Disentangling the Roles of Homeless-Specific and Poverty-Related Factors On Children's Health and Development: Prospective Cohort Design Study

Background and Purpose: While many homeless children are known to have physical, developmental, and mental health problems, it is unclear whether homelessness exacerbates children's health problems or other adverse life events, such as exposure to violence and extreme poverty, aggravate health problems. Additionally, little is known about the role of doubled-up arrangements, involving moving in with relatives or friends without paying rent, on health outcomes. We examine to what extent homelessness explains differences and changes in children's health outcomes and whether doubled-up children are different from homeless and other low-income groups in their health status.

Methods: This study uses longitudinal data of children in 20 large U.S. cities who have been followed since their birth, the Fragile Families and Child Wellbeing Study. The sample included 2,792 low-income children, including 260 homeless, 515 doubled-up, and 2,017 other low-income children. Bivariate analyses were conducted using a weighted χ2 analysis for categorical variables and a weighted t-test for continuous variables. To estimate the effect of homeless and doubled-up episodes on children's health outcomes over time, logistic regression with generalized estimation equations method was applied in order to produce standard errors and test statistics that adjusted for dependence resulting from the use of repeated measures.

Results: Of children who have experienced homelessness, 25% had diagnosed asthma, 20% had CBCL externalizing problems in clinical range, and 44% had standardized PPVT scores below average by 5 years of age. While homelessness was associated with increased risk of physical disability (OR=1.50, p<.01) and ER visits (OR=1.13, p<.10) compared to other low-income children, it did not have a significant independent effect on young children's overall health status, asthma, mental health, and cognitive development. Children in doubled-up arrangements had a lower risk of having diagnosed asthma (OR=0.85, p<.01) and a greater likelihood of having PPVT scores above average (OR=1.56, p<.001). The effects of socio-demographic characteristics, child's health conditions at birth, and family characteristics on children's health and development were also examined.

Conclusions and Implications: This is the first prospective cohort design study using a sample selected from multiple jurisdictions to examine independent effects of housing instability and other poverty-related factors on children's health and development. High rates of asthma and mental health problems among low-income children, particularly homeless children, suggest a critical need for early screening and prevention efforts for this vulnerable population. Significant effects of family and social environment on young children's health rather than homelessness suggest that clinicians need to identify and respond to parents needs for support services to effectively reduce the need for extensive health services for homeless children. Lingering effects of infant health conditions on subsequent health indicate the importance of screening and assessment for health risks. Clinicians and practitioners need to be cautious in classifying families sharing the housing of other persons voluntarily as the homeless.