Homeless Children: Update on Research, Policy, Programs, and Opportunities

Publication Date

May 14, 2010

Prepared by:
Judith Samuels, Ph.D., The Nathan S. Kline Institute for Psychiatric Research and Department of Child and Adolescent Psychiatry, NYU School of Medicine
Marybeth Shinn, Ph.D., Department of Human and Organizational Behavior,
Peabody College, Vanderbilt University
John C. Buckner, Ph.D., Children’s Hospital Boston, Harvard Medical School

Under contract to:
Policy Research Associates, Inc.
Delmar, NY

Prepared for:
Office of the Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services.

Despite the knowledge that homeless children face poor outcomes, research has largely focused on the parent(s) in a homeless family, perhaps because these children are still part of a family unit. However, the children themselves have different and separate needs from their parent(s). Given the impact of the current recession, it is critical to understand the impact of homelessness on our youngest population, and to ensure that resources are mobilized to guarantee that these children's needs are met quickly and thoroughly. This paper provides an update on the research, policy, laws, and funding for programs and services for children who are homeless in the United States. Education, health, and mental health for homeless children are examined.

Section I. Introduction, Definitions, Context, and Data

I-A. Introduction

This paper provides an update on the research, policy, laws, and funding for programs and services for children who are homeless in the United States. Education, health, and mental health for homeless children are examined. “Homeless children” here refers to minor children accompanying their parent(s)/guardian(s) during a homeless episode. Unaccompanied youth who are homeless are intentionally excluded in this paper. Their issues, needs, and the systems responsible for responding are different and, thus, are outside the purview of this paper.

Children and their families who become homeless enter this status from a much larger number of at-risk families with very limited incomes. Because family homelessness is a temporary state and not a permanent condition, almost all homeless families will eventually be re-housed and rejoin this larger group of housed families. An episode of homelessness is an adversity encountered by many children living in low-income neighborhoods. Children who become homeless are at risk for, or have already faced, other major issues, such as exposure to family and community violence, which can impact children regardless of whether they are living in shelter or in permanent housing. Because of the fluid nature of family homelessness, it is difficult to intervene over the long-term with homeless children without looking to settings, such as schools, that children will be in regardless of whether they are presently living in shelter or in permanent housing. The recent economic downturn and housing foreclosure crisis also impacts homelessness.

The federal response to child homelessness has included enacting laws that seek to protect the rights of these children, such as those ensuring their inclusion in the education system. This is achieved through the McKinney-Vento Homeless Assistance Act as reauthorized in the No Child Left Behind legislation. But there are many other federal, state, and local programs and funding streams in place to assist homeless children. These programs cover direct services to children, such as health care, nutrition, and transportation, and programs to assist their families, such as the U.S. Department of Health and Human Services (HHS) Temporary Assistance for Needy Families (TANF) program and U.S. Department of Housing and Urban Development (HUD) programs (e.g., Section 8 and emergency housing).

I-B. Definitions of homeless families

Definitions of homelessness pertaining to families differ, depending upon whether HUD’s or the Department of Education (ED) McKinney-Vento criteria are being used.

The HUD definition of homelessness (below) is used to determine qualification for participation in HUD programs. It does not include individuals living doubled-up or in hotels/motels, situations in which homeless children often are found. According to the HUD definition, an individual who is homeless:

lacks a fixed, regular, and adequate nighttime residence; and
has a primary nighttime residence that is —
1. a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for people with mental illness);
2. an institution that provides a temporary residence for individuals intended to be institutionalized; or
3. a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

The ED definition is broader than HUD's as it includes children in the HUD definition plus those who are living doubled up due to economic distress. According to the ED definition (U.S. Code, Title 42, Chapter 119, Subchapter I, § 11301), the term “homeless children and youths”:

means individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 11302 (a)(1) of this title); and
includes —
1. children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement;
2. children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 11302 (a)(2)(C) of this title);
3. children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings;
4. migratory children (as such term is defined in section 6399 of title 20) who qualify as homeless for the purposes of this part because the children are living in circumstances described in clauses (A) through (C).

Many families begin their journey through homelessness by staying temporarily with other people or in a motel to avoid sleeping outdoors in public spaces and in cars. Doubled-up situations are often overcrowded and unstable. Motel rooms, also crowded, rarely include cooking and appropriate food storage facilities, making adequate nutrition difficult. Many localities lack adequate room in family shelters, including domestic violence shelters, and some areas lack family shelters altogether. In these circumstances, families find alternatives, most often temporary housing with others. The ED homeless definition includes these children.

Other federal agencies also use definitions of homelessness to determine eligibility of children for programs and services. Table 1 (below) indicates the federal program that serves homeless children, the agency responsible for the program, and the “overnight” eligibility criteria for each program.

Table 1.

Definitions of Homelessness Used by Federal Programs Serving Children

Program	Agency/Department	Shelter	Doubled-up	Hotel/ Motel	Other locations
All HUD programs	Department of Housing and Urban Development	X
McKinney-Vento Education for Homeless Children and Youth Program	Office of Elementary and Secondary Education, Department of Education	X	X	X	X
Head Start	Administration for Children and Families, Department of Health and Human Services	X	X	X	X
Runaway and Homeless Youth	Administration for Children and Families, Department of Health and Human Services	X	X	X	X
Health Care for the Homeless	Health Resources and Services Administration, Department of Health and Human Services	X	X	X	X
Treatment for the Homeless	Substance Abuse and Mental Health Services Administration, Department of Health and Human Services	X	X	X	X
Homeless Veterans Reintegration Program	Veterans Employment and Training Service, Department of Labor	X	X	X	X
Violence Against Women	Office of Violence Against Women, Department of Justice	X	X	X	X
School Lunch Program	Food and Nutrition Service, Department of Agriculture	X	X	X	X

I-C. Counts of homeless children

Children in families meeting the HUD definition of homelessness

HUD’s most recent counts of homeless children are summarized in the 2008 Annual Homeless Assessment Report (AHAR) released July 2009, which includes a count of children residing in HUD-funded shelters and transitional housing. The report includes information about point-in-time counts as well as an annual count reflecting the 12-month period October 2007 to September 2008. The data in AHAR are collected through HUD’s Homeless Management Information System (HMIS). The annual count in the 2008 AHAR was 326,400 children, representing 20 percent of the total number of homeless individuals in the HUD data (see Figure 1). About half (51 percent) of these children were under age 6 (see Figure 2). These numbers exclude families in domestic violence shelters who did not access a residential program serving the general homeless population during the year, families that accessed other shelters that do not receive HUD funds, homeless families that never entered shelter, and families in which the parent is under age 18.

Figure 1

Distribution of Homeless Persons, HUD HMIS Annual Data

Figure 2Age Distribution of Homeless Chlidren, HUD HMIS Annual Data<img alt="Figure 2: Age Distribution of Homeless Chlidren, HUD HMIS Annual Data" src="/sites/default/files/private/images-reports/homeless-children-update-research-policy-programs-and-opportunities/fig2.png" />At the time of the national point-in-time count of homeless people in the United States in January 2008, 27 percent of all homeless family members were unsheltered (HUD, 2009). While homeless families are more likely than homeless individuals to be in shelter, it appears that substantial numbers of families with children experience episodes of homelessness where they never enter shelter. They may stay in cars, campgrounds, and other places not fit for human habitation. Virtually nothing is known about the numbers or characteristics of children in families that become homeless (by the HUD definition) but never enter shelter.Most of what is known about homeless children derives from studies of children in families sampled at homeless shelters. All such children meet the HUD definition of homelessness. More rarely there is information about these children after they are re-housed or, from school records, before they became homeless. Virtually all of the research that has been published on homelessness among children was conducted prior to the current recession and increase in housing foreclosures. Thus, studies do not include children whose families became homeless as a result of the recent economic recession.<h4>Children in families meeting the ED definition of homelessness</h4>Data on the numbers of children and youth who are enrolled in school and homeless under the ED definition are collected by State Education Agencies (SEAs) and Local Education Agencies (LEAs) under the Education for Homeless Children and Youth (EHCY) Program and collated by the National Center for Homeless Education (NCHE) (2009). In the 2007–08 school year, more than 773,800 homeless children and youth were enrolled in school. ED data show that more than half of the homeless children enrolled in schools (65 percent) were living doubled up as their “primary nighttime residence,” 7 percent were living in hotels or motels, 21 percent were living in shelter, and 7 percent were unsheltered (see Figure 3). All of these children were age 5 and older, as pre-K enrollments are not included in this report.Figure 3ED Data, Primary Nighttime Residence by Category, SY 2007-2008<img alt="Figure 3: ED Data, Primary Nighttime Residence by Category, SY 2007-2008" src="/sites/default/files/private/images-reports/homeless-children-update-research-policy-programs-and-opportunities/fig3.png" />Data as reported by LEAs to ED show that there were 27,815 homeless children in public pre-K programs during the 2007-08 school year (NCHE, 2009). The number of homeless children in Head Start and Early Head Start programs during the 2008 program year was 29,684 (HHS, 2009), or a total of about 60,000. This small figure is an underestimate of the number of homeless preschoolers in that year.The primary source of data for the NCHE report on ED data comes from the LEAs as required in the McKinney-Vento Homeless Assistance Act. LEAs in each school district submit data on homeless students to the SEAs who submit the data to ED. There were a total of 15,198 LEAs in the 2007–08 school year, 91 percent of which reported data. While fewer than 10 percent (1,364) of the LEAs received McKinney-Vento Education for Homeless Children and Youth Program subgrants, LEAs with these grants include 59 percent of enrolled homeless children. LEAs have access to other federal funds such as Title I, and many also have both local and state funds that they can use to provide services to homeless students.ED data shows a 17 percent increase in the number of homeless children over the previous school year (2006–07). States that had an increase of at least 2,000 homeless students over the previous year were California (an increase of 46,235), Illinois (6,417), Iowa (3,032), Minnesota (2,155), New York (27,200), North Carolina (4,278), and Texas (19,346). States indicating a decrease in homeless students from the previous year were Louisiana, Michigan, and Mississippi. The report offers three possible reasons for these changes: better data collection, the impact of natural disasters, and the economic downturn.As previously stated, much research on homeless children to date defines homelessness in a manner consistent with the HUD definition.  Very little existing research has studied children who meet the ED definition of homelessness. Such children can sometimes be found in comparison groups in studies that contrast families living in shelter to low-income families living in housing.  The difference between the ED group of children and the HUD group sampled in shelter is sometimes a matter of timing.  Episodes of homelessness among families meeting HUD criteria are often preceded by periods of residential instability, as families without housing double up with others, turning to shelter only after they wear out their welcomes with relatives and friends (e.g., Weitzman, Knickman, & Shinn, 1990).<h3>I-D. The changing economic context of homelessness for children</h3>This section describes the rise of homelessness generally and in families with children specifically. Contextual factors include changes in poverty, fluctuations in the availability of low-income housing, and the recent recession and foreclosure crisis. <h4>Economic environment</h4>Evidence is surfacing that the current economic and foreclosure crisis has led to an increase in the number of homeless children. We know from prior research that family homelessness is more sensitive to economic cycles than individual homelessness (Culhane et al., 2003). While it is difficult to find data that accurately describes the impact of the current economic crisis on families and children, several reports from 2008 discuss what is likely the beginning of a trend; see, for example, HUD’s 2008 AHAR and the NAEHCY report, The Economic Crisis Hits Home (Duffield & Lovell, 2008). AHAR data collection for the 2008 report ended in September 2008, just as the economic crisis was accelerating. The HUD report warns that the full effect has yet to be observed in their data. In addition, the report acknowledges, as we note above, that people who lose their homes due to financial struggles often stay with friends and relatives as long as possible before resorting to shelter. Since AHAR counts only families that enter the formal shelter system and not those living doubled up or in motels, this is another reason why the impact of the economic crisis is not fully reflected in this report. AHAR shows an overall increase from 2007 to 2008 of 9 percent, which represents about 43,000 persons in homeless families, while there was an overall reduction in the number of sheltered individuals not in families. Also, there is growing evidence of the negative impact of the economic and foreclosure crisis on families in suburban and rural areas. Historically, sheltered homelessness is concentrated in urban areas. Between 2007 and 2008, AHAR shows a shift from urban to suburban and rural areas. Part of this shift is due to a large increase in the percentage of sheltered homeless families in suburban and rural areas, from 26.9 percent to 38.3 percent, while the number in cities decreased. Reports on the state level indicate a similar trend. For instance, in Connecticut, while there was an overall decrease of 12 percent for homeless families, there was a 33 percent increase in homeless families and children in rural and suburban areas during the same reporting period. The impact of the economic and foreclosure crisis can also be seen in data that show a higher rate of movement from stable housing to homelessness. AHAR shows that the share of homeless families that indicated they had been in the place they stayed prior to shelter entry for at least a year rose from 18 percent to 23 percent. The NAEHCY report (2008) examined recent increases in student homelessness as reported by school districts across the county. The report was based on a survey conducted in the fourth quarter of 2008. A link to the Web-based survey was sent to state education coordinators who either forwarded the survey to their local school districts or provided NAEHCY with email addresses to contact LEAs directly. At the time of the survey there were 14,598 school districts nationwide, of which 1,716 completed the survey. Schools from urban, suburban, and rural areas across the country participated. While the report is not statistically representative of all school districts in terms of geography, demography, or size, it does provide insight into the impact of the economic and foreclosure crisis on enrollment of homeless children in schools. Of the school districts that participated in the NAEHCY survey, 330 (19 percent) reported that during the first few months of the 2008–09 school year they had enrolled the same number or more homeless students as in the entire 2007–08 school year. Three months into the 2008–09 school year, 847 (49 percent) of the responding school districts reported homeless student caseloads had increased 50 percent or more over the entire previous year. The NAEHCY survey also asked school districts to report on their perceived reasons for increases in homelessness. By far the most common reason reported was the “economic downturn (e.g., job loss, high cost of living).” Second, and more specific, was the foreclosure crisis, and third, other housing-related factors. Notably, the fourth most cited reason was “increasing incidences of domestic violence, substance abuse or other factors negatively influencing mental or physical health.” And fifth, 149 school districts listed “high medical expenses, with inadequate or no health insurance” as a reason for increased homelessness among students. No doubt some children who are now homeless and have been over the past several years are those whose families became homeless (under either HUD or ED definitions) as a result of the current recession and foreclosure crisis, which began in early 2007. From 2000 to 2006, the number of foreclosures in the United States ranged from 500,000 to 1 million per year. By the summer of 2007, the annualized rate of foreclosures hit 1.5 million and increased to 3 million by the beginning of 2009 (Zandi, 2009). Many of these children have experienced precipitous changes in economic circumstances rather than ongoing poverty, so they may have different characteristics from children studied in the past. Although children who became homeless as a result of the economic crisis have not been studied as a group, there is research on the impact of parental job loss and economic hardship on children. Family, human, or social capital may also offer some protection to these children. The U.S. Conference of Mayors 2009 Hunger & Homelessness Survey reports that three quarters of participating cities reported an increase in family homelessness, which the report attributed to the recession and the lack of affordable housing. The U.S. Conference of Mayors also reported the largest increase in requests for food assistance observed in the last 18 years. <h2>Section II. Research About Homeless Children</h2>Beginning with the earliest published reports in 1987, the literature on homeless children now spans about 23 years. Viewing these studies in the aggregate, a set of “first generation” studies, many of which were reviewed 15 years ago by Rafferty and Shinn (1991), can be distinguished from a second stage of investigations published after the review. The first studies conducted on homeless children sounded a public health alarm (Alperstein, Rappaport, & Flanigan, 1987; Bassuk & Rubin, 1987; Miller & Lin, 1988; Rescorla, Parker, & Stolley, 1991; Wood, Valdez, Hayashi, & Shen, 1990). Findings indicated that homeless children had a range of health and mental health problems. Data for these investigations were collected in the mid-1980s, not long after the issue of homelessness for families became apparent in the United States. A second generation of studies followed in the early 1990s to further clarify the impact of homelessness on children (Buckner, 2004). Some of these investigations were funded by the National Institute of Mental Health, while others were supported by foundations and other funding sources. Investigators who conducted these studies attempted to further an understanding of the effects of homelessness on children by involving larger study populations, including comparison groups of housed children from low-income families, administering a greater breadth and quality of assessment instruments, and applying more advanced statistical techniques with which to analyze the data (Bassuk, Weinreb, Dawson, Perloff, & Buckner, 1997; Buckner, Bassuk, Weinreb, & Brooks, 1999; Masten, Miliotis, Graham-Bermann, Ramirez, & Neemann, 1993; Rafferty, Shinn, & Weitzman, 2004; Rubin, Erickson, San Agustin, Cleary, Allen, & Cohen, 1996; Schteingart, Molnar, Klein, Lowe, & Hartmann, 1995; Shinn et al., 2008; Zeismer, Marcoux, & Marwell, 1994). Almost all investigations of homeless children sample children in shelter in the midst of an episode of homelessness. As such, all homeless children in these studies fit the HUD definition of homelessness. Masten and colleagues (1993) described children as falling on a “continuum of risk” in which children who experience homelessness are worse off than other poor children, and both are worse off than middle class groups. That is, children who are homeless share all of the adversities of poverty and also experience additional risks associated with episodes of homelessness, which for most are temporary. By and large, differences between children in homeless shelters and poor domiciled children are smaller in recent, second-generation, research than in earlier research (Buckner, 2008). Buckner suggests three principal reasons for this. First, as more and more families experience episodes of homelessness in tight housing markets, differences between poor families that do and do not become homeless are diminished. In a housing market in the early stages of dwindling supply, family difficulties (such as mental health or substance use problems in mothers), which can put children at risk, are prominent in explaining which families are most vulnerable to experiencing homelessness. Over time, as the housing supply worsens, families that become homeless will have characteristics increasingly similar to the broader group of low-income housed families. Thus, the family-level risks that children are exposed to will be more alike in each group. Second, as shelter conditions have improved in many jurisdictions and as legal changes and funding have reduced obstacles to stable schooling for children, the plight of sheltered homeless children may have become less severe. Third, homeless children and children from low-income families living in housed conditions are exposed to many of the same stressors, such as community and family violence. As such, the effects of homelessness per se, above and beyond the effects of poverty, can sometimes be difficult to discern. Buckner (2005, 2008) conducted a comprehensive review of the published literature on homeless children from its inception in 1987 through 2005. The chief criteria for inclusion in this review were that the study be published in an academic journal and that it involve a comparison of homeless children to either normative data on children or a housed comparison group. This eliminated unpublished reports or a few studies that examined only homeless children. The dominant research question across these publications was ascertaining the impact of homelessness on children, an issue that requires comparative data. Some studies focused on a particular domain, such as mental health or academic achievement, while others looked across several domains. With studies that examined children of different age groups and/or across various domains, findings from the same overall investigation can sometimes be found dispersed across academic journals due to journals' space limitations and areas of focus (e.g., mental health, education, health). For instance, child-related findings from the Worcester Family Research Project, a comprehensive investigation of 436 homeless and low-income housed mothers and more than 600 of their children conducted in Worcester, Massachusetts, during the 1990s, can be found in various publications (Bassuk et al., 1997; Buckner et al., 1997, 1999, 2001, 2004; Garcia Coll et al., 1998; Weinreb et al., 1998, 2002). While these articles may seem to be separate studies, they report on data collected during the same time period, in the identical community context, and with the same overall study population. This section of the paper begins with an overview of the demographic characteristics of homeless children and is followed by a review of studies, including those examined by Buckner (2005, 2008) and other studies published more recently. Table 2 (Parts A–D) distinguishes among studies focusing on the impact of homelessness in various domains: health status (Part A), developmental status (Part B), mental health and behavior (Part C), and education/academic achievement (Part D). The table includes all published studies of the effects of homelessness on children, emphasizing studies that included housed comparison groups and that followed homeless families over time and used relatively comprehensive measurement. This section continues with a discussion of the small number of studies that follow children longitudinally and the finding that homeless children’s outcomes improve with the passage of time. Next, it describes the subgroup of children who become separated from their homeless families. Finally, it concludes with what is known about interventions for homeless families and children. <h3>Demographic characteristics </h3>As noted above, according to AHAR, just over half (51 percent) of homeless children in emergency shelters and transitional housing were under 6 years of age in 2008, 34 percent were 6 to 12, while only 15 percent were 13 to 17. Slightly over half (51 percent) were Black or African American; 24 percent were White, non-Hispanic or Latino; 13 percent were White and Hispanic or Latino; and the remaining were mixed race (7 percent), American Indian or Alaska Native (2 percent), Native Hawaiian or Pacific Islander (2 percent), or Asian (1 percent). This racial breakdown refers to all people in homeless families, not just children. Homeless families are more likely than homeless individuals to be members of minority groups. <h3>Health and development</h3>As shown in Table 2 Part A, five studies of children’s health produced results consistent with the idea of a continuum of risk. Three studies found homeless children worse off than other poor children, who in turn were worse off than the general population, typically on measures of global health. A fourth, which did not include a poor-housed comparison group, found homeless children worse off than the general population. Only one study found no differences between groups. Overall, although the majority of homeless children were rated by parents as in good or excellent health, the proportion in fair or poor health was greater than for other groups. Homeless children were less likely to have a regular source of medical care and more likely to use emergency rooms. A long-term follow-up study not included in the review found no health differences between formerly homeless and housed children five years after shelter entry, but the children who had been homeless were still less likely to have a usual source of medical care (Shinn et al., 2008). There were no consistent patterns by age of children. A study of children in 16 supported housing programs in Minnesota found that rates of health insurance, well child checkups, and immunizations were greater than that of the general population of Minnesota (Gewirtz, Hart-Shegos, & Medhanie, 2008). Table 2: Summary of Published Homelessness Studies 1987-2005 by Domain Part A: Health-related Problems <table cellpadding="2" cellspacing="0" class="footable table-align-left"><thead><tr valign="Bottom"><th scope="col">Publication</th> <th scope="col">Location</th> <th scope="col">Sample</th> <th scope="col">Age (years)</th> <th scope="col">Outcomes</th> <th scope="col">Findings</th> <th scope="col">Comments</th> </tr></thead><tbody><tr><td>Alperstein et al. (1987)</td> <td>New York City</td> <td>265 homeless children 1600 housed children</td> <td align="Center">0-5</td> <td>Miscellaneous</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td> </td> </tr><tr><td>Miller & Lin (1988)</td> <td>King County, WA</td> <td>158 homeless children</td> <td align="Center">0-17</td> <td>Miscellaneous</td> <td>Homeless Children > General Population</td> <td> </td> </tr><tr><td>Wood et al. (1990)</td> <td>Los Angeles</td> <td>194 homeless children 193 housed children</td> <td align="Center">0-5</td> <td>Miscellaneous</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td> </td> </tr><tr><td>Menke & Wagner (1997)</td> <td>Midwest</td> <td>134 children</td> <td align="Center">8-12</td> <td>Miscellaneous.</td> <td>Homeless Children = Housed Low Income Children = General Population</td> <td> </td> </tr><tr><td>Weinreb et al. (1998)</td> <td>Worcester, MA</td> <td>293 homeless children 334 housed children</td> <td align="Center">0-17</td> <td>Miscellaneous</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>Multivariate analyses</td> </tr></tbody></table>Three studies examined the development of young children from birth until age 3 or 5 (see Table 2 Part B). Two found that homeless children were delayed in comparison to housed children or the general population, particularly in language, using screening instruments. However, the third study by Garcia Coll and colleagues (1998), which used a more thorough assessment instrument (the Bayley Scales of Infant Development), did not find differences between homeless and low-income housed infants and toddlers. Table 2: Summary of Published Homelessness Studies 1987-2005 by Domain (continued) Part B: Developmental-related Problems <div class="table-responsive"><table cellpadding="2" cellspacing="0" class="footable table-align-left table"><thead><tr valign="Bottom"><th scope="col">Publication</th> <th scope="col">Location</th> <th scope="col">Sample</th> <th scope="col">Age (years)</th> <th scope="col">Outcomes1</th> <th scope="col">Findings</th> <th scope="col">Comments1</th> </tr></thead><tfoot><tr><td colspan="7">1. Bayley = Bayley Scales of Infant Development; DDST = Denver Developmental Screening Test</td> </tr></tfoot><tbody><tr><td>Bassuk & Rosenberg (1990</td> <td>Boston</td> <td>134 homeless children 81 housed children </td> <td>0-5</td> <td>DDST</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>DDST is a brief screening instrument</td> </tr><tr><td>Wood et al. (1990) </td> <td>Los Angeles</td> <td>194 homeless children</td> <td>0-5</td> <td>DDST</td> <td>Homeless Children > General Population</td> <td>Housed children were not assessed</td> </tr><tr><td>Garcia Coll et al. (1999)</td> <td>Worcester, MA</td> <td>127 homeless children 91 housed children </td> <td>0-3</td> <td>Bayley</td> <td>Homeless Children = Housed Low Income Children = General Population</td> <td>Bayley is the “gold-standard” measure of developmental status</td> </tr></tbody></table></div> <h3>Mental health and behavior</h3>As shown in Table 2 Part C, 11 studies reviewed by Buckner (2005, 2008) examined children’s mental health and behavior. Nine studies used maternal reports of both internalizing symptoms (such as depression and anxiety) and externalizing symptoms (disruptive behavior) on the Child Behavior Checklist. Six studies additionally used child reports of depressive symptoms on the Children’s Depression Inventory; one study included teacher reports and one used a diagnostic interview. All 11 studies found homeless children to experience more mental health and behavioral problems than normative samples of the general population, but only five of nine studies that included housed poor children found homeless children to have more problems than their housed peers. The two studies with the strongest measurement (teacher reports and the diagnostic interview) were among those that found no difference between homeless children and their housed peers. Again, these studies are broadly consistent with the continuum of risk, with a substantial effect of poverty and a more modest additional effect of homelessness on children’s mental health and behavior. There were no consistent differences by age of children studied. Shinn and colleagues (2008) found small differences favoring continuously housed over formerly homeless children five years after the homeless children entered shelter on both maternal report and diagnostic interviews, but the differences were largely accounted for by recent stressors rather than past homelessness. Table 2: Summary of Published Homelessness Studies 1987-2005 by Domain (continued) Part C: Mental Health/Behavior Problems <div class="table-responsive"><table cellpadding="2" cellspacing="0" class="footable table-align-left table"><thead><tr valign="Bottom"><th scope="col">Publication</th> <th scope="col">Location</th> <th scope="col">Sample</th> <th scope="col">Age (years)</th> <th scope="col">Outcomes2</th> <th scope="col">Findings</th> <th scope="col">Comments2</th> </tr></thead><tfoot><tr><td colspan="7">2. CBCL = Child Behavior Checklist; CDI = Children’s Depression Inventory; DISC = Diagnostic Interview Schedule for Children</td> </tr></tfoot><tbody><tr><td>Bassuk & Rubin (1987)</td> <td>MA</td> <td>156 homeless children</td> <td align="Center">0-18</td> <td>CBCL, CDI</td> <td>Homeless Children > General Population</td> <td>First study to involve homeless children</td> </tr><tr><td>Bassuk & Rosenberg (1990)</td> <td>Boston</td> <td>134 homeless children 81 housed children </td> <td align="Center">0-18</td> <td>CBCL, CDI, etc.</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>Mostly the same homeless sample as Bassuk & Rubin (1987)</td> </tr><tr><td>Rescorla et al. (1991)</td> <td>Philadelphia</td> <td> 83 homeless children 45 housed / clinic children </td> <td align="Center">3-12</td> <td>CBCL, etc.</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>Homeless children much worse on CBCL than housed peers</td> </tr><tr><td>Masten et al. (1993)</td> <td>Minneapolis</td> <td>159 homeless children 62 housed children </td> <td align="Center">8-17</td> <td>CBCL, CDI</td> <td>Homeless Children = Housed Low Income Children > General Population</td> <td>Multivariate analyses controlled for other explanatory variables</td> </tr><tr><td>Zima et al. (1994)</td> <td>Los Angeles</td> <td>169 homeless children</td> <td align="Center">6-12</td> <td>CBCL, CDI</td> <td>Homeless Children > General Population</td> <td> </td> </tr><tr><td>Ziesemer et al. (1994)</td> <td>Madison, WI</td> <td>145 homeless children 142 housed children </td> <td align="Center">School-age</td> <td>CBCL-Teacher</td> <td>Homeless Children = Housed Low Income Children > General Population</td> <td>Teacher version of CBCL used, not parent version as in the other studies</td> </tr><tr><td>Schteingart et al. (1995)</td> <td>New York City</td> <td>82 homeless children 62 housed children </td> <td align="Center">3-5</td> <td>CBCL</td> <td>Homeless Children = Housed Low Income Children > General Population</td> <td>Multivariate analyses controlled for other explanatory variables</td> </tr><tr><td>Menke & Wagner (1997)</td> <td>Midwest</td> <td>134 homeless and housed children</td> <td align="Center">8-12</td> <td>CBCL, CDI, etc.</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>No differences on CBCL</td> </tr><tr><td>Bassuk et al. (1997)</td> <td>Worcester, MA</td> <td>77 homeless children 90 housed children </td> <td align="Center">2-5</td> <td>CBCL</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>Multivariate analyses. Difference between homeless/housed on CBCL-Externalizing only</td> </tr><tr><td>Buckner & Bassuk (1997)</td> <td>Worcester, MA</td> <td>41 homeless children 53 housed children </td> <td align="Center">9-17</td> <td>DISC (DSM-III-R diagnoses) </td> <td>Homeless Children = Housed Low Income Children > General Population</td> <td>Children age 9 and older in Worcester study. Only study to report DSM diagnoses</td> </tr><tr><td>Buckner et al. (1999)</td> <td>Worcester, MA</td> <td> 80 homeless children 148 housed children </td> <td align="Center">6-17</td> <td>CBCL, CDI, etc.</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>Multivariate analyses. Difference between homeless/housed on CBCL-Internalizing only</td> </tr></tbody></table></div>A more recent study (Gewirtz et al., 2008) examined 454 children living in 16 supportive housing programs. Staff had concerns about the psychosocial well-being of 36 percent of the children but, because the study did not use standard measures and had no comparison group, it is hard to know what to make of this percentage. However, the fact that over half of the 100 children age 12–19 had behaved in ways that led to school suspensions would seem to support the staff assessments. Problems in this study increased with the age of the child (Gewirtz et al., 2008). Families of children in this study were eligible for permanent supportive housing because mothers had mental illness, substance abuse problems (most programs), HIV, or experience of domestic violence (one program each), so children were exposed to risks beyond homelessness. <h3>Education</h3>Nine studies reviewed by Buckner (2005, 2008) examined attendance, achievement, and other academic outcomes for homeless children using a variety of measures (Table 2 Part D). All but one study found homeless children worse off than general population samples; and six of seven studies found them worse off than housed children. The one study that found homeless children equivalent to both housed children and the general population was conducted after the EHCY program was established, reducing school mobility and barriers to school enrollment for homeless children. The age of the children did not appear to be related to findings. In the study of children in supportive housing programs, 22 percent of children age 12–19 but only 8 percent of younger children attended school less than 80 percent of the time. An important exception to the generalization that studies of homeless children are confined to those who experience shelter is a study in the Minneapolis public schools (Obradovic, Long, Cutuli, Chan, Hinz, Heistad, & Masten, 2009). Children in four primary school grade cohorts who met the criteria for homelessness under the ED definition or who moved three or more times in a 12-month period were classified as “homeless and highly mobile” and were compared to children who were poor (eligible for free or reduced-price lunch) but not homeless or highly mobile, and children who were neither homeless nor highly mobile at any time during the three school years of the study. Homeless and highly mobile children, who made up 9.5 percent of the 14,754 students in the sample, scored significantly lower on both reading and math than other poor children, and both groups fell well below more socioeconomically advantaged peers. In the three oldest cohorts of children, either reading (5th grade cohort) or math (3rd and 4th grade cohorts) scores also increased faster for advantaged students than for the two disadvantaged groups. There was considerable variability within the homeless and highly mobile group, with approximately 20 percent of students scoring at or above national means, but 40 percent scoring a standard deviation or more below those means. <h3>Subgroups of homeless children</h3>Huntington, Buckner, and Bassuk (2008) found that homeless children in Worcester, Massachusetts, could be classified into two distinctly different subgroups based on measures of behavior problems, adaptive functioning, and academic achievement, using cluster analysis. Almost half of the sample was doing well across each of these domains, despite the stressors they faced, while slightly over half of the group was doing more poorly across each of these three realms. These findings were similar for both preschool-age (2–5 years) and school-age children (6–17). This study suggests that homeless children are not a homogenous group and that interventions should be targeted toward those experiencing the most problems. Table 2: Summary of Published Homelessness Studies 1987-2005 by Domain (continued) Part D: Education-related Problems <div class="table-responsive"><table cellpadding="2" cellspacing="0" class="footable table-align-left table"><thead><tr valign="Bottom"><th scope="col">Publication</th> <th scope="col">Location</th> <th scope="col">Sample</th> <th scope="col">Age (years)</th> <th scope="col">Outcomes3</th> <th scope="col">Findings</th> <th scope="col">Comments</th> </tr></thead><tbody><tr><td>Bassuk & Rubin (1987)</td> <td>MA</td> <td>156 homeless children</td> <td align="Center">0-18</td> <td>Attendance, etc.</td> <td>Homeless Children > General Population</td> <td> </td> </tr><tr><td>Rescorla et al. (1991)</td> <td>Philadelphia</td> <td>83 homeless children 45 housed / clinic children </td> <td align="Center">3-12</td> <td>WRAT-Reading</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>Homeless children scored lower in reading achievement than housed peers</td> </tr><tr><td>Masten et al. (1993)</td> <td>Minneapolis</td> <td>159 homeless children 62 housed children </td> <td align="Center">8-17</td> <td>Changes in school</td> <td>Homeless Children > Housed Low Income Children</td> <td> </td> </tr><tr><td>Masten et al. (1997)</td> <td>Minneapolis</td> <td>73 homeless children</td> <td align="Center">6-11</td> <td>WIAT-S, etc.</td> <td>Homeless Children > General Population</td> <td>Compared to children for whom the test was normed, homeless children scored lower in achievement</td> </tr><tr><td>Ziesemer et al. (1994)</td> <td>Madison, WI</td> <td>145 homeless children 142 housed children </td> <td>School-age</td> <td>CBCL-Teacher</td> <td>Homeless Children = Housed Low Income Children > General Population</td> <td>Ratings of academic performance using teacher version of CBCL</td> </tr><tr><td>Zima et al. (1994; 1997)</td> <td>Los Angeles</td> <td>169 homeless children</td> <td align="Center">6-12</td> <td>Attendance, reading delays, unmet need for special ed., etc.</td> <td>Homeless Children > General Population</td> <td>Homeless children have elevated rates of academic problems, unmet need for special ed., etc.</td> </tr><tr><td>Rubin et al. (1996)</td> <td>New York City</td> <td>102 homeless children 178 housed children </td> <td align="Center">6-11</td> <td>WRAT-R</td> <td>Homeless Children > Housed Low Income Children > General Population</td> <td>Multivariate analyses. No differences between homeless and housed on IQ measure</td> </tr><tr><td>Buckner et al. (2001)</td> <td>Worcester, MA</td> <td>80 homeless children 148 housed children </td> <td align="Center">6-17</td> <td>Attendance, WIAT-S, KBIT-Non-verbal</td> <td>Homeless Children = Housed Low Income Children = General Population</td> <td>Multivariate analyses. No differences between homeless and housed on any measure, including IQ</td> </tr><tr><td>Rafferty et al. (2004)</td> <td>New York City</td> <td>46 formerly homeless children 87 permanently housed children </td> <td align="Center">11-17</td> <td>Changes in school, WISC-R Similarities,Reading achievement</td> <td>Homeless Children > Housed Low Income Children</td> <td>No differences on IQ measure</td> </tr></tbody><tfoot><tr><td colspan="7">3. CBCL = Child Behavior Checklist; KBIT = Kaufman Brief Intelligence Test; WIAT-S = Wechsler Individual Achievement Test- Screener; WISC-R = Wechsler Intelligence Scale for Children – Revised; WRAT-R = Wide Range Achievement Test – Revised</td> </tr></tfoot></table></div><h3>Improvements in children’s outcomes over time</h3>Problems of children living in homeless shelters may diminish over time. Buckner, Bassuk, Weinreb, and Brooks (1999) found in a cross-sectional analysis that children’s psychiatric symptoms peaked after about four months in shelter; thereafter, children seemed to adapt to the shelter environment. One to two years after living in shelter, the initial effects of homelessness on children's internalizing problems that were noted by Buckner and colleagues (1999) had diminished (Buckner, Beardslee, & Bassuk, 2004). Longitudinally, they observed exposure to violence, which can impact homeless and housed children alike, to be a more potent predictor of children's mental health problems over time than homelessness. And in a longitudinal study, Shinn and colleagues (2008) found only modest differences across all domains between housed poor children and homeless children who remained with their families five years after shelter entry, by which time most families were re-housed. Differences between groups were more strongly related to current stressors than to past homelessness. Using a city’s Board of Education records for children in the same sample, Rafferty and colleagues (2004) found that the about-to-be homeless children did not differ from continuously housed children in achievement before the homeless children entered shelter. Rather, the homeless children’s performance dropped while they were in shelter and partially recovered after they were re-housed, so that they no longer differed significantly from the other poor children. Over the five years following shelter entry, the homeless youth had more school mobility and greater grade retention (repeating a grade) than poor, continually housed youth. The eight sites of the Homeless Families Program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) enrolled over 1,100 children ages 2–16 years while they were living in shelter and followed them (and their mothers) for 15 months. Families were eligible if mothers had a mental illness or substance problem. Children's behavior problems were measured repeatedly over four time points. A fairly similar pattern was observed in which behavior problems were initially elevated when children were assessed in a shelter environment but then moderated in severity over time as families became re-housed (Buckner, Weinreb, Rog, Holupka, & Samuels, in press). Five subgroups of children were identified by these investigators. The trajectory of behavior problems over time looked virtually identical across these groups (some initial elevation followed by improvement). What was different was the initial level of behavior problems these different groups had (ranging from virtually none to severe). Such findings are consistent with the Huntington, Buckner, and Bassuk (2008) finding that homeless children are not one homogenous group. Finally, Shinn, Samuels, and Fischer (under review) randomized homeless families in which the mother had a mental illness or substance problem to a Family Critical Time Intervention (described below) or to usual care, and followed them over time. The most dramatic finding was an improvement in children’s mental health and school outcomes in both experimental and control groups from 3 months to 24 months following shelter entry. Improvements were observed across all age groups from preschool to adolescence and in both mother and child reports. <h3>Children separated from homeless families</h3>One frequent consequence of homelessness among families is separation of children from their parents. In a national survey, 60 percent of homeless women and 41 percent of homeless men had at least one minor child, but only 39 percent of women and 3 percent of men lived with any children (Burt et al., 1999). Some separations occur in shelter systems that do not allow men or older boys to be housed with women and younger children. But separations are common even in cities where families can be housed together. Some separations are associated with formal placements in foster care; probably more are informal arrangements where children stay with relatives or friends. For example, Park and colleagues (2004) found that 16 percent of 8,251 children under 16 who entered shelters with their families in New York City for the first time in 1996 spent some time in out-of-home placements in the child welfare system (before shelter or in the next five years). In the same city, Cowal and colleagues (2002) used interview data that tracked informal as well as formal placements in a smaller sample of 543 homeless and low-income housed families sampled in 1988. They found that five years after entering shelter in New York City in 1988, 44 percent of mothers experiencing homelessness had become separated from one or more of their children, compared to only 8 percent of continuously housed mothers. Consistent with Park and colleagues (2004), fewer than half of these separations were the result of actions by child welfare authorities or the courts, and many children were in informal placements. Similarly, Bassuk and colleagues (1997) in a study of 167 homeless and low-income families found that 19 percent of preschool-age children in homeless families had been placed in foster care, as compared to 8 percent of the low-income children. There is some literature on the circumstances of family separations. Cowal and colleagues (2002) found that the mother’s drug dependence, institutional placement (most often for drug treatment), and experience of domestic violence each made independent contributions to the prediction of separation. Homelessness did not augment the effects of other risk factors but was itself by far the most powerful risk factor for separation. A homeless mother with no other risk factor had about the same risk of becoming separated from a child as a housed mother who experienced domestic violence and was drug dependent. Barrow and Lawinski (2009), using qualitative interviews with homeless mothers with psychiatric or substance use disorders who had been separated from one or more children, confirmed these three factors and added partner abuse of children; substance use by others in household, building, or neighborhood; and children’s needs. They also documented mothers’ problem-solving efforts in an attempt to find the best choices for their children, often among a set of undesirable alternatives. Barrow and Laborde (2008) focused on homeless mothers who were separated from their children and recruited in single shelters for women with psychiatric problems or substance abuse problems. All 20 of the women they interviewed were actively involved in parenting their children, and most hoped to be reunited, although none were currently living with them. Barrow and Laborde describe women who were caught between demands and conflicting expectations of multiple systems, including shelters, child welfare, foster care, and family courts. Although the researchers did not interview children, they documented multiple cases in which children were shifted repeatedly among relatives or foster care placements and where both shelters and foster care agencies canceled or changed plans for visitation. Model child welfare guidelines state that homelessness is not by itself a reason to remove children from homes (Williams, 1991), but empirically, it played a large role in these studies both as a cause of initial separations and as a barrier to reunification. A handbook published by the New York State Society for the Prevention of Cruelty to Children (1990) (during the time of the study by Cowal et al.) listed poverty and homelessness as risk factors that “may predispose an individual to abuse or neglect a child” (p. 21). Research suggests that observers rate the same parental behaviors as more abusive in low-income rather than middle-income families (McLoyd, 1990), and it is possible that homeless families were judged more harshly than comparable families that were not homeless. Freidman (2000) and Park and colleagues (2004) note that homeless parents must do their parenting “in a fishbowl” under the watchful eye of shelter and social service staff who may not forgive lapses that go unobserved for housed families. Further, homeless shelters are difficult places to parent due to financial stress, crowding, lack of privacy, and the fact that staff often usurp parental functions, such as providing meals or setting curfews (e.g., Boxhill & Beaty, 1990; Hausman & Hammen, 1993; Lindsey, 1998). Studies have not examined the effects of separations of children from homeless families on the children themselves. A hint of the effects of separation more generally may be found in a study that compared two groups of 4th to 6th grade children from highly stressed families: those deemed stress-resilient on the basis of “wholesome adjustment in the face of profound life stress” and those deemed stress-affected by both teacher and parent report. An important predictor of resilience was lack of separation of the child and the primary caregiver during the first two years of the child’s life (Cowen, Wyman, Work, & Parker, 1990). A number of studies have documented that childhood separation is a predictor of future homelessness in adults (cf. Rog & Buckner, 2007). However, it is not clear to what extent separation serves as a marker of other factors that may lead families to become homeless or is itself causal. Childhood separations ceased to predict housing instability in adulthood in New York after access to subsidized housing was controlled (Shinn et al., 1998), suggesting that separations may reduce access or indicate the lack of access to familial financial and housing resources. <h3>Interventions</h3>Interventions for homeless families include subsidized housing, permanent supportive housing, and transitional housing. There are very few studies on any of the interventions, and those that exist are primarily descriptive. Few studies are rigorously designed, most lack comparison groups, and most lack data on children. Subsidized housing with or without services clearly reduces repeat episodes of homelessness for families. Studies in New York City have found that homeless families that received subsidies were far less likely to return to shelter (Wong et al., 1997) and far more likely to attain long-term stability (Shinn et al., 1998). The policy of providing subsidies to families in shelter also reduced shelter populations in New York (Cragg & O’Flaherty, 1999; O’Flaherty & Wu, 2006) and Philadelphia (Culhane, 1992). The Homeless Families Program, sponsored by HUD and the Robert Wood Johnson Foundation, offered Section 8 certificates along with various packages of services to families selected for their recurrent histories of homelessness and other risk factors in nine cities. Housing retention was excellent — 88 percent of the 601 families remained in housing for up to 18 months in the six cities where follow-up data were available — but cities with more intense service packages did not have higher rates of housing stability (Rog et al., 1995a, 1995b). Informal discussions with providers suggested that failure to renew Section 8 certificates was one reason for returns to shelter (Rog & Buckner, 2007). Intensive permanent supportive housing programs have also shown excellent housing stability and modest rates of parental employment or participation in education programs (e.g., Nolan et al., 2004; Philliber Research Associates, 2006; see also summary by Bassuk et al., 2006). However, these studies have not included comparison groups, making it hard to know whether families would have done as well with less intensive interventions. More restrictive programs had lower retention rates but may have had benefits for family self-sufficiency and reunification with children who were separated (Bassuk et al., 2006; Philliber Research Associates, 2006). But again, without studies where comparable groups are assigned to different programs, this is difficult to judge. It is also not clear what proportion of families would benefit from these intensive programs. A large-scale study of transitional housing, the Sound Families Program in the Seattle area, which served 1,487 families between 2000 and 2007, was primarily descriptive (Northwest Institute for Children and Families, 2007). A quarter of families (25 percent) were asked to leave (Northwest Institute for Children and Families, 2006). However, consistent with results in both experimental and control groups of the SAMHSA Homeless Families Program (described on p. 16), families that stayed showed gains over time in employment, income, and attendance and school stability for children. Shinn, Samuels, and Fischer (under review), randomized homeless families in which the mother had a mental illness or substance problem to a Family Critical Time Intervention or to usual care in Westchester, New York. The intervention involved rapid re-housing in the community and caseworkers who followed families from shelter to housing in the community in a nine-month program designed to establish a relationship with the mother, link the family to community services, and withdraw. The comparison group also received casework services, but from multiple workers, and were provided housing, but not as quickly as that provided the experimental group. Children in the experimental group did modestly better or showed greater improvements on mental health and school outcomes than children in the comparison group. Effects of the intervention were less consistent than children’s general improvement over time in both groups as their families left shelter and returned to the community. There is a dearth of rigorous studies of child outcomes of interventions for homeless families. However, HUD has funded a large-scale study (conducted by Abt Associates) to randomize 2,400 homeless families across 12 sites to four housing and service interventions: subsidy only, rapid re-housing, transitional housing, and usual care. The study will include a small amount of data based on parent report on one target child per family. Finally, homeless children are likely to benefit from the same sorts of interventions that help other poor children. For example, Schteingart, Molnar, Klein, Lowe, and Hartmann (1995) found that early childhood education improved the developmental status of both homeless and housed preschoolers (although both groups fared poorly compared to norms); however, there were no differences between the homeless and housed groups. <h3>Prevention</h3>Housing subsidies can prevent homelessness for poor families. A national random assignment study showed that provision of housing subsidies to families receiving public assistance reduced subsequent homelessness by 74 percent (Wood et al., 2008). This analysis took into account the fact that not all families that were offered vouchers utilized them for a lease. Cross-city studies of rates of subsidized housing and rates of homelessness have mixed results. Some researchers find clear benefits to subsidies (Mansur et al, 2002); others do not, perhaps because housing subsidies are not well targeted to those in need of them (Early, 1998, 2004; Early & Olsen, 2002). Other studies of prevention of family homelessness with strategies such as eviction prevention are poorly designed and lack comparison groups so it is difficult to tell how much they help (e.g., Shinn, Baumohl, & Hopper, 2001). New York City has funded an experimental evaluation of its community-based prevention services, but the dependent variable will be prevention of shelter entry, with the possible addition of information on child protective services. Only record data, no interview data with parents or children, will be included. <h2>Section III. Research Related to Unstably Housed Children and Other Children At Risk of Homelessness</h2>There is little research on the needs or characteristics of children whose families are living doubled up with others or staying in temporary accommodations such as hotels, except for counts of school-age children provided by SEAs and LEAs and the study by Obradovic and colleagues (2009) described above. The NCHE (2009) provides some additional data about children in jurisdictions served by LEAs with ED McKinney-Vento Education for Homeless Children and Youth Program subgrants to provide additional services, but does not distinguish between the different definitions of homelessness for this purpose. Of 472,000 homeless school-age children served by subgrants, approximately 13 percent were reported to have limited English proficiency, 14 percent were reported to have unspecified disabilities, and fewer than 2 percent were from migratory families. Only 189,000 children (two fifths of those served by subgrants) were tested in reading and mathematics. Of these, 43 percent were judged proficient by state standards in reading and 42 percent in math. High school students were much less likely to meet proficiency standards (35 percent reading, 29 percent math) than younger children. The report contains no comparison data for other poor children, so it is hard to judge the relative progress of children who experience homelessness. The most mobile children were probably the least likely to be tested, but it is difficult to know the extent of the bias. Although there is little direct data on children whose families are living doubled up or who are staying in hotels, there is a larger body of research on conditions to which these children are especially likely to be exposed, including extreme poverty, financial setbacks such as parental job loss, violence, residential mobility, school mobility, crowding, hunger, and other conditions recently summarized under the rubric of chaos (Evans & Wachs, 2010). This report considers each of these risk factors in turn and attempts to determine whether they are causally related to the poor outcomes with which they are associated or whether they simply serve as markers for poverty for which the adverse causal impact on children has been clearly demonstrated. Several researchers comparing children in shelter with poor domiciled children have found that a variety of risk factors are more important in predicting children’s outcomes than residential status per se (Buckner, Bassuk, Weinreb, & Brooks, 1999; Buckner, Beardslee, & Bassuk, 2004; Masten et al., 1993; Shinn et al., 2008). Thus this report discusses cumulative risk and also factors associated with children’s resilience. The review is necessarily selective, relying on other published review articles where they are available. <h3>Poverty</h3>A large body of research summarized by McLoyd (1998) links poverty to adverse outcomes for children in the areas of health, cognitive development, academic achievement, and socio-emotional or mental health outcomes. Increasingly sophisticated research designs control for background characteristics of families that might lead both to poverty and to adverse outcomes for children. These include longitudinal designs that follow children over extended periods of time so that the effects of income loss can be examined for children, controlling for more stable background characteristics, as well as comparisons of siblings who experience different economic environments growing up. It is also possible to examine the associations of outcomes, such as poor achievement, with poverty experienced by children either before or after the outcome is measured. If poverty causes the outcome, then poverty experienced by children before the outcome is measured should have a larger association than poverty measured later. If the association of the outcome with poverty measured earlier is comparable to the association with poverty measured later, then the relationship is not likely to be causal. Under these circumstances, it is more likely that stable background characteristics explain both exposure to poverty and the poor outcome. Family income has stronger effects on children’s cognitive development and school achievement than on socio-emotional functioning, whereas social class, typically assessed by parental education and occupation, is more strongly associated with socio-emotional problems, especially externalizing symptoms. Studies suggest that the timing of poverty is unrelated to cognitive or socio-emotional functioning, but that poverty in the preschool years reduces ultimate educational attainment more than poverty experienced later. The effects of income on children’s outcomes are nonlinear; that is, additional income makes more difference for children at or near poverty than for children higher in the income distribution (McLoyd, 1998). Poverty can have adverse effects on children's health, developmental status, mental health and behavior through various mechanisms or intervening variables. Several of the mechanisms by which poverty exerts its detrimental effects are particularly relevant to the situation of homeless children. Cognitive stimulation in the home environment, such as the presence of books and of toys that teach color, size, or shape, is important to cognitive development. Both loss of income and duration of poverty predict declines in the quality of the home environment and declines in children’s IQ. Poor nutrition, exposure to legal and illegal drugs prenatally, and exposure to lead in poorly maintained older housing can lead to poor health or impairment of neurological functioning. Teachers may perceive students who are poor and of low socio-economic status less positively and thus expect less of them, give them less positive attention, offer fewer learning opportunities, and provide them with less positive reinforcement when they do well. Economic stressors may lead to parental depression or harsh or inconsistent parenting, which are associated with socio-emotional problems in children. Poor children are exposed to more chronic stressors — from family conflict to overcrowding — and also to more stressful life events than non-poor peers. Their self-esteem may be eroded by circumstances such as living in poor housing or bad neighborhoods that mark their membership in a stigmatized group (McLoyd, 1998). Each of these mechanisms seems likely to be in play for homeless children living in doubled-up situations, although perhaps not to the same extent as for children living in shelter or without shelter or in hotels or motels. The effects of stigma associated with homelessness may go beyond the effects of material deprivation. Nutrition and crowding are considered in more detail below. <h3>Economic stressors, parental job loss, and parental financial distress</h3>Across multiple outcomes, including intelligence, school achievement, and socio-emotional functioning, persistent poverty has more detrimental effects than transitory poverty (Bolger et al., 1995; Duncan, Brooks-Gunn, Klebanov, 1994; McLoyd, 1998). Thus children from families that have always been poor are likely to be worse off than children in families that experience sudden hardship due, for example, to the recession and foreclosure crisis. However, sudden hardship also takes its toll. Conger and colleagues (1994) studied the effects on children and families of the dramatic economic decline in the rural Midwest in the 1980s, when thousands of farmers and small-town businessmen went bankrupt. In a sample of 378 seventh graders living in two-parent middle class families (mean income of $33,800 in 1988 dollars, mean education of 13.8 years), they found that economic pressures experienced by parents led to parental mood changes and marital conflict, along with conflict with children about money. These, in turn, led to greater general hostility of parents toward children and to adolescent emotional and behavioral problems. Using data from the Panel Study in Income Dynamics, which followed a nationally representative sample of 5,000 families, Yeung and Hofferth (1998) examined instances where families had income reductions of 50 percent or more (which transpired for 894 families). Families who experienced a major income loss were more likely to move within the following year. The researchers found that higher income White families were more likely to reduce food expenditures when experiencing work reduction than lower income White families, but the opposite was true for Black families. Families who started with higher incomes were less likely over time to receive public assistance such as food stamps and TANF. A recent paper from the National Bureau of Economic Research (Stevens & Schaller, 2009) examined data from the Survey of Income and Program Participation (SIPP) from 1996 to 2006. The authors looked at the relationship between parental job loss and children’s academic difficulties. The data include a series of panel datasets covering between 14,000 and 46,000 households per panel, each of which were followed for two to four years. This study shows that when a parent loses his or her job, the probability that a child will repeat a grade in school increases by almost one percentage point a year, or about a 15 percent increase in the probability of grade retention. These results using recent data represent the short-term impact of job loss and may be indicative of the impact of the current rise in unemployment and job loss that has affected many children who fit the broad definition of homelessness. Also, a substantial body of literature shows that unemployment leads to depression among both people who lose jobs and their spouses (e.g., Howe, Levy, & Caplan, 2004; Vinokur, Price, & Caplan, 1996), and that depression among parents is associated with adverse outcomes for children (e.g., Downey & Coyne, 1990). <h3>Residential mobility</h3>Residential moves feature prominently in inventories of stressful life events for adults and children alike. Although researchers caution that the context of moves and the extent to which they are freely chosen are important determinants of their impact (Stokols & Shumaker, 1982), moves among families experiencing homelessness are likely associated with evictions by landlords or by the primary tenants at a previous residence and other adverse events over which children typically exercise little control. Scanlon and Devine (2001) reviewed research on residential mobility and found clear adverse effects on academic performance, rates of grade retention, and rates of high school graduation. At that time they judged the literature on behavioral outcomes to be too sparse to draw firm conclusions. A more recent review of the relationship of residential moves to health, broadly construed, found high rates of residential mobility were associated with increased behavioral problems in both children and adolescents (Jellyman & Spencer, 2008). Children who moved more often exhibited more indirect aggression, committed more property offenses, and had more behavioral problems requiring psychological help. Adolescents had higher rates or earlier instances of drug use, depression, sexual behavior, and teen pregnancy. Families had less continuity in health care. Other studies (summarized by Hertzman, 2010) have found residential instability to be associated with lower school readiness and early behavioral and emotional problems for younger children. For obvious reasons, families are never randomly assigned to high versus low mobility conditions to examine the effects, so an important concern in this literature is the extent to which mobility is simply a marker for poverty and other risk factors or is itself a causal variable. It is clear, for example, that low-income children move more often than their middle-income peers (e.g., Evans, Eckenrode, & Marcynyszyn, 2010). Jellyman and Spencer (2008) consider this caution, but find that effects of mobility hold after controlling for confounding variables. They suggest that mobility may be one way in which poverty exerts its effects on child outcomes. <h3>School mobility</h3>School mobility is, of course, related to residential mobility and thereby difficult to tease apart. Like residential mobility, school mobility is associated with poverty (e.g., Evans et al., 2010). Studies consistently find that school mobility is associated with lower academic achievement when there are no controls for achievement prior to the moves. However, the small number of studies where achievement is measured during (Buckner, Bassuk, & Weinreb, 2001), or both before and after the onset of mobility (e.g., Heinlein & Shinn, 2000), do not show clear effects of mobility between the two waves of data collection. Thus, school mobility, like residential mobility, may be more of a marker of a constellation of adverse conditions rather than an independent cause of poor outcomes. Nonetheless, stable schooling may serve as an anchor for children who experience other forms of instability. Homeless children may be more likely than other children to experience school mobility in the midst of a school year, when they are confronted with new curricular demands as well as a new set of peers and teachers. Thus it is plausible that midyear moves are more problematic than moves over the summer. The McKinney-Vento Homeless Assistance Act requires that homeless children be allowed to stay in their school of origin if that is in the child’s best interest, and that school districts provide transportation to that school if requested by the child’s parent or guardian. Nevertheless, LEAs continue to report that transportation is the top barrier to access to education for homeless children (NCHE, 2009). <h3>Crowding</h3>Homeless children living doubled up or in motels and hotels, like homeless children in shelters, often experience high levels of crowding, typically indexed by the number of people per room. Residential crowding, across a number of studies reviewed by Evans (2006), has been associated with social withdrawal, elevated levels of aggression, psychological distress, poor behavioral adjustment in school, and lower levels of social and cognitive competency. Parents in crowded homes talk less to infants, are less responsive to young children, and are more likely to engage in punitive parenting than other parents. Crowding effects appear in studies with good controls for socio-economic status and in laboratory and field experiments. <h3>Hunger and nutrition</h3>According to a U.S. Department of Agriculture survey (Nord, 2009), 15.8 percent of households with children were food insecure at some time during 2007. In many of those households, parents were able to protect children from food insecurity, but in 8.3 percent of these households, children too were food insecure, typically due to reductions in the quality and variety of meals. In 0.8 percent of households, children had very low food security: they had been hungry when the household could not afford food, skipped a meal, or did not eat for an entire day because of lack of money for food. Food insecurity is associated with poorer health, higher hospitalization levels, more behavioral and emotional problems, and lower cognitive achievement and achievement gains. Food insecurity is higher in households with some characteristics that are common among homeless families, such as African American race; single female-headed households; and incomes below the poverty line, although more than two thirds of families with food insecurity among children had at least one full-time worker (Nord, 2009). Poor nutrition appears to be a cause of poor child outcomes and not simply a marker of other conditions. In multiple experimental studies, most in other nations, provision of nutritional supplements to pregnant mothers and to infants improved children’s developmental outcomes. Longer term supplementation during pregnancy and early childhood had positive effects on adolescent cognitive development 12 years after the supplements were discontinued. Temporary food shortages affected social involvement and classroom attentiveness during a drought in Kenya and mathematics skills assessed several years later (Sigman, 1995). Weinreb and colleagues (2002) examined hunger and its impact on child health and mental health in a sample of homeless and low-income housed children (some of whom would meet the ED definition of homeless) ages 2–18 in Worcester, MA. Among preschool age children in both groups, 51 percent experienced moderate hunger and 8 percent experienced severe hunger. Severe hunger was more common among homeless children and was associated with high levels of chronic illness and internalizing behavior problems. More school-age children in the housed group experienced hunger than did homeless children. Severe hunger among school-age children was linked to chronic illness and symptoms of anxiety and depression. <h3>Cumulative risk</h3>Researchers often attempt to single out the unique effects of particular stressors on various aspects of children’s well-being. However, there exist many different types of negative events that children living in poverty can experience, making it difficult to examine their effects individually. Moreover, the conditions just described often co-occur in the lives of homeless children. Masten and colleagues (1993) described the count of significant negative life events a child has dealt with as cumulative risk. Researchers have typically found that such counts are more predictive of children’s outcomes than homelessness per se. This is not surprising as indices of cumulative risk capture a much broader array of adversities that children living in poverty can experience than just homelessness per se. Similarly, Buckner, Beardslee, and Bassuk (2004), who followed up families after they were re-housed, found that negative life events, particularly exposure to violence in the home and the community, were more important to children’s mental health than prior homelessness. This is not to argue that the effects of homelessness on children are inconsequential. However, it is important to remember that homelessness is but one of many major adversities that children living in poverty can experience and is often time limited. Living in a dangerous neighborhood and intermittently witnessing or being the victim of violence can be an even more chronic stressor than homelessness and can have more enduring effects on children's social-emotional functioning. Finally, Shinn and colleagues (2008), who examined formerly homeless and continuously housed children five years after the former group entered shelter, found recent life events and proximal stressors reported by the mother (current economic stressors, current maternal depressive symptoms, perceived lack of safety in the current neighborhood) were more important than distal stressors (over the past five years or in the last year) or prior homelessness to children’s mental health. Wachs and Evans (2010) conceptualize all of the conditions described here and other forms of instability as manifestations of chaos, having a profound effect on children’s lives. Just as lack of stimulation can impede development, unpredictable and uncontrollable settings may have adverse physiological consequences, interfere with children’s self-regulation and sense of efficacy, impair the quality of parenting they receive, and impede their ability to regulate external demands and acquire a sense of order and continuity. While it would be a mistake to assume that the lives of most homeless families in America are chaotic, it can be difficult for parents to provide stability and routines for their children without a secure residence. Families who double up with others; live in hotels, motels, or shelters; or live in campgrounds, vehicles, or other places not designed for human habitation must struggle to provide a sense of stability and security for their children. Homeless families living doubled up with others live in a more normalized setting, but it cannot be assumed they are at lower risk without research. Homeless families living in shelter at least have the advantage of being better linked to the social service system than families living doubled up in the community. <h3>Resilience</h3>Resilience in children has been defined as "achieving desirable outcomes in spite of significant challenges to adaptation or development" (Masten & Coatsworth, 1995, p.737). The prerequisite for evidencing resilience is to have faced a major adversity of some sort. Of the many published studies of resilience involving children and adolescents, relatively few have examined children's resilience in the context of poverty. Buckner, Mezzacappa, and Beardslee (2003) conducted a study comparing 45 resilient to 70 non-resilient youths from extremely low-income families in Worcester, Massachusetts. A third of these school-age children had been homeless within the past two years and all were from households with incomes below the poverty line. Hence this study has applicability to children meeting the HUD and ED definitions of homelessness. Resilience was operationally defined in a multidimensional manner using well-established instruments that measured children's emotional well-being, behavior, competence, and level of functioning. Children deemed resilient showed positive adjustment in each of these realms, whereas those determined to be non-resilient evidenced significant problems in one or more of these areas. Although participants in this study all lived below the poverty line, there was still substantial variation in the quantity of negative events and chronic stressors they had experienced in recent years. Because these adversities were predictive of outcomes in expected directions, it was necessary to statistically control for them in order to better understand the independent contributions of inner and external resources to predicting resilience. While this study was limited to a cross-sectional comparison of children, a decided strength was its extensive assessment battery, which comprised data collected directly from the child as well as from a parent and an external rater. In combination with multivariate analyses, this allowed the investigators to examine the relative contribution of an array of variables, reflecting both inner and external resources of a child, in predicting their resilience status. Among inner resources, self-esteem and, especially, self-regulation skills emerged as independent predictors of resilience. Likewise, among external resources that were examined, parental monitoring stood out as a predictor, controlling for all other explanatory variables. The parental monitoring variable tapped into a parent's proclivity to pay close attention to the whereabouts of a child when away from home and with whom the child was spending time. Of note, the nonverbal intelligence of a child, while associated with resilience status in some analyses, was not a predictor of resilience status in multivariate modeling. Instead, self-regulation (which was positively associated with intelligence) was the much more potent predictor. Similarly, Obradovic (2010) examined the relationship between effortful control, assessed in laboratory tasks such as the ability to play “Simon Says,” and adaptive functioning for 58 homeless children who were entering kindergarten or first grade and were sampled in shelter. Effortful control, a skill closely related to self-regulation, was strongly related to all four measures of adaptive functioning rated by teachers (academic functioning, peer competence, low levels of internalizing behaviors, and low levels of externalizing behaviors), controlling for IQ, parenting quality, and risk levels. Further, age and effortful control were the only predictors of resilience, defined as showing adaptive behavior across all four domains. Both theory and recent empirical findings are supportive of the argument that self-regulation skills may be an important inner resource for children, including those who are currently homeless or otherwise living in poverty (Buckner, Mezzacappa, & Beardslee, 2009). Self-regulation refers to an integrated set of meta-cognitive skills that draw from both executive function and emotion regulation capacities, which are invoked in the service of accomplishing both proximal and distal goals. While associated with intelligence, self-regulation is a somewhat separate construct that may have closer links to adaptive functioning in children and adults. An appeal of self-regulation is that it can be conceived as a set of skills that can be improved through intervention. (e.g., Diamond, Barnett, Thomas, & Munro, 2007). <h2>Section IV. Targeted and Mainstream Programs</h2>This section reviews targeted and mainstream programs for homeless children. The major source of targeted funding specifically for homeless children is the McKinney-Vento Education for Homeless Children and Youth Program, which was renewed in No Child Left Behind legislation. As reported in the America’s Youngest Outcasts: State Report Card on Child Homelessness recently released by the National Center on Family Homelessness, many jurisdictions report multiple funding sources for services for homeless families and children, including use of McKinney-Vento education funds, Medicaid, TANF funds, and emergency assistance funds from HUD. Table 3 (below) summarizes many of the programs in place to assist homeless children and their families. More detailed information on health, mental health, education, and food and nutrition programs follows <h3>IV-A. Access to health and mental health care</h3>Access to health insurance is an important step in securing health care for homeless children. Medicaid is the primary source of health insurance for homeless children (National Center on Family Homelessness, 2009 p.43). Medicaid is health insurance for children and adults who meet the financial and general eligibility requirements. Eligibility depends on income and asset limitations, family size, and living situation. Persons under age 65 who don’t meet standard eligibility criteria may be eligible for Medicaid if they meet government disability standards. The Children's Health Insurance Program (CHIP) program extends health insurance coverage to more than 5 million children who are not eligible to receive Medicaid, usually because their household income is above what Medicaid will allow but below what is required to purchase private health insurance. Both Medicaid and CHIP are jointly financed by the federal and state governments, and the programs are administered at the state level. For children in some states, Medicaid and CHIP are combined in one program. Many homeless children without health insurance are likely eligible for Medicaid or CHIP. Fourteen states have presumptive eligibility for Medicaid and 11 states have presumptive eligibility for CHIP for poor children (Kaiser Family Foundation, 2009). Presumptive eligibility allows qualified health care providers to immediately enroll children who appear to meet the state’s income eligibility requirements into Medicaid or CHIP. Thus, immediate care can be given to children without documentation of eligibility, although documentation must be provided by the end of the following month (HHS, 2001). In some states homeless shelters are considered qualified entities for presumptive enrollment of children into Medicaid and CHIP. Because Medicaid and CHIP do not collect information about children’s housing status when they receive services, the amount of Medicaid or CHIP funding that is spent on children who are homeless is unknown. The recently enacted Patient Protection and Affordable Care Act (health reform) will help individuals and families keep quality, affordable health insurance whether they lose their jobs, switch jobs, move, or get sick. The Act also will increase Medicaid eligibility for many more homeless families and individuals by creating a uniform minimum eligibility threshold and allowing adults without dependent children to enroll. Another widely used source of health care for homeless children is the Health Care for the Homeless Program administered by the Health Resources and Services Administration within the Department of Health and Human Services. This program was first established with the McKinney Homeless Assistance Act of 1987 and reauthorized in 2002 in the Health Care Safety Net Amendments Act and then again in 2008 in the Health Care Next Act. In FY 2010, the Health Care for the Homeless Program received $185.5 million (National Health Care for the Homeless Coalition, 2009). About 17 percent of those served by this program are children (HHS, 2007). Table 3. Selected Federal Programs That Assist Homeless Children and Their Families <table cellpadding="2" cellspacing="0" class="footable table-align-left"><thead><tr valign="Bottom"><th scope="col">Program</th> <th scope="col">Agency/ Department</th> <th scope="col">Who is eligible</th> <th scope="col">Eligibility</th> <th scope="col">Service(s)</th> </tr></thead><tbody><tr><td>McKinney-Vento Education for Homeless Children and Youth Program</td> <td>Office of Elementary and Secondary Education, Department of Education</td> <td>Homeless children in schools.</td> <td>Must report they are homeless at a school</td> <td>Transportation to school of origin</td> </tr><tr><td>Medicaid & Children’s Health Insurance Program (CHIP)</td> <td>Centers for Medicare & Medicaid Services, Department of Health and Human Services</td> <td>Low income children</td> <td>US Citizen or lawfully admitted immigrant, must meet specific income levels by state and age</td> <td>Health/mental health insurance</td> </tr><tr><td>National School Lunch and Breakfast Programs</td> <td>Food and Nutrition Service, Department of Agriculture</td> <td>Homeless children in school</td> <td>Must report they are homeless at a school. Then they are categorically eligible</td> <td>Free lunch and breakfast where available at schools</td> </tr><tr><td>Supplemental Nutrition Assistance Program (SNAP)</td> <td>Food and Nutrition Service, Department of Agriculture</td> <td>Children in households with a citizen or legal immigrant</td> <td>Income and resource limitations</td> <td>SNAP benefits (formerly, food stamps)</td> </tr><tr><td>Earned Income Tax Credit (EITC)</td> <td>Internal Revenue Service</td> <td>Low to moderate income workers</td> <td> </td> <td>Refundable tax credit</td> </tr><tr><td>Child Tax Credit (CTC)</td> <td>Internal Revenue Service</td> <td>Working individual with care of a child</td> <td>Must have a child under age 17, some citizenship requirements</td> <td>Federal tax reduction</td> </tr><tr><td>Section 8: Housing Choice Voucher Program</td> <td>Public and Indian Housing, Department of Housing and Urban Development</td> <td>Low income families, seniors and the disabled</td> <td>US Citizens and some with eligible immigration status. Income requirements vary by location.</td> <td>Rent assistance</td> </tr><tr><td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:42.25pt">Temporary Assistance for Needy Families (TANF)</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:42.25pt">Administration for Children and Families, Department of Health and Human Services</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:42.25pt">Low income families</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:42.25pt">Eligibility varies by state as do work, school and other requirements</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:42.25pt">Cash assistance</td> </tr><tr><td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:53.5pt">Low Income Home Energy Assistance Program (LIHEAP)</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:53.5pt">Administration for Children and Families, Department of Health and Human Services</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:53.5pt">Low income households</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:53.5pt">Varies by state. In some states households who receive TANF, Social Security Income (SSI) or Food Stamps are categorically eligible</td> <td style=" padding:2.9pt 2.9pt 2.9pt 2.9pt;height:53.5pt">Assistance for paying energy bills</td> </tr><tr><td>Federal-State Unemployment Insurance Program</td> <td>Employment and Training Administration, Department of Labor</td> <td>Workers who became unemployed through no fault of their own</td> <td>Varies by state</td> <td>Temporary financial assistance</td> </tr><tr><td>Home Affordable Refinance Program (HARP)</td> <td>Departments of the Treasury and Housing and Urban Development</td> <td>Homeowners</td> <td>Homeowners with good credit and payment histories</td> <td>Home loan refinancing</td> </tr><tr><td>Home Affordable Mortgage Program (HAMP)</td> <td>Departments of the Treasury and Housing and Urban Development</td> <td>Homeowners</td> <td>Homeowners with good credit and payment histories</td> <td>Home mortgage modifications to lower payments and terms</td> </tr><tr><td>Child Care Assistance through the Child Care and Development Fund</td> <td>Administration for Children and Families, Department of Health and Human Services</td> <td>Low income families, families receiving TANF and those transitioning</td> <td>Assistance is for families that need child care to work or attend training or education for children under age 13 unless disabled or under court supervision</td> <td>Subsidies and payments for child care</td> </tr></tbody></table>The National Health Care for the Homeless Council Pediatric Working Group has recognized the special health needs of homeless children and has developed a detailed set of pediatric protocols for the Health Care for the Homeless network of providers. These protocols include specific care guidelines for general and supportive care, emergencies, trauma, HEENT (head, eyes, ears, nose and throat), hematology, respiratory, gastrointestinal, genito-urinary, and dermatology. Also included are addenda for specific diseases such as tuberculosis and other health-related concerns. Each section includes specific recommendations for assessment, intervention, and referral within the context of a homeless child’s life and experience. <h3>IV-B. Education</h3>Federal legislation ensures homeless children’s access to school, and federal funding has been made available to schools that serve homeless children. The goal is to keep a child’s education as stable as possible despite residential instability. As discussed above, homelessness can have a negative impact on educational achievement, particularly in situations where children cannot attend school. By providing homeless children with immediate access to schools and by providing schools with funding to help homeless children, the goal is to mitigate, or at least lessen, the effects of homelessness on school outcomes. Most of the regulations for education and homeless children come from the <a href="http://www2.ed.gov/programs/homeless/legislation.html">McKinney-Vento Homeless Assistance Act: Education for Homeless Children and Youth</a> (2002), Title 42, which was reauthorized as part of No Child Left Behind legislation. The McKinney-Vento Homeless Assistance Act defines the homeless population to be targeted, specifies how education funding is to be distributed to states and then localities, describes a system of SEAs and LEAs that are to oversee the subgrants and ensure that the educational needs of homeless children are met, and appropriates funds for this purpose. The McKinney-Vento Homeless Assistance Act specifies that: <ul><li>Each homeless child should have “equal access” to education and education services. And “each child of a homeless individual and each homeless youth has access to the same free, appropriate public education, including a public preschool education.”</li> <li>Homeless children are to be “immediately enrolled” in school where enrollment is sought even if required documents and records such as medical, academic and residency are not available. Enrollment should be immediate “pending resolution of the dispute.” In addition, if a state has a compulsory residency requirement that may act as a barrier to enrollment, attendance or success of homeless children and youths, “the State will review and undertake steps to revise such la+-ws, regulation, practices or policies.”</li> <li>Segregation of homeless children is prohibited. Homeless children are not to be separated from other children in mainstream school just because they are homeless.</li> <li>Homeless children and youth should have access to same education and services as other children.</li> <li>Homeless children have the right to continue to attend their school of origin without having to pay the transportation costs.</li> </ul>McKinney-Vento also requires that “notice of educational rights” be distributed in places where homeless children may receive services and that parents/guardians are fully informed of all education, transportation services, and rights of students. McKinney-Vento describes a system of SEAs and LEAs that take the lead on ensuring the McKinney-Vento Act and its regulations are followed. In addition, each state has a coordinator of education for homeless children and youth. This coordinator must collect information about access issues related to homeless children and schools. The coordinator is also responsible to collect information about difficulties identifying homeless students who have special needs and service access issues. Coordinators must also carry out the state plan, which is submitted to the Secretary of Education. State plans must include information about how homeless children in the state are given the opportunity to meet the same academic standards as other children in the state; procedures used to identify homeless children and assess their special needs; procedures for resolution of enrollment disputes; programs for school personnel to increase knowledge of issues, particularly for homeless youth; procedures to ensure homeless students participate in federal food programs; and procedures to ensure equal access to all other school programs and services. The plan must also include procedures to eliminate barriers to immediate enrollment. Additional provisions of McKinney-Vento Homeless Assistance Act require that the LEA focus on the “best interest” of the child. Decisions related to homeless children’s education must be made on an individual basis. This includes the right of the children to continue their education in the school of origin. LEAs are also responsible for coordinating the provision of services for homeless children with local service agencies and other service providers. And, LEAs can coordinate with local and state housing agencies to develop a housing affordability strategy to minimize the educational disruption for homeless children. Title I of the Elementary and Secondary Education Act provides funding to schools and school districts with high percentages of low-income students; these funds can be used to assist homeless students. The statute requires the LEA to develop plans to include “a description of the services the local education agency will provide homeless children, including services provided with funds reserved under section 1113(c)(3)(A).” However, these funds cannot be used for transportation to school of origin, cannot be used to support the school district homeless liaison and other homeless support staff, and cannot be used for educationally related support services that may allow a homeless student to participate in the educational opportunities offered by the school. <h3>IV-C. Pre-K and preschool programs</h3>For younger children, typically under age 5, efforts are geared toward increasing access to child care or education programs such as the Department of Health and Human Services’ Head Start Program. According to ED (2006), there is an underrepresentation of homeless preschoolers in early education programs. Under McKinney-Vento, reauthorized as part of the No Child Left Behind Act, homeless children are entitled to a free, appropriate public education, including preschool education. The Improving Head Start for School Readiness Act of 2007 made homeless children categorically eligible to participate in Head Start. States are required to ensure that homeless children have equal access to the same public preschool programs administered by state agencies and attended by housed children in the state. Also every LEA must designate a liaison for preschool students who are homeless. LEA liaisons must ensure that homeless children are identified and immediately enrolled in preschool. Parents and guardians are to be informed about education rights, including transportation, and receive educational services to which they are entitled. This includes Even Start and preschool programs. State coordinators for the education of homeless children and youth must coordinate with social services agencies, child development and preschool program personnel, and other agencies to provide comprehensive services to preschoolers. Homeless preschoolers are categorically eligible for Head Start and other preschool programs. The McKinney-Vento Homeless Assistance Act requires homeless children to have access to preschool programs “comparable” to the programs attended by other children. Every state runs its prekindergarten programs differently. Head Start programs are required to identify and prioritize homeless children. However, many Head Start programs operate with waiting lists. <h3>IV-D. Food nutrition programs</h3>As noted earlier, we know that for many homeless children food insecurity is an important issue. As authorized in the Richard B. Russell National School Lunch Act, 2004, if a student is homeless according to ED definition, he or she is categorically eligible for the National School Lunch Program and the National School Breakfast Program administered by the USDA. <h2>Section V. Discussion</h2>This section describes five categories of open questions and issues for discussion at the roundtable meeting. <ol type="I"><li>Data/Information <ul><li>HUD and ED (via the SEAs and LEAs) collect information on children who are homeless, but as with all data collection efforts there are limitations to these data. The Bureau of the Census will count homeless children this spring. How can data be used to help policymakers and providers better understand the needs of homeless children and the services they use?</li> <li>Given that in HUD data young children are more likely to be homeless than school-age children, should data be collected on children who meet the ED definition of homelessness but are too young for school?</li> <li>Are there ways to better understand the dynamics of homelessness for children, including the number who experience homelessness over different time frames?</li> <li>Could greater coordination with mainstream services — such as TANF, Medicaid, and SNAP — help in assessing the extent to which beneficiaries are currently homeless or have recently experienced homelessness? Can trends be identified?</li> <li>How can we better understand housing status and school mobility using mainstream surveys such as the American Community Survey and the Survey of Income and Program Participation (SIPP)?</li> <li>Since most homeless children qualify and are enrolled in Medicaid and CHIP programs, could these programs help develop a better understanding of the differential and unique health and mental health care needs of homeless children, thus allowing researchers, program planners, and practitioners to develop a more comprehensive view of the health challenges facing homeless children?</li> <li>Since family separation is high among homeless families, can we use data to learn more about children who are living separately from their homeless parents? For example, could HMIS be expanded to track information about these children and could LEA data include where parents are and if children are not living with them?</li> </ul></li> <li>Definitions <ul><li>What is the scope of issues and implications related to the definitions of homeless children?</li> <li>Information about programs, services, and educational rights of homeless children is often readily available at HUD-funded family shelters through staff and social workers. How can schools reach out to identify and enroll students who meet different definitions of homelessness?</li> </ul></li> <li>Education <ul><li>How can we learn more about the costs to transport children to their school of origin and how school districts fund this expense?</li> <li>How can we learn more about the impact of the current method of distributing ED funds to school districts?</li> <li>Are schools a good location to concentrate efforts to help school-age homeless children and their families?</li> <li>How can we better document the services provided to homeless children at schools?</li> <li>What are some promising ways that schools coordinate with social service agencies to assist homeless students and their families?</li> <li>What are some ways to promote quality of services offered by schools?</li> <li>Schools are enrolling unsheltered children but we know little about them, their circumstances, and what services they receive. How are schools identifying this population and addressing the particular needs of unsheltered homeless children?</li> <li>What proportions of homeless children who attend school receive free lunch and free breakfast? Are these programs effective in alleviating food insecurity issues?</li> <li>How do school enrollment questions and needs assessment of homeless children in schools differ? How do these differences impact homeless children and the services they receive?</li> <li>Reports on enrollment of homeless children in pre-K, Head Start, other preschool programs and child care are sparse. Homeless children are categorically eligible to enroll in these programs. How can we develop a better understanding of how many homeless children enroll in these programs? Are there barriers to the enrollment of homeless children in these programs?</li> </ul></li> <li>Prevention <ul><li>How can we devise programs that are preventive and effectively target for intervention the broad population of at-risk families from which homeless families emerge?</li> <li>Federal programs address the needs of at-risk families on a nationwide scale, and a number of local programs attempt to prevent homelessness. What can we learn from such programs to ameliorate risk factors or enhance protective factors that are linked to family homelessness?</li> <li>What is the impact of federal programs such as the Earned Income Tax Credit, SNAP, TANF, Medicaid, the Section 8 housing voucher program, and foreclosure prevention programs on at-risk families? Do programs that provide assistance for basic needs or provide additional income (e.g., EITC) help families secure stable housing and avoid homelessness?</li> <li>Some very important assistance programs, such as SNAP, may be underutilized by children and families that are eligible. How can we make eligible families aware of such programs, and how can we reduce barriers to utilization?</li> <li>Homelessness among families is much lower in Europe than in the United States (Toro et al. 2007; Shinn, 2007). Are there specific strategies used by countries in Europe that are successful, and what can we learn from those strategies?</li> </ul></li> <li>Research <ul><li>How can we learn more about the effects on homeless children of programs such as transitional housing, permanent family supportive housing, and other programs?</li> <li>How can we learn more about homeless children from existing data sources that do not now focus on homelessness? For example, <ul><li>How can longitudinal studies such as the Panel Study of Income Dynamics be used to provide information about homeless children and their families?</li> <li>How can we best capture information about the most fragile and mobile families?</li> <li>Can we conduct retrospective studies using school, medical, and child protection records for children identified as homeless?</li> </ul></li> <li>How can we learn more about different groups of children from existing data sources that do include homeless children? For example, children who are homeless due to the current economic and foreclosure crisis cannot be currently separated from their peers in HUD and ED data. Can information be gathered on the previous residence of children who become homeless and on parental backgrounds to determine whether children with different histories face different challenges?</li> <li>How can the federal government, states, localities, non-governmental organizations, and researchers work together to identify effective programs to prevent and end homelessness, and evaluate promising and innovative strategies to improve the lives of homeless children and their families? What structures would facilitate research efforts? How can we disseminate information about what we know works?</li> </ul></li> </ol><h2>References</h2>Alperstein, G., Rappaport, C., & Flanigan, J.M. (1987). Health problems of homeless children in New York City. American Journal of Public Health, 78, 1232-1233. Barrow, S. M. & Laborde, N. D. (2008). Invisible mothers: Parenting by homeless women separated from their children. Gender Issues, 25, 157–172. Barrow, S. M., & Lawinski, T. (2009). 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