integration (z = -7.5, P = .000), and lower perceived adequacy of social integration (z = -8.8, P = .000). They were also more likely to have had arguments or unpleasant interactions with their close friends or relatives (z = -1.8, P = .07), although the difference did not reach statistical significance. Children
TABLE 1 Family Characteristics Homeless Group (n
Mothers' ethnic status: No. (%) White Black Asian Mothers' age (yr) Mean Range No. of children Median Range Family composition: No. (%) Single mothers Both parents Single fathers Partner's status: No. (%) Currently lives with family Previously lived with family Never lived with family No partner Not known
Comparison Group (n = 29)
86 (76.1) 12 (10.6) 7 (13.3)
21 (72.4) 2 (6.9) 6 (20.7)
96 (85) 13 (11.5) 4 (3.5)
13 (45) 16 (55) 0
13 58 28 9 5
16 (55) 2 (7) 2 (7) 9(31) 0
(11.5) (51.3) (24.8) (8) (4.4)
The average age of the participating 249 homeless children was 7.1 years (Table 4), i.e., significantly lower than of the 83 housed controls (mean 8.4, analysis of
TABLE 2 Path to Homelessness (n = 113 Families)
Reason for leaving last residence Domestic violence Violence from neighbors Mortgage arrears Rent arrears Left voluntarily Not known/other reason Type of previous residence Rented house or apartment Owned house or apartment Lodging with friends Lodging with family Other homeless facility
63 33 1 2 7 7
55.8 29.1 0.9 1.8 6.2 6.2
93 14 2 3 1
82.3 12.3 1.8 2.7 0.9
Note: Period in previous residence: mean 37.1 weeks (I day through 5 years).
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MENTAL HEALTH OF HOMELESS CHILDREN
TABLE 3 Mothers' Reported Problems Homeless (n History of sexual abuse: No. (%) Relationship with partner: No. (%) Supportive/confiding Minor problems Major problems Very poor/violence Not applicable General Health Questionnaire Total score: mean (SO) No. (%) of possible cases ISSI: mean score (SO) Availability of attachments Perceived adequacy of attachment Availability of social integration Adequacy of social integration Rows with close friends/relatives
16 11 23 41 18
(14.7) (10.1) (21.1) (37.6) (16.5)
18 (62) 1 (3.5) 1 (3.5)
36.1 (18.2) 52 (49.1)
14.6 (7.1) 0
4.4 6.7 4.5 10.6 0.4
(2.5) (4.0) (3.4) (4.5) (0.5)
6.8 10.5 9.0 15.3 0.3
(3.4) (1.5) (0.7)
NS (p = .07)
Note: ISS I = Interview Schedule for Social Interacrion; MW = Mann-Whitney U test; NS = not significant. "p < .01; '*'p < .001.
variance: F = 7.13, P = .008). As the controls were selected from primary schools, the difference was possibly due to the composition of homeless families, who had more preschool children. The difference in age was taken into account in the statistical analysis. School Attendance
In the homeless group, 180 children (72.2%) had been attending mainstream primary schools, 4 (1.6%) were in special schools, and 33 (13.3%) were in preschool or day care prior to their admission to the hostel. After their admission, only 72 children (28.9%) attended mainstream education, 3 (1.2%) still attended special schools, and 12 (4.8%) were in preschool or day care. The decrease of educational provisions since becoming homeless was significant for both mainstream schools (analysis of variance: F = 40.4, P = .000) and preschools/day-care centers (F = 68.2, P = .000). All controls attended a primary school at the time of the study. Reported Problems
21.7%) controls (X 2 = 1.8, P = .18). Although reported rates of abuse or being placed on the child protection register were not compared with official records, and were therefore likely to be underestimates, they were still significantly higher among homeless families (established sexual and/or physical abuse: X2 = 6.3, P = .01; at-risk child protection register: X2 = 9.0, p = .002). There were also more homeless children who had lived in the care of the local authority (Table 4). Height and Weight Percentiles
Children in both groups had height and weight percentiles distributed as in the general population. The mean height percentile was 53.8 for homeless children (SO = 28.5, 3 through 97) and 50.3 for controls (SO = 32.6, 10 through 90; Mann-Whitney: z = -0.39, P = .70). The mean weight percentile was 41.5 for homeless children (SO = 30.3, 3 through 97) and 47.5 for controls (SO = 29.3,3 through 97; z = -0.82,p = .4 I). Vineland Adaptive Behavior Scales: Communication Domain Scores
There were similarly high rates of difficult births (28% and 36%, respectively, for homeless families and controls), developmental delays (18% and 17%), and chronic or acute physical problems (40% and 47%) in both groups. About one third of homeless children (n = 73, or 29.3%) were described as presenting with significant behavioral problems, compared with 18 (or
VABS standard scores were significantly lower in homeless children (Table 4) (z = -2.0, P = .045). There was a higher proportion of homeless children of moderately low or low ability (26.6%), compared with controls (18.1 %), but the difference did not reach a statistically significant level (X 2 = 2.86, P = .4 I).
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TABLE 4 Children's Reported Problems Controls (11 = 83)
Sex: No. (%) Boys Girls Age (yr) Mean Rangc History of: No. (%) Established abuse (physical and/or sexual) Previously in carc On at-risk register Communicarion (VABS) 11
Srandard score: mean (SO) Range CBCL Tscores: mcan (SD) 11
Externalizing Internalizing CBCL cascncss: No. (%) CBCL cases Internal izi ng cases Externalizing cases
249) (52.6) (47.4)
7.1 2-16 24 16 25
(9.6) (6.4) (10)
240 92.3 (17.7) 20-134
80 96.9 (12.7) 65-125
229 55.3 (12.3) 53.5 (12.6)
83 49.8 (11.8) 48.1 (9.8)
65 46 66
Note: VABS = Vineland Adaptivc Behavior Scales; CBCL analysis of variancc; MW = Mann-Whitncy U test.
(28.4) (20.1) (28.9)
15 6 13
(18.1) (7.2) (15.7)
Behavior Checklist; NS
not significant; ANOVA
'p < .05; "p < .01; "'p < .001.
Sixty-five homeless children had CBCL scores within the clinical range (or 28.4% of those completed), compared with 15 controls (or 18.1 % of those completed: X2 = 3.4, P = .06). There were significantly more homeless children with either externalizing (X 2 = 5.6, P < .01) or internalizing scores in the clinical range (Xl = 7.3, P < .001) (Table 4). They had significantly higher externalizing (Mann-Whitney: z = - 3.7, P = .000) and internalizing scores (z = -4.1, P = .000). The two groups did not differ significantly on social competence ratings (z = -0.16, P = .87). Owing to the small number of adolescents, only eight homeless subjects completed the Youth Self-Report (one scored within the clinical range). The TRF was completed for 23 (n = 6, or 26.1 % within clinical range) of the 75 homeless children who attended primary school after their admission to the hostel and for 33 controls (n = 4, or 12.1 % within clinical range; X2 = 1.8, P = .18). The small number of completed TRFs was due to lack of school attendance, lack of permission to contact schools, or low completion rate by teachers. Homeless children had
significantly lower TRF scores on school adaptive functioning (z = - 3.71, P = .000) and academic performance (z = -4.06, P = .000). Within the homeless group, total CBCL scores were negatively associated with VABS Communication standard scores (Spearman rank coefficient of correlation r = -.22, P = .00l). Social competence scores were positively correlated with VABS scores (r = .18, P = .032). This indicates the concurrence of developmental delays and psychosocial difficulties in a proportion of high-risk families. Factors Associated With CBCL Caseness
To investigate which factors in the child's history best predicted psychiatric morbidity, CBCL scores were entered as the dependent variable in a stepwise forward logistic regression, with child-related variables as the covariates. A history of developmental delay was significantly associated with caseness in the homeless group (B = 1.03, P = .045), accounting for 68.3% of the variability of the model. In a second logistic regression analysis, we tested the value of family-related factors in predicting child psychiatric caseness. The best predictor
J. AM. ACAD. CHILO ADOLESC. PSYCHIATRY..~6:7, JULY 1997
MENTAL HEALTH OF HOMELESS CHILDREN
This study, which was the first to investigate the psychosocial characteristics of homeless families outside the United States, found a similar pattern to that of U.S. subjects. Overall, these were multiproblem families with histories of chronic adversities, which precipitated the event of homelessness, although this finding should be
tested further in longitudinal research. They were more likely to be single-parent families, most of whom became homeless to escape from domestic violence or violence from neighbors. This path to homelessness has been previously reported in American shelters (Wood et aI., 1990). Risk factors such as mothers' histories ofhaving suffered previous abuse, having unsupportive or violent relationships, and poor social support networks precipitated the recent housing problem. The pattern is consistent with research on homeless (Wood et aI., 1990) and other at-risk families (Quinton and Rutter, 1984), and it supports the theory of cumulative risk status and adversity, rather than the housing problem per se (Masten et aI., 1993). However, such underlying mechanisms do not negate the presence of high levels of mental health needs among homeless mothers and their children. Mothers, in particular, reported high rates of psychological distress or possible psychiatric caseness (49%), similar to rates from studies with single homeless women (Adams et aI., 1996) and homeless mothers (Connelly and Crown, 1994; Zima et al., 1996). It is important to stress mothers' abusive experiences and indication for treatment. The established association between mothers' social isolation and mental health problems with children's behavioral/emotional difficulties is not specific to this population (Weissman et aI., 1984; Zima et al., 1996), and it may reflect impaired parenting ability (Hausman and Hammen, 1993). It is thus essential that intervention programs target both parents and children. As in similar child psychiatry research, we need to acknowledge that mothers were the only informants. Their reports may thus reflect some of their own characteristics (Lang et al., 1996), which could indicate smaller differences on CBCL and VABS ratings. Some problems reported for homeless children in this study, such as general developmental delay and major physical illness, were not significantly higher than among housed controls. Masten et al. (1993) supported the view that homeless children share many problems with other American children reared in poverty. There were, however, differences in previous life events such as sexual/physical abuse, having been admitted into care, and having been placed on the at-risk child protection register. All these child- and mother-related events act as vulnerability factors for the development of child psychopathology. The delayed communication found among homeless children may be an effect of chronic
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, j(':7, JULY 1997
was mothers' GHQ score (B = -0.04, P = .018), which accounted for 75.4% of the variability. CBCL and GHQ scores were significantly correlated (Spearman coefficient r = .35. P = .000). All associations between GHQ and CBCL subscales also reached statistical significance. As both the CBCL and the GHQ were rated by the same informant, we entered these variables in the reverse order in a stepwise logistic regression, i.e., with GHQ scores as the dependent variable and CBCL scores as the covariate. The reverse pattern was not found, i.e., maternal psychiatric morbidity was not predicted by child behavioral problems. A mother's psychiatric morbidity was best predicted by her own previous history of abuse (B = -1.26, P = .043). Maternal GHQ scores were negatively correlated with length of stay in the previous residence (r = -.14, P = .042). The level of social support available to homeless mothers was highly significant in the presence of child psychiatric symptoms. Mothers' scores of adequacy of social integration were negatively associated with children's CBCL total scores (r = -.14,p = .041), recent history of arguments was positively correlated with CBCL externalizing scores (r = .15, P = .030), and availability of social integration was correlated with social competence scores (r = .28, P = .002). Factors Predictive of School Attendance While Homeless
As children's school registration and attendance after admission to homeless centers dropped dramatically, we investigated the predictive value of child- and family-related variables, as well as of variables related to homelessness. The most significant factor was the type of homeless hostel to which they had been admitted (B = 0.49, P = .000), accounting for 68% of the variability of the model. This clearly indicates the lack of policy for school provision, which appears to rely on direct arrangements by the residential care staff and availability of places in local schools. DISCUSSION
VOSTANIS ET AL.
family adversity, which then acts as an additional risk factor for behavioral and emotional disorders. The latter were also significantly increased in the homeless group. It was of major concern that only one third of homeless children attended preschool, day care, or school after their admission to the homeless center. This could be related to lack of school placements for this mobile population, lack of financial support to enable them to attend their previous school, or fear of being traced by their violent father (Power et aI., 1995). The finding that school attendance was mainly predicted by the type of hostel demonstrates the absence of policy across the educational authority. Some schools may be more accepting and tolerant of homeless children. In any case, this needy group is thus deprived of protective factors such as maintenance of friendships, academic achievement, and self-esteem. Limitations in the design and sampling frame need to considered. The reasons for selecting a relatively small comparison sample (i.e., homogeneity in social background) have already been described. A comparison group of other high-risk families, such as poor but housed single mothers who have been abused or exposed to violence, could be selected in future cross-sectional research. This design would thus separate the impact of homelessness from other family/social variables. Mothers' reports were nor corroborated with social services records and are rherefore likely to be underestimates. Future studies should aim at identifYing risk and protective factors of short- and long-term children's psychosocial outcome, particularly after rehousing. New intervention programs (Hammond and Bell, 1995; Loosley, 1994) require evaluation. For example, by comparing the outcome of families placed in hosrels with designated child care workers, wirh centers without any planned help and support in dealing with mental health problems.
homeless families have little or no access to traditional types of health services (Hu et aI., 1989; Miller and Lin, 1988; Victor et aI., 1989). Health care should be provided directly to homeless centers. This can be best achieved through dedicated sessions by the local mental health, pediatric, and health visiting teams. Collaboration should also be established among centers, health teams, social services departments, local schools (which should provide a minimum number of places for homeless children), and the voluntary sector. Intervention programs need to maintain education and provide parents and children with comprehensive support, to prevent further psychosocial decline. It is as yet unclear whether rehousing will affect outcome, for which reason this cohort of homeless families is currently being followed up at 9 months.
The population of homeless families is on the increase in both North America and Western Europe. The complexity and severity of parents' and children's mental health and related problems, and their frequent change of address, indicate that rheir needs can only be mer by specialized services that rake into account rheir characteristics. Studies in the United States and the United Kingdom have shown rhat the majority of
Achenbach TM (1991a), Manual for lh, Child B,havior Ch,ck/isr/4-1B and /991 Profi/'. Burlington: University of Vermont Department of Psychiatry Achenbach TM (199Ib). Manual for ,h, You,h S'!fR'porl and 1991 Profil,. Burlington: Univetsity of Vermont Department of Psychiatry Achenbach TM (l99Ic). Manual for th, uachtrs R'port Form and 1991 Profilt. Burlington: University of Vermont Department of Psychiatry Achenbach TM (1992), Manual for th, Child B,havior Ch,ck/isr/2-3 and /992 Profil,. Burlington: University of Vermont Department of Psychiatry Adams C, Pantelis C, Duke P, Barnes T (1996), Psychopathology, social and cognitive functioning in a hostel for homeless women. Br J Psychiatry 168:82-86 Alperstein G. Rappaport C, Flanigan) (1988). Health problems of homeless children in New York City. Am J Public H,al,h 78: 1232-1233 Bachrach L (1992), What we know about homelessness among mentally ill persons. HOJp Community Psychiatry 43:4 '>3-464 Bassuk E. Rosenburg L (1990). Psychosocial characteristics of homeless children and children with homes. hdiatTics 85:257-261 Bassuk E. Rubin L. uuriat A (1986), Characteristics of sheltered homeless families. Am J Public H,al,h 76: 1097-110 1 Connelly J. Crown ), eds (1994). Hom,lfSSnfSS and l/I H,a/lh: R,porl of a W0rking Party ofth, Royal Colltg' ofPhysiciam. London: Royal College of Physicians Conway J, ed (1988), Pmcriplion for Poor H,alrh: Th, Crisis For Hom,ltss FamilifS. London: LFC, Maternity Alliance, SHAC, and Shelter Fierman A, Dreyer B. Quinn L. Shulman S, Courtlandt C, Guzzo R (1991). Growth delay in homeless children. PtdiatTics 88:918-925 Finkelstein J. Parker R (1993). Homeless children in America. Am J Dis Child 147:520-521 Fox S. Barmen R. Davies M. Bird H (1990). Psychopathology and developmental delay in homeless children. JAm Acad Child Adoltsc Psychiatry 29:732-735 Goldberg D (1978). Manual oflh, Gmtral H,allh Qumionnairt. Windsor: NFER Nelson Goldberg D. Huxley P (1992), Common Mmlal Disordm: A Bio-Social MotUl. London: Tavistock Hammond L, Bell J (1995), The setting up of a drop-in service to a homeless families project. Assoc Child Psychol Psychiatry N,ws/17: 132-138 Hausman B, Hammen C (1993), Parenting in homeless families. Am J Orlhopsychiatry 63:358-369
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:7. JULY 1997
MENTAL HEALTH OF HOMELESS CHILDREN
Henderson S, Byrne DG, Duncan-Jones P (1981), Nrorosis and rhr Social Environmrnr. Australia: Academic Press Hu D, Covell R, Morgan J, Arcia J (1989), Health care needs for children of the recently homeless. J Community Hralrh 14: 1-8 Lang C. Field T, Pickens Jet al. (1996). Preschoolers of dysphoric mothers. J Child Psychol Psychiatry 37:221-224 LefT J (1993), All the homeless people: where do they all come from? Br Mrd J 306:669-670 Loosley S (1994), Women's community house children's program. In: Childrrn Living Wirh Dommie Violrna, Mullender A, Morley R, eds. London: Whiting and Birch, pp 176-187 Masten A, Miliotis D, Graham-Bermann S, Ramitez ML, Neemann J (1993), Children in homeless families: risks to mental healrh and developmenr. J Consult C/in Psychol 61 :335-343 Mihaly L (1991), Beyond the numbers: homeless families with children. In: Homrless Childrrn and Yourh: A Nrw Amrrican Dilrmma, Kryder-Coe J, Salamon L, Molnar J, eds. New Brunswick, NJ: Transaction Publishers, pp 11-32 Miller D, Lin E (1988), Children in sheltered homeless families: reported health status and use of health services. Prdiatrics 81 :668-673 Office of Population Censuses and Surveys (1980), ClaHificarion of Occupations /980. London: HMSO Page A, Ainsworth A, Pett M (1993), Homeless families and their children's health problems. WmJ Mrd 158:30-35 Parker R, Rescorla L, Finkelstein J, Barnes N, Holmes J, Stolley P (991), A survey of the health of homeless children in Philadelphia shelters. Am J Dis Child 145:520-526 Power S, Whitty G, Youdell D (995), No pfaa to Lrarn: Homrlrssness and Education. London: Shelter Quinton D, Rutter M (984), Parenting behavior of mothers raised in care. In: Longitudinal Studirs in Child Psychology and Psychiatry, Nicol AR, ed. Chichester. England: Wiley. pp 91-134 Rafferty Y (1991), Developmental and educational consequences of homelessness on children and youth. In: Homrless Childrrn and Youth: A Nrw
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:7, JULY 1997
Amrrican Dilrmma, Kryder-Coe J, Salamon L, Molnat J, eds. New Brunswick, NJ: Transaction Publishers, pp 105-142 Rescorla L, Parker R, Stolley P (1991), Ability, achievement, and adjustment in homeless children. Am J Orthopsychiatry 61 :210-220 Robertson M (1991), Homeless youth: an overview of recent literature. In: Homrlm Childrm and Youth: A Nrw Amrrican Dikmma. Kryder-Coe J, Salamon L, Molnar J, eds. New Brunswick, NJ: Transaction Publishers, pp 33-70 Shanks N (1988), Medical morbidity of the homeless. J Epidrmiol Community Hralth 42: 183-186 Sherman D (1992), The neglected health care needs of street youth. Public Hralth Rrp 107:433-440 Sparrow S, Bella D, Cicchetti D (1984), Vinrfand Adaptivr Bthavior Scaks. Circle Pines, MN: American Guidance Services Tanner JM, Whitehouse RA (1975), Growth and Drvrlopmrnr Rrcord. London: Castlemead Publishers Victor C (1992), Health status of the temporarily homeless population and residents of North West Thames region. Br MrdJ 305:387-391 Victor C. Connelly J, Roderick P, Cohen C (1989), Use of hospital services by homeless families in an inner London health district. Br Mrd J 299:725-727 Vostanis P, Cumella S, Briscoe J, Oyebode F (1996), A survey of psychosocial characteristics of homeless children. Eur J Psychiatry 10: 108-117 Weissman M, Prusoff B, Gammon D, Merikangas K, Leckman J, Kidd K (1984), Psychopathology in the children (ages 6-18) of depressed and normal parents. JAm Acad Child Psychiatry 23: 78-84 Wood D, Valdez R, Hayashi T, Shen A (1990), Health of homeless children and housed, poor childten. Prdiatrics 86:858-866 Wright J (1993), Homeless children: two years later. Am J Dis Child 147:518-519 Zima B, Wells K, Benjamin B, Duan N (1996), Mental healrh problems among homeless mothers: relationship ro service use and child mental health problems. Arch Gm Psychiatry 53:332-338