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Homeless Families with Children

Published by the National Coalition for the Homeless, August 2007 Homelessness is a devastating experience for families. It disrupts virtually every aspect offamily life, damaging the physical and emotional health of family members, interfering withchildren’s education and development, and frequently resulting in the separation of familymembers. The dimensions, causes, and consequences of family homelessness are discussedbelow. An overview of policy issues and a list of resources for further study are also provided. DIMENSIONS One of the fastest growing segments of the homeless population is families with children. A2005 study revealed that of the counted homeless population there were 98,452 homelessfamilies, making up 41% of the entire homeless population (Homelessness Counts, 2007). Research indicates that families, single mothers, and children make up the largest group ofpeople who are homeless in rural areas (Vissing, 1996). Approximately 924,000 children arehomeless, and in 1995, 4.2% of children under the age of one year were homeless (UrbanInstitute, 2000; Culhane & Metraux, 1999). Homeless families are most commonly headed bysingle mothers in their late 20s with approximately two children (Rog & Buckner, 2007). Homeless families often double up with other families. This causes them to be exempt from thefederal definition of chronic homelessness, which states that a chronically homeless person isone who is on the streets or in a shelter (The Annual Homeless Assessment Report to Congress,2007). Therefore, many homeless families are prevented from receiving assistance. Recent evidence confirms that homelessness among families is increasing. Requests for assistedhousing by low-income families and individuals increased in 86 percent of the cities during thepast year. The same study found the requests increased by an average of 5% in 2005 (U.S.Conference of Mayors, 2005). While the average number of emergency shelter beds forhomeless families with children increased by 8% in 2005, an average of 32% of requests forshelter by homeless families were denied in 2005 due to lack of resources. CAUSES Poverty and the lack of affordable housing are the principal causes of family homelessness.While the number of poor people decreased every year between 1993 and 2000, in recent yearsthe number and percentage of poor people has increased. The percentage of poor people hasrisen from 11.3% of the population in 2000 to 12.1% in 2002 (U.S. House of Representatives,2004), and by 2004 the number of poor people grew by 4.3 million from 2000 (Center of Budgetand Policy Priorities, 2004). Today, 35.2% of persons living in poverty are children; in fact, the2004 poverty rate of 17.8% for children under 18 years old is significantly higher than thepoverty rate for any other age group (U.S. Bureau of the Census, 2005). Declining wages and changes in welfare programs account for increasing poverty amongfamilies. Declining wages have put housing out of reach for many families: in every state,metropolitan area, county, and town, more than the minimum wage is required to afford a one- ortwo-bedroom apartment at Fair Market Rent1 (National Low Income Housing Coalition, 2000).In fact, the median wage needed to afford a two-bedroom apartment is more than twice theminimum wage. Until its repeal in August 1996, the largest cash assistance program for poorfamilies with children was the Aid to Families with Dependent Children (AFDC) program.Between 1970 and 1994, the typical state's AFDC benefits for a family of three fell 47%, afteradjusting for inflation (Greenberg and Baumohl, 1996). The Personal Responsibility and WorkOpportunity Reconciliation Act of 1996 (the federal welfare reform law) repealed the AFDCprogram and replaced it with a block grant program called Temporary Assistance to NeedyFamilies (TANF). Current TANF benefits and Food Stamps combined are below the povertylevel in every state; in fact, the median TANF benefit for a family of three is approximately onethirdof the poverty level. In addition, as the percentage and number of poor people hasincreased in recent years, the number of people receiving TANF has decreased. Between 2000and 2003 the number of poor children rose 11%, and during this same period, the number ofpeople receiving TANF fell by nine percent (Center of Budget and Policy Priorities, 2004). Thus,contrary to popular opinion, welfare does not provide relief from poverty.Welfare caseloads have dropped sharply since the passage and implementation of welfare reformlegislation. However, declining welfare rolls simply mean that fewer people are receivingbenefits -- not that they are employed or doing better financially. Early findings suggest thatalthough more families are moving from welfare to work, many of them are faring poorly due tolow wages and inadequate work supports. Only a small fraction of welfare recipients’ new jobspay above-poverty wages; most of the new jobs pay far below the poverty line (Children’sDefense Fund and the National Coalition for the Homeless, 1998). Moreover, extreme poverty isgrowing more common for children, especially those in female-headed and working families.This increase can be traced directly to the declining number of children lifted above one-half ofthe poverty line by government cash assistance for the poor. As a result of loss of benefits, low wages, and unstable employment, many families leavingwelfare struggle to get medical care, food, and housing. Many lose health insurance, despitecontinued Medicaid eligibility. A study found that 675,000 people lost health insurance in 1997as a result of the federal welfare reform legislation, including 400,000 children (Families USA,1999). Moreover, over 725,000 workers, laid off from their jobs due to the recession in 2000,lost their health insurance (Families USA, 2001). According to the Children’s Defense Fund,over nine million children in America have no health insurance, and over 90 percent of them arein working families. In addition, housing is rarely affordable for families leaving welfare for lowwages, yet subsidized housing is so limited that fewer than one in four TANF familiesnationwide lives in public housing or receives a housing voucher to help them rent a private unit.For most families leaving the rolls, housing subsidies are not an option. In some communities,1 FMRs are the monthly amounts “needed to rent privately owned, decent, safe, and sanitaryrental housing of a modest (nonluxury) nature with suitable amenities.” 62 Federal Register50724 (September 26, 1997) HUD determines FMRs for localities in all 50 states.former welfare families appear to be experiencing homelessness in increasing numbers(Children's Defense Fund and the National Coalition for the Homeless, 1998). The shrinking supply of affordable housing is another factor underlying the growth in familyhomelessness. The gap between the number of affordable housing units and the number ofpeople needing them is currently the largest on record, estimated at 4.4 million units (Daskal,1998). According to HUD, in recent years the shortages of affordable housing are most severefor units affordable to renters with extremely low incomes. Federal support for low-incomehousing has fallen 49% from 1980 to 2003 (National Low Income Housing Coalition, 2005).The affordable housing crisis has had a particularly severe impact on poor families with children.Families with children represent 40% of households with “worst case housing needs” -- thoserenters with incomes below 50% of the area median income who are involuntarily displaced, paymore than half of their income for rent and utilities, or live in substandard housing (U.S.Department of Housing and Urban Development, 1998). With less income available for food andother necessities, these families are only an accident, illness, or paycheck away from becominghomeless. More recently, the strong economy has caused rents to soar, putting housing out of reach for thepoorest Americans. After the 1980s, income growth has never kept pace with rents, and since2000, the incomes of low-income households has declined as rents continue to rise (NationalLow Income Housing Coalition, 2005). As a result, more families are in need of housingassistance. The average waiting period for a Section 8 rental assistance voucher rose from 26months to 28 months between 1996 and 1998. Today the average wait for Section 8 Vouchers is35 months (U.S. Conference of Mayors, 2004). Excessive waiting lists for public housing meanthat families must remain in shelters or inadequate housing arrangements longer. Consequently,there is less shelter space available for other homeless families, who must find shelter elsewhereor live on the streets. Domestic violence also contributes to homelessness among families. When a woman leaves anabusive relationship, she often has nowhere to go. This is particularly true of women with fewresources. Lack of affordable housing and long waiting lists for assisted housing mean thatmany women are forced to choose between abuse and the streets. In a study of 777 homelessparents (the majority of whom were mothers) in ten U.S. cities, 22% said they had left their lastplace of residence because of domestic violence (Homes for the Homeless, 1998). In addition,50% of the cities surveyed by the U.S. Conference of Mayors identified domestic violence as aprimary cause of homelessness (U.S. Conference of Mayors, 2005). Nationally, approximatelyhalf of all women and children experiencing homelessness are fleeing domestic violence (Zorza,1991; National Coalition Against Domestic Violence, 2001).CONSEQUENCESHomelessness severely impacts the health and well being of all family members. Childrenwithout a home are in fair or poor health twice as often as other children, and have higher ratesof asthma, ear infections, stomach problems, and speech problems (Better Homes Fund, 1999). Homeless children also experience more mental health problems, such as anxiety, depression,and withdrawal. They are twice as likely to experience hunger, and four times as likely to havedelayed development. These illnesses have potentially devastating consequences if not treatedearly. Deep poverty and housing instability are especially harmful during the earliest years ofchildhood; alarmingly, it is estimated that almost half of children in shelter are under the age offive (Homes for the Homeless, 1998). School-age homeless children face barriers to enrollingand attending school, including transportation problems, residency requirements, inability toobtain previous school records, and lack of clothing and school supplies. Parents also suffer the ill effects of homelessness and poverty. One study of homeless and lowincomehoused families found that both groups experienced higher rates of depressive disordersthan the overall female population, and that one-third of homeless mothers (compared to onefourthof poor housed mothers) had made at least one suicide attempt (Bassuk et al., 1996). Inboth groups, over one-third of the sample had a chronic health condition.Homelessness frequently breaks up families. Families may be separated as a result of shelterpolicies which deny access to older boys or fathers. Separations may also be caused byplacement of children into foster care when their parents become homeless. In addition, parentsmay leave their children with relatives and friends in order to save them from the ordeal ofhomelessness or to permit them to continue attending their regular school. The break-up offamilies is a well-documented phenomenon: in 56% of the 27 cities surveyed in 2004, homelessfamilies had to break up in order to enter emergency shelters (U.S. Conference of Mayors, 2004).POLICY ISSUESPolicies to end homelessness must include jobs that pay livable wages. In order to work,families with children need access to quality childcare that they can afford, and adequatetransportation. Education and training are also essential elements in preparing parents for betterpaying jobs to support their families.But jobs, childcare, and transportation are not enough. Without affordable, decent housing,people cannot keep their jobs and they cannot remain healthy. A recent longitudinal study ofpoor and homeless families in New York City found that regardless of social disorders, 80% offormerly homeless families who received subsidized housing stayed stably housed, i.e. lived intheir own residence for the previous 12 months (Shinn and Weitzman, 1998). In contrast, only18% of the families who did not receive subsidized housing were stable at the end of the study. As this study and others demonstrate, affordable housing is a key component to resolving familyhomelessness. Preventing poverty and homelessness also requires access to affordable healthcare, so that illness and accidents no longer threaten to throw individuals and families into thestreets. Only concerted efforts to meet all of these needs will end the tragedy of homelessness forAmerica's families and children.

Homeless Families and

Children: A Psychiatric

Perspective

INTRODUCTION

Within the last decade, families with children have become the fastest

growing segment of the homeless population (U.S. Conference of May

ors). Depending on the city, families may constitute an estimated one-third

of the overall homeless population. Most homeless families are headed by

women with two to three children. The majority of these children are

preschoolers,* spending their formative years without the basic resources

needed for normal development. Recent government estimates (GAO re

port) indicate that on any given night at least 68,000 to 100,000 children

are homeless and an additional 186,000 may be doubled-up in

overcrowded living situations. Extreme poverty, lack of affordable housing,

unmet medical needs, and inadequate social supports create severe

stress in homeless family members, which is likely to cause or exacerbate

existing emotional problems. Community mental health programs are

generally not equipped to reach out and understand the needs of this

vulnerable population, nor can they provide the special preventive or

therapeutic services required. Psychiatrists and other mental health

professionals are concerned about the emotional needs of this

underserved and growing population, and the following outlines sonic of

their concerns.

__________

* The task force points out there are significant numbers of runaway adolescents

and abandoned children who are on the streets without a parent and whose mental

health needs are largely unmet. Those populations have particular needs that also

require urgent attention; however, this paper focuses on homeless children living

within a family unit.

BACKGROUND

Economic

There is widening gap between family income and median rents,

significantly contributing to family homelessness. This problem is made

worse by a dearth of low income housing units. Often supported only by

AFDC and food stamps, poor families receive income well below the

federally established poverty level in most states. A majority of homeless

families, usually supported by welfare or jobs paying minimum wage,

spend far more on rent and utilities than the 30% that is generally

considered reasonable. A precariously housed family, spending a large

percentage of its income on rent, becomes easily dislodged by a drop in

income or sudden rise in expenses.

Social Support

Many homeless families have fragmented and inadequate social

supports. Families who lose their homes often turn to family members and

friends for help, frequently doubling up in shared living arrangements.

Families may be come homeless when relationships with formerly

supportive individuals be come strained due to overcrowded living

arrangements. Those who exhaust their limited social supports are forced

to turn to emergency shelters or welfare hotels for refuge, while others

sleep in abandoned buildings or on the streets.

Mental Health

Homelessness has a major traumatic impact on individuals and

families. Parents’ capacities to provide a nurturing environment for their

children are severely strained and their ability to support one another may

be insufficient to withstand the stresses imposed upon family relationships.

Within the family, the emotional needs of children may receive low priority

as the parents expend most of their energy on meeting basic survival

needs.

Many homeless mothers have experienced traumatic events prior to

be coming homeless, compounding the stress with which they have to

contend. Often homeless mothers report a child hood history of physical

and sexual abuse, family instability, foster care placement, or an adult

history of being beaten by a spouse or partner. Others are disadvantaged

by youth and inexperience or by personality vulnerabilities, which hinder

them in struggling with the overwhelming stresses of homelessness. Many

have weak support networks and few friends or relatives to help them in

time of need. Such experiences and characteristics, combined with

inadequate social support, profoundly undermine attachments, selfesteem,

and abilities and may partly account for difficulties with sustaining

relationships. In spite of these difficulties, many homeless parents show

remarkable persistence and ingenuity in overcoming adversity.

Surveys indicate the presence of a wide range of psychiatric disorders

among homeless mothers. While higher than in the general population, the

prevalence of major mental illness and alcohol and/or drug abuse among

homeless mothers is lower than in single homeless people. In contrast to

public perceptions of the homeless, sheltered homeless mothers with

children do not commonly have a history of long-term psychiatric

hospitalization. Workers in inner-city shelters and welfare hotels indicate,

however, that many homeless mothers use alcohol and other drugs,

notably “crack” cocaine. The medical and psychological problems

associated with addiction compound other difficulties inherent to

homelessness.

Children of homeless families grow and develop in unstable and

dangerous environments. Parents may feel compelled, for safety’s sake, to

keep children confined in motel or shelter rooms, restricting their

opportunities for constructive play, social learning, and physical exercise.

Children may share one room with other family members and sometimes

also with other families, allowing little privacy or study areas for doing

homework. Transportation and child care may be unavailable and

schooling repeatedly interrupted by frequent moves.

Homeless Families and Children: A Psychiatric Perspective

© American Psychiatric Association, All Rights Reserved

Page 2 of 3

Homeless children experience considerable anxiety, depression,

demoralization, and other emotional difficulties. Preliminary studies of

sheltered homeless children estimate that a majority of these children

suffer from multiple developmental delays, behavioral problems, and poor

academic achievement. The development of homeless preschoolers often

lags particularly behind in the areas of language and social development.

Because many homeless women are pregnant (12%-20%) and are

abusing drugs, a large number of infants are at great risk for manifesting

severe developmental de lays and neurobehavioral problems.

Homeless children attend school erratically or not at all. A 1989 U.S.

Department of Education report estimated that 30% of 22,000 school-aged

homeless children nationwide do not attend school regularly. Because so

many are deprived of essential education opportunities, they frequently

have repeated a grade or are in special classes. In addition, without ageappropriate

academic skills and sound social development, a child’s ability

to function competitively in today’s society is impaired.

Access to mental health services for homeless families is often limited.

Cut backs in public health care financing programs, such as Medicaid,

create additional barriers to care. Accessible and appropriate mental

health services for children of impoverished families do not exist in most

places. Alcohol and drug abuse treatment facilities for the poor and for

women with children are few. An atmosphere of increasing public support

for punitive rather than therapeutic approaches may compromise the care

provided by existing programs. Furthermore, parents’ efforts to meet the

family’s survival needs come before seeking counseling or therapy.

In addressing the mental health needs of homeless families, both

short-term interventions to meet families’ immediate psychosocial needs

and long-term preventive services are indicated. However, existing

services are geared primarily to providing crisis- oriented services and are

not aimed at meeting chronic psychosocial needs. Furthermore, families

with multiple difficulties, such as poverty, homelessness, substance abuse,

and family violence, often use services in a crisis-oriented manner, if at all.

Therapeutic interventions must be developed that offer outreach and

continuous, comprehensive care. A particular area of need is to identify

and develop interventions that protect individuals at greatest risk for

becoming and remaining homeless and that provide effective care for their

children.

Physical Health

In addition to greater mental health problems, homeless mothers and

children have higher rates of physical illnesses and poorer access to care

than the general population. Homeless mothers in New York welfare hotels

were more likely to give birth to low-birth-weight babies and receive no

prenatal or less adequate prenatal care than low-income housed mothers.

Lack of shelter, unsanitary living conditions, and poor nutrition increase the

family member’s risk for communicable disease. Many homeless children

are delayed in their immunizations or have not received any, increasing

their susceptibility to potentially fatal and preventable common childhood

illnesses. Most important, like other poor families, homeless families have

difficulty accessing traditional health services.

GENERAL RECOMMENDATIONS

A comprehensive service delivery approach, including both short-term

crisis intervention and long-term preventive strategies, must be developed

within the context of permanent housing. Unless homeless families are

stabilized in permanent housing and integrated into community life, mental

health and social services cannot be fully effective. While delivering

services to homeless families, psychiatrists should lobby for an increased

supply of affordable housing options and ad equate human services for

poor and homeless families.

SPECIFIC RECOMMENDATIONS

1. Implement the following on-site intervention strategies at shelters,

hotels, and transitional housing to meet the immediate needs of families in

crisis.

• Aggressive outreach to homeless families.

• Screening and referral programs to identify individuals with emotional

disorders, substance abuse, and medical problems.

• Education and training of service providers to help them identify signs

of serious mental illness and substance abuse and improve their

understanding of how to approach families in chronic crisis.

• Substance abuse and family violence support groups, education and

counseling.

• Support groups for parents to share their experiences and develop

individual plans for coping and establishing adequate social supports.

• Access to early intervention, day care, and Head Start programs for

homeless preschoolers.

• Prompt registration of children in school and enrollment policies that

ensure continuity of schooling in spite of residential instability. Pro

vision of transportation, school supplies, and child care as needed.

2. Develop and evaluate long-term strategies in the community to stabilize

families and promote better health and family functioning, such as efforts

to:

• Provide intensive long-term case management for homeless families,

particularly those with fragmented social supports. Case managers

should function not only as service brokers and advocates but also as

counselors. They should have extensive clinical experience with

families in chronic crises.

• Develop family support centers that offer to provide links with case

management and a comprehensive system of services. Family support

centers are nonresidential, neighborhood-based sites that serve as the

hub of community service net works. They foster the development of

social supports that can be sustained beyond a particular crisis. Life

skills, home maintenance, and parent training groups should be made

available at or through family support centers.

• Develop outpatient and residential substance abuse detoxification and

rehabilitation programs for women with children. These programs

should try to ensure the integrity of the family unit.

• Provide casefinding and prenatal care for homeless pregnant mothers

and special programs if they are substance abusers. These programs

should have the capacity to improve access to services and provide

support for families during pregnancy and after delivery. These families

should be followed after delivery, and the mothers should be offered

assistance with parenting skills and education in child care and

development.

• Revise child protection laws to reduce the threat of arrest or loss of

custody if a mother seeks help for a drug program or is admitted to an

inpatient drug program.

• Continue to reexamine state plans for the education of homeless

children. Define more adequate solutions and add mechanisms for

regulation.

• Change administrative procedures to ensure that children who move

frequently continue to attend school and change schools as

infrequently as possible, such as removing geo graphic restrictions and

making sure records are sent.

• Develop mechanisms for expeditious referral of children with special

needs for formal evaluation and access to special education pro grams.

• Expand the Stewart B. McKinney Act to provide additional services to

help children escape the cycle of homelessness, such as after-school

programs, tutoring, school meals, and school supplies. Increase

eligibility for these services to include children at risk for becoming

homeless.

Homeless Families and Children: A Psychiatric Perspective

© American Psychiatric Association, All Rights Reserved

Page 3 of 3

3. Support public policy initiatives that provide greater economic stability,

increase the supply of low-income housing for families, and facilitate better

family functioning, such as proposals to:

• Build affordable low-income housing, some of which is serviceenriched.

Service enriched permanent housing, with varying levels of

support and structure, should serve as the centerpiece of the housing

continuum. Reserve transitional housing for the most dysfunctional

families who do not have the supports and skills to become integrated

into community life.

• Supplement income as necessary to reflect the cost of living. Raise

AFDC grants to at least the federal poverty level and support efforts to

index AFDC grants to local fair market rents. Modify welfare

administrative procedures to eliminate inappropriate discontinuation of

funding to families. Provide job training and job finding assistance. To

be come truly self-sufficient, heads of households must earn more than

the minimum wage.

• Extend the health and child care assistance in the new JOBS programs

for some AFDC mothers beyond the one-year limit. Ensure that job

training and placement are ad equate.

4. Develop a research agenda that focuses on the special needs for

homeless children and families, supporting studies such as:

• Population-based descriptive epidemiologic studies designed to provide

information about the characteristics and needs of homeless families.

• Longitudinal studies to better elucidate the causes, course, and con

sequences of family homelessness.

• Evaluation of homeless family pro grams to plan and build upon

effective intervention strategies.

• Coordination of research to include multiple sites and design methods

with sensitivity to minority issues and cultural differences among

homeless families and children.