1. Homeless Children: What Every Health Care Provider Should Know Catherine Karr, MD Joining Hands. Healing Lives. Health Care for the Homeless Clinicians’ Network

2. Acknowledgements Prepared in collaboration with the Health Care for the Homeless Clinicians Network - Pediatric Work Group Work space provided by the Harborview Injury and Prevention Research Center

3. Did you know? The number of homeless families with children is increasing The number of unaccompanied homeless adolescents is increasing Homelessness is an important risk factor for a number of health issues

4. If you care for children…. You are likely to care for children who are homeless or at risk of becoming homeless

5. Contents Recognizing homelessness Understanding the specific health problems of homeless children Infectious disease, injury, lead, mental health & behavior problems, nutrition and growth, anemia, dental health, immunizations, asthma, vision, child abuse Modifying health care plans and prevention strategies Finding resources for your homeless patients and their families

6. This presentation is designed as a primer. The goals are to help you: Recognize homelessness and the risks of homelessness in families with children Understand the specific health problems of homeless children Modify health care plans and prevention strategies appropriately Know how to find resources for your homeless patients and their families

7. Recognizing homelessness and the risks of becoming homeless in families with children

8. A legal definition Stewart B. McKinney Act, 42 U.S.C. § 11301, et seq. (1994) a person who "lacks a fixed, regular, and adequate night-time residence and... has a primary night time residency that is: (A) a supervised publicly or privately operated shelter designed to provide temporary living accommodations... (B) an institution that provides a temporary residence for individuals intended to be institutionalized, or (C) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings." 42 U.S.C. § 11302(a) The term "'homeless individual' does not include any individual imprisoned or otherwise detained pursuant to an Act of Congress or a state law." 42 U.S.C. § 11302.

9. An operational definition Homelessness includes: Camping with no permanent home to return to Doubling-up temporarily with another family Having no permanent place to return to after hospitalization Living out of a car Living in an emergency or transitional shelter

10. Who is homeless? U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: a 27-city survey. December 2001.

11. What about homeless children? 41% are under age 5 1 85% are in families headed by single mothers 2 1. The Institute for Children and Poverty. Homeless in America: A Children’s Story. Part One. New York. 1999. 2. The Better Homes Fund. Homeless Children: America’s New Outcasts. 1999.

12. How many children are homeless in the United States? Modified from Bassuk EL Homeless Families. Scientific American 265:66-74 (1991).

13. Recent estimates suggest that 2% of American children are homeless in the course of one year. Urban Institute. America’s Homeless II: Population & Services. February 2000. (www.urban.org/presentations/AmericasHomelessII/index/htm)

14. What are the trends? Families with children are among the fastest growing segment of people experiencing homelessness

15. What are the trends? Nationwide, city officials predict: 4Requests for emergency shelter by homeless families will increase (Request for shelter by homeless families 2000 - 01 -  22%) 4The nation’s weak economy will mean that the number of homeless people will increase U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: a 27-city survey. December 2001.

16. How can I identify families & children at risk? Know the important risk factors for homelessness Know how to ask sensitively about homelessness—homelessness carries a stigma

17. An overview of risk and protective factors that influence family homelessness Bassuk EL et al. Homelessness in female-headed families: childhood and adult risk and protective factors. AJPH 87:242-248 (1997). Public Sector Assistance for Low-Income Families Precipitating Risk or Protective Factors Childhood/Distal Risk Factors Background Factors Proximal Risk Factors Gender Parental Socioeconomic Status Race/Ethnicity Events & conditions in childhood 1. Monetary Resources 2. Social Resources 3. Non-cash Benefits 4. Current Health Status 5. Current Substance Use 6. Primary Tenancy 7. Pregnancy 8. Dependent Children 9. Partner Violence Housing & Job Market Conditions Homelessness 1. Work History 2. Mental Health Status 3. Chronic Health Conditions 4. Educational Attainment 5. Victimization 6. Drug & Alcohol Use

18. Causes of homelessness: Lack of affordable housing Low paying jobs Substance abuse and lack of needed services Mental illness and lack of needed services Domestic violence Unemployment Poverty Prison release Change/cuts in public assistance U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: a 27-city survey. December 2001.

19. Lack of affordable housing: The gap between the number of affordable housing units and the number of people who need them is the largest on record — 5.4 million units National Coalition for the Homeless. NCH Fact sheet #1. Why Are People Homeless? June 1999.

20. Domestic Violence: One of the most common reasons for women and their children becoming homeless 1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-income Housed Children. Pediatrics 102: 554-562 (1998). 3. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). (p <0.01) (not stat. sign.)

21. Mental Illness: An important risk factor for homelessness (p <0.01) (p <0.001) 1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 2. Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization. AJPH 82:1547-1550 (1992). (not stat. sign.)

22. Mental Illness: An under-treated problem (p<0.001) Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization. AJPH 82:1547-1550 (1992).

23. Alcohol and drug abuse are associated with homelessness (p<0.05) (p<0.001) 1. Coll CG et al. The Developmental Status and Adaptive Behavior of Homeless and Low-Income Housed Infants and Toddlers. AJPH 88:1371-1374 (1998). 2. Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization. AJPH 82:1547-1550 (1992). 3. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

24. Substance abuse plays an important role in single parent families (p<0.05) Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). (not stat. sign.)

25. Homelessness is a dynamic state Children are homeless on average 10 months at a time 25% of homeless children are homeless more than once U.S. Department of Health & Human Services. Bureau of Primary Health Care. No Place to Call Home. April 2001.

26. Understanding the specific health problems of homeless children

27. How do the health issues of homeless children differ from housed children? Data are limited* but suggest an overall increased morbidity The specific areas of concern and increased morbidity reflect “poverty medicine” in the extreme *most studies are descriptive with small, non-representative samples and often without an appropriate comparison group

28. Overall Health

29. Homeless parents rate their children’s health as fair or poor more often 1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-income Housed Children. Pediatrics 102: 554-562 (1998). 3. Hu DJ et al. Health Care Needs for Children of the Recently Homeless. Journal of Community Health 14:10-7 (1989). 4. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988). 5. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991) 6. Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues in Comprehensive Pediatric Nursing 20: 153-173 (1997). * No statistical comparison reported (not stat. sign.) (p<0.05) (*)

30. Hospitalization is common for homeless children 1. p<0.05 2. No statistical comparison reported

31. Homeless children are more likely to be seen in an ED Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

32. Homeless children often have multiple health problems Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001).

33. Clinic visits by homeless children underscore increased acute problems 1. Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

34. Infectious Disease

35. Homeless families often live in crowded quarters, which increase the risk of the common infectious diseases of childhood such as upper respiratory infections, ear infections, and diarrhea

36. Infectious Disease (p<0.001) 1. Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992) 2. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). * No statistically significant difference between homeless and housed, no statistical comparison with general population reported. (*)

37. Infectious Disease: Acute Otitis Media The Children’s Health Fund. Still in Crisis: The health status of New York City’s homeless children. 1999. The Children’s Health Fund. The Crisis Continues: The health status of New York City’s homeless children. 2000. * No statistical comparison reported. (*)

38. Infectious Disease: Diarrhea Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). *No statistically significant difference between homeless and housed, no statistical comparison with general population reported. (*)

39. Infectious Disease: Lice & scabies 1. Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992). 2. Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991). 3. Page AJ et al. Homeless Families and their Children’s Health Problems: a Utah Urban Experience. Western Journal of Medicine 158:30-35 (1993). * No statistical comparison reported. (*)

40. Injury

41. Homeless children live in less structured and less safe environments that may place them at risk of injury

42. Injury (p<0.05) (not stat. sign.) 1. Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998). 3. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520- 526 (1991).

43. Lead

44. Elevated blood lead levels are associated with poverty This is related to increased exposure to dust and dilapidated housing There may also be increased absorption of lead in settings of poor nutrition Iron and calcium deficiencies increase lead absorption

45. Lead toxicity 1. Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988). 2. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). 3. Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical Pediatrics 32:151-155 (1993). 4. U.S. Department of Health & Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2010: Understanding and Improving Health.

46. Lead screening is inadequate Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

47. Mental Health & Behavior Problems

48. Homeless children are more likely to come from backgrounds of domestic violence, mental illness, and substance abuse These and other stresses associated with homelessness and poverty impact psychosocial well-being

49. Mental Health: A chart review of comprehensive care visits at a school-based clinic Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal Pediatric Health Care 15:244-250 (2001). (p<0.05)

50. Depression: A summary of studies reporting performance on the Children’s Depression Inventory - School-Aged Children Percent exceeding the cut-off suggesting further psychiatric evaluation (not stat. sign.) 1. Zima BT et al. Emotional and Behavioral Problems and Severe Academic Delays among Sheltered Homeless Children in Los Angeles County. AJPH 84:260-264 (1994). 2. Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues of Comprehensive Pediatric Nursing 20: 153-173 (1997). 3. Menke EM. The Mental Health of Homeless School-age Children. JCAPN 11:87-98 (1998). 4. Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990).

51. Behavior Problems: Children’s performance on the Behavior Problems Index p<0.05 Differences were primarily due to aggressive behaviors such as frequently stubborn, sullen or irritable, hitting other children or adults, frequent temper tantrums There were similar ratings on withdrawal, delinquency, and immaturity dimensions Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).

52. Behavior Problems: Reported performance on the Child Behavior Checklist - School-Aged Children Percent exceeding the cut-off suggesting further psychiatric evaluation: (criteria T>60 for 1,2, T>65 for 3) 1. Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues in Comprehensive Pediatric Nursing 20: 153-173 (1997). 2. Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990). 3. Rescorla L et al. Ability, Achievement and Adjustment in Homeless Children. American Journal of Orthopsychology 61:210-220 (1991). (not stat. sign.)

53. Behavior Problems: Reported performance on the Child Behavior Checklist - Homeless School-aged Children 26% met criteria for clinical diagnosis (T>70) More problems in males. Compared to normative data: Homeless males had statistically significantly higher scores for total behavior and subcategories of externalizing, uncommunicative, and obsessive-compulsive behavior. No statistically significant differences for homeless females. 9% met criteria for clinical diagnosis (T>70) Mean scores were comparable to population means. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520- 526 (1991). Menke EM. The Mental Health of Homeless School-Age Children. JCAPN 11:87-98 (1998).

54. Behavior Problems: Reported performance on the Child Behavior Checklist – Pre-School Children Homeless, sheltered children compared with poor, housed children Statistically significant worse scores for total problems, externalizing and internalizing subgroup scores Total T score > 70 (clinical range) Homeless 21% Housed 5% Homeless, sheltered children compared with normative data No statistically significant differences in scores Total T score > 70 (clinical range) Homeless 20% Rescorla L et al. Ability, Achievement and Adjustment in Homeless Children. American Journal of Orthopsychology 61:210-220 (1991). Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

55. Behavior Problems: Reported performance on the Simmons Behavior Checklist - Pre-School Children Homeless, sheltered children compared with housed, poor children No statistically significant difference in mean score or specific factor scores

56. Development

57. Psychosocial and environmental stresses undermine normal development Developmental screening has identified more developmental lags in homeless pre- school children Among school-age children, academic problems are common

58. Denver Developmental Screening Test Results Reported prevalence of homeless children failing at least one section—a wide range: 5 percent, 1 15 percent, 2 54 percent 3 Reported prevalence of homeless children failing at least two sections—9 percent 2 Most common area of delay reported is speech/language (prevalence reported = 4 percent, 1 13 percent, 2 42 percent 3 ) 1.Page AJ et al. Homeless families and their children’s health problems: a Utah urban experience. Western Journal of Medicine 158: 30-35 (1993). 2. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 3. Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990).

59. Denver Developmental Screening Test Results Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990). (p<0.05)

60. Psychometric testing of pre-school children and toddlers Homeless, sheltered pre-school children (age 3 - 5 years) performed more than one standard deviation below general population on tests of: Visual-motor skills (Draw-A-Person) Verbal ability (Binet IV vocabulary) Receptive vocabulary (PPVT-R) Visual-motor skill (Beery VMI) Homeless, sheltered toddlers (age 2) performed similarly to general population. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

61. Psychometric testing of school-age children Homeless, sheltered children (age 6 - 12) performed more than one standard deviation below general population on tests of: verbal ability (WISC-revised vocabulary) reading (WRAT-R) Only 30% of the homeless children were reading at age level Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991).

62. Nutrition & Growth

63. Poverty has been associated with both obesity and malnutrition Obesity reflects a diet containing excessive cheaper, carbohydrate rich foods Malnutrition reflects caloric deficiency

64. Obesity and malnutrition 1. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988). 2. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 3. Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988). * No statistical comparison made. (*)

65. Access to nutritious food is problematic (p<0.01) Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).

66. Access to adequate amounts of food is problematic (p<0.01) Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990).

67. Evidence of stunting in homeless children: chronic malnutrition decreases attained height Fierman AH et al. Growth Delay in Homeless Children. Pediatrics 88:918-925 (1991). Percentile Distribution of Height

68. Evidence of obesity in poor, housed children Fierman AH et al. Growth Delay in Homeless Children. Pediatrics 88:918-925 (1991). Percentile Distribution of Weight-Height

69. Anemia

70. Anemia is another well-known disease of poverty (p<0.05) (not stat. sign.) 1. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). 2. Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical Pediatrics 32:151-155 (1993). 3. Page AJ et al. Homeless families and their children’s health problems: a Utah urban experience. Western Journal of Medicine 158: 30-35 (1993).

71. Dental Health

72. Dental caries and lack of dental care is common among the poor 36% of children have dental problems according to homeless families surveyed 1 28% of children have visible caries according to providers of health care for homeless children 2 10 times rate of poor dentition in homeless children compared with general population according to national homeless health care providers 3 1. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988). 2. Page AJ et al. Homeless families and their children’s health problems: a Utah urban experience. Western Journal of Medicine 158: 30-35 (1993). 3. Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991).

73. Access to Dental Care Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues in Comprehensive Pediatric Nursing 20: 153- 173 (1997). *No statistical comparison reported. (*)

74. Immunization Delay

75. Immunization delay is common, particularly in young children Percent of children lacking up-to-date immunizations (p<0.05) (*) 1. Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical Pediatrics 32:151- 155 (1993). 2. Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988). 3. The Children’s Health Fund. Still in Crisis: The health status of New York City’s homeless children. 1999. 4. Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988). *No statistical comparison reported. (*)

76. Immunization delay in school-aged children Percent of children lacking up-to-date immunizations 1. Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001). 2. Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues in Comprehensive Pediatric Nursing 20: 153-173 (1997). * no statistical comparison reported (not stat. sign.) (*)

77. Asthma

78. Asthma rates increase with poverty Dust mites, cockroaches, rodents, and indoor molds are common asthma triggers found in most shelter housing Upper respiratory infection is common in homeless children and is a well-identified asthma trigger There is increasing evidence that psychosocial stress may also be an important asthma trigger

79. Asthma 1. Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001). 2. The Children’s Health Fund. Still in Crisis: The health status of New York City’s homeless children. 1999. 3. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 4. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998). 5. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). * No statistical comparison reported. (p<0.05) (*) (p<0.01) (not stat. sign.)

80. Vision

81. Problems with vision are common among homeless children Percent with visual acuity deficits identified during screening (p<0.01) 1. Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001). 2. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). 3. Page AJ et al. Homeless families and their children’s health problems: a Utah urban experience. Western Journal of Medicine 158: 30-35 (1993).

82. Child Abuse

83. It is well known that perpetrators of child abuse are often victims of abuse themselves As such, it is not surprising that many homeless children are at risk of abuse

84. Families involved in child abuse investigation (p<0.05) (not stat. sign.)(p<0.01) 1. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). 2. Coll CG et al. The Developmental Status and Adaptive Behavior of Homeless and Low-Income Housed Infants and Toddlers. AJPH 88:1371-1374 (1998). 3. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998).

85. Families reporting abuse of their children 1. Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). 2. Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998). (not stat. sign.)

86. Homeless Child Syndrome In summary, the typical homeless child problem list will include: poverty-related health problems immunization delays untreated or under-treated acute and chronic problems mental health, behavior and academic problems child abuse/neglect

87. Modifying health care plans and prevention strategies

88. Homelessness carries a stigma Determining housing status requires asking questions in a sensitive and non-threatening manner

89. Suggested assessment questions Do you have safe and permanent housing? Where are you staying? How long have you been there? Have there been any changes in your housing situation since your last visit?

90. Suggested assessment questions (continued) Do you have any concerns about your housing? How many times have you moved in the last year? Homeless mothers living in shelters move an average of three to four times per year

91. Altering your plan of care Determine the safety of the living environment If it is not safe, provide access to resources

92. Altering your plan of care Recognize that homelessness is dynamic Reassess potential for homelessness at every encounter

93. Altering your plan of care Use acute problem visits as a “window of opportunity” Provide a thorough medical, developmental and psychological history as well as physical exam

94. Altering your plan of care Be alert to medical conditions that result from lack of access to medical care, preceded homelessness, or occur with homelessness Prescribing practices should reflect the fact that the child may be living and eating in a shelter or on the street

95. Altering your plan of care Pay particular attention to health care maintenance Provide immunizations and screening for lead toxicity, anemia, visual acuity, and hearing loss Monitor growth and nutrition

96. Altering your plan of care Provide a “medical home” Include primary pediatric care plus access to subspecialty care, developmental and psychological evaluation/treatment, medication and medical devices, case management, and 24 hr/7day access through an answering service

97. Altering your plan of care Address continuity of care limitations Ensure patient transportation and availability of providers Ensure means of communication taking into consideration that patients often have limited phone access

98. Altering your plan of care Screen parents for depression, substance abuse, and child abuse or neglect Make appropriate referrals As a final reality check, ask the parent if there is anything in the plan that will be difficult or impossible to follow

99. Know how to find resources for your homeless patients and their families

100. Finding resources Web-based information Health Care for the Homeless Information Resource Center www.hchirc.com Web site supported by Health Resources & Service Administration, U.S. Department of Health & Human Services Includes state-based directory of health care for the homeless projects Links to federal agencies, national and student organizations Links to hotlines including domestic violence and crisis lines

101. Finding resources Web-based information National Health Care for the Homeless Council and HCH Clinicians’ Network www.nhchc.org Web site for membership organization serving health care providers working with homeless people across the U.S. Features numerous publications including Healing Kids: the pediatric interest group update Includes sections on training, research, public policy and advocacy Links to other organizations and agencies serving homeless populations

102. Finding resources Print-based information No place to call home: Overview of outreach and primary health care services for the Homeless Children’s Program. 2001. (Health Care for the Homeless Information Resource Center; phone 1 888-439-3300) America’s Homeless Children: New Outcasts. A Public Policy Report from The Better Homes Fund. 1999. (617/964-3834)

103. Homelessness and Children “ It is hard to imagine a social environment less conducive to health or normal maturation and development.” —J.D. Wright

104. References used in this presentation U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America’s Cities: a 27-city survey. December 2001 The Institute for Children and Poverty. Homeless in America: A Children’s Story. Part One. New York. 1999. The Better Homes Fund. Homeless Children: America’s New Outcasts. 1999. Bassuk EL. Homeless Families. Scientific American 265:66-74 (1991). Urban Institute. America’s Homeless II: Population & Services. February 2000. (www.urban.org/presentations/AmericasHomelessII/index/htm) Bassuk EL et al. Homelessness in female-headed families: childhood and adult risk and protective factors. AJPH 87:242-248 (1997). National Coalition for the Homeless. NCH Fact sheet #1. Why Are People Homeless?June 1999. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). Weinreb L et al. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102: 554-562 (1998). Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). Weitzman BC et al. Predictors of Shelter Use Among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization. AJPH 82:1547-1550 (1992). Coll CG et al. The Developmental Status and Adaptive Behavior of Homeless and Low-Income Housed Infants and Toddlers. AJPH 88:1371-1374 (1998). Parker RM et al. A Survey of the Health of Homeless Children in Philadelphia Shelters. AJDC 145:520-526 (1991). U.S. Department of Health & Human Services. Bureau of Primary Health Care. No Place to Call Home. April 2001. Wood D et al. Health of Homeless Children and Housed Poor Children. Pediatrics 86:858-866 (1990). Hu DJ et al. Health Care Needs for Children of the Recently Homeless. Journal of Community Health 14:10-7 (1989).

105. References used in this presentation Miller DS et al. Children in Sheltered Homeless Families: Reported Health Status and Use of Health Services. Pediatrics 81: 668-673 (1988). Menke EM & Wagner JD. A Comparative Study of Homeless, Previously Homeless, and Never Homeless School-Aged Children’s Health. Issues in Comprehensive Pediatric Nursing 20: 153-173 (1997). Berti LC et al. Comparison of Health Status of Children Using a School-Based Health Center for Comprehensive Care. Journal of Pediatric Health Care 15:244-250 (2001). Murata J et al. Disease Patterns in Homeless Children: A Comparison with National Data. Journal of Pediatric Nursing 7:196-204 (1992). The Children’s Health Fund. Still in Crisis: The health status of New York City’s homeless children. 1999. The Children’s Health Fund. The Crisis Continues: The health status of New York City’s homeless children. 2000. Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991). Page AJ et al. Homeless Families and their Children’s Health Problems: a Utah Urban Experience. Western Journal of Medicine 158:30-35 (1993). Alperstein G et al. Health Problems of Homeless Children in New York City. AJPH 78:1232-1233 (1988). Fierman AH et al. Status of Immunization and Iron Nutrition in New York City Homeless Children. Clinical Pediatrics 32:151-155 (1993). U.S. Department of Health & Human Services. Office of Disease Prevention & Health Promotion. Healthy People 2010: Understanding and Improving Health. Zima BT et al. Emotional and Behavioral Problems and Severe Academic Delays among Sheltered Homeless Children in Los Angeles County. AJPH 84:260-264 (1994). Menke EM. The Mental Health of Homeless School-Age Children. JCAPN 11:87-98 (1998). Bassuk EL et al. Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-261 (1990). Rescorla L et al. Ability, Achievement and Adjustment in Homeless Children. American Journal of Orthopsychology 61:210-220 (1991). Fierman AH et al. Growth Delay in Homeless Children. Pediatrics 88:918-925 (1991). Wright JD. Children in and of the Streets. AJDC 145:516-519 (1991).