Thursday, December 11, 2008

Mental health of homeless children and their families

Panos Vostanis
Panos Vostanis is Professor of Child and Adolescent Psychiatry at the University of Leicester (Greenwood Institute of Child Health, Westcotes House, Westcotes Drive, Leicester LE3 0QU, UK. Tel: 0116 225 2880; fax: 0116 225 2881; e-mail: pv11@le.ac.uk). In his National Health Service (NHS) capacity, he provides a mental health service for children looked after by local authorities, youth offenders and homeless families. The research projects on homeless children have been supported by the Nuffield Foundation (1996–1998), West Midlands NHS Executive Research and Development (1998–2000) and, currently, the PPP Healthcare Medical Trust.

Homeless families are defined as all adults with dependent children who are statutorily accepted by local authorities (housing departments) in the UK, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period varies from a few days to several months, although the target for rehousing is usually around 4 to 6 weeks. Some housing departments, particularly in London, also use bed and breakfast accommodation.

This definition is obviously fairly broad and does not include those children and their carers who have lost their homes and live with friends or relatives, on the streets, in squats or as travellers. For this reason, official statistics are not often accurate, although it is estimated that about 140 000 families in the UK fulfil these criteria each year (Vostanis & Cumella, 1999). Many of these families become homeless again within 1 year of rehousing. The average family comprises a single mother and at least two children (usually under 11 years), although there are a number of adolescents and fathers living in homeless centres.

On the whole, reasons for family homelessness are different from those for single homeless adults. The majority of families become homeless because of domestic violence and, to a lesser extent, harassment from neighbours. In our epidemiological studies (Vostanis et al, 1997), the corresponding figures were 50% and 25%. These very much depend on the type of accommodation, as most local authorities or voluntary organisations (for example, Women’s Aid or Crisis Response) have hostels exclusively or predominantly for victims of domestic violence. The proportion of families who are refugees has fluctuated since the late 1990s. Initially, they were confined to the London area, but in the past few years their numbers have been rising in most parts of the UK. There is, however, an increasing tendency for refugees not to go through the above homelessness route. Similar trends in homelessness have been evident in other Western societies, mainly in North America (Weinreb & Rossi, 1995; Bassuk et al, 1996; Better Homes Fund, 1999).

Characteristics and needs

Homeless children and families are a heterogeneous population, with multiple and interrelated needs. This is a crucial observation for the development of services. The episode of homelessness is rarely a one-off event. Most families have histories of previous chronic adversities that constitute risk factors for both children and parents (Bassuk et al, 1997). Such events include family conflict, violence and breakdown; limited or absent networks for family and social support; recurring moves; poverty; and unemployment. Mothers are more likely to have suffered abuse in their own childhood and adult life and children have increased rates of placement on the at-risk child protection register, because of neglect, physical and/or sexual abuse.

Studies have looked at a range of health needs among homeless children and their parents. Not surprisingly, a number of problems appear to cluster in this population. In particular, the children are more likely to have a history of low birthweight, anaemia, dental decay and delayed immunisations, to be of lower stature and have a greater degree of nutritional stress. They are also more likely to suffer accidents, injuries and burns. Some studies have found that child health problems increase with the duration of homelessness, although this finding is not consistent. A substantial proportion of homeless children have delayed development compared with the general population of children of a similar chronological age. This includes both specific developmental delays, such as in receptive and expressive language and visual, motor and reading skills, as well as general skills and educational status (Page et al, 1993; Webb et al, 2001).

Mental health problems and disorders

The social profile of homeless children includes many well-established risk factors for the development and maintenance of psychopathology. These are not specific to child or adult psychiatric disorders, as research has found high prevalence rates for a number of emotional and behavioural problems and disorders (Amery et al, 1995). In children of pre-school and primary school age, behavioural problems include sleep disturbance, feeding problems, aggression and hyperactivity. These are often comorbid with emotional or developmental disorders. Anxiety and post-traumatic stress disorder (PTSD) are often precipitated by life events such as witnessing domestic violence. About one-third of children admitted to hostels in Birmingham were reported to have mental health problems which required clinical assessment and treatment (Vostanis et al, 1997). Histories of abuse and the presence of mental illness in mothers were the strongest predictors of child psychopathology. In the absence of any intervention, child mental health problems remained 1 year later (Vostanis et al, 1998). In a subsequent cohort, mental health problems among both children and their mothers were strongly associated with poor family and social support networks (Vostanis et al, 2001).

Homeless adolescents and street youth are likely to present with depression and attempted suicide, alcohol and drug misuse, and vulnerability to sexually transmitted diseases, including acquired immune deficiency syndrome (AIDS). Two major studies of this group in London (Craig et al, 1996) and Edinburgh (Wrate & Blair, 1999) found significant histories of residential care, family breakdown, poor educational attainment and instability of accommodation. These were associated with sexual risk behaviours, substance misuse and comorbid psychiatric disorders, particularly depression. A high proportion of homeless mothers also have similar psychiatric disorders, again primarily depression and substance misuse. Prevalence rates of 45–50% have been reported (Connelly & Crown, 1994; Zima et al, 1996; Vostanis et al, 1997). These are similar to rates found among single homeless women (Adams et al, 1996).

Access to services

There are several reasons why homeless children and their families cannot access mainstream health and social care services, despite their high level of need. The main one is their mobility between different health and local authority sectors. As most families will have changed address frequently or urgently, they are less likely than the rest of the population to be registered with a general practitioner (GP) or, in the best of situations, to be registered as temporary patients with a GP covering the hostel residents. This reduces their access to primary and secondary medical care as well as to immunisations and other preventive health procedures (Brooks et al, 1998). Homeless families therefore, tend to rely on accident and emergency departments for medical treatment and to have high rates of hospital admission (Lissauer et al, 1993).

The same applies to social services (access teams, family teams and family support units) and other community agencies. Homeless children are also more likely to be out of school, to avoid being traced by a violent ex-partner or because of the distance from the hostel (particularly in large cities). Parents may wait until they know where they are to be rehoused before registering the children with a new nursery or school. Nurseries and primary schools in the proximity of hostels usually have a high pupil turnover, with resulting high costs, and there are often limited vacancies for short periods (Power et al, 1995). These problems are compounded for refugee children. The outcome is that children miss out on their only source of social stability, i.e. their peers, their routines and a sense of achievement, which are important protective factors.

Apart from the organisational problems in accessing services, considering the frequency of child protection incidents and registrations, children may also be at increased risk because of a lack of continuity and information transfer as they often move between different parts of the country and local social services departments may not be aware of their previous history or be informed of it sufficiently well in advance.

These family and service characteristics inevitably have an impact on any potential contact with mental health services. They are less obvious for adults with mental illness, who may be known to local services. However, psychiatric cover of a hostel can be a contentious issue, as residents can be classified as having no fixed abode. The local service may argue that this population substantially increases the number of referrals and therefore requires extra resources. Areas with such additional resources usually target them at the single adult homeless population, where it is more likely that there will be individuals presenting with severe mental illness. It is more difficult to provide cover for parents with depressive or anxiety disorders, self-harm and substance misuse. In our research (Cumella et al, 1998), homeless mothers had a 49% prevalence rate of psychopathology and an 11% rate of contact with mental health services in the previous year, compared with the corresponding rates for children of 30% (need) and 3% (contact with child and adolescent mental health services (CAMHS)).

Child and adolescent mental health services are undergoing an unprecedented change, seeking to improve their accessibility and response to the general population by distinguishing between different levels of intervention (Box 1). Adopting such a service model is even more important for homeless children who cannot at present access services structured around stability and waiting lists for assessment and treatment. Ways of addressing these problems are discussed below.

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