Characteristics and Dynamics of Homeless Families with Children. Part I: Literature Review

Using data from the National Survey of Homelessness Assistance Providers conducted in 1996, The Urban Institute (2000) estimated that families with children account for about 39 percent of the homeless population in this country on any given night.¹ Based on this survey, researchers at The Urban Institute estimated that somewhere between 874,000 and 1,360,000 children experienced a homeless episode² at some point in 1996. This implies that about 9 percent of poor children in the United States had a spell of homelessness that year. In most cases, a homeless family is comprised of a single mother with one or two young children in tow. This is particularly true in the Northeast, where, for instance, in Massachusetts about 95 percent of homeless families are single parent female headed (Bassuk et al., 1996). In some parts of the country it is more common to also encounter two-parent (or couple) families or families headed by a single father (U.S. Conference of Mayors, 2001).

• Mental Health and Problem Behaviors

  • The mental health of homeless children has been a central concern for service providers as well as researchers. The most widely used instrument in homelessness research with children has been the Child Behavior Checklist (CBCL) (Achenbach, 1991; Achenbach and Rescorla, 2001). The CBCL is an instrument that is administered to the parent of a child and assesses the signs (i.e., observable manifestations) as opposed to the symptoms of mental health problems. The CBCL has two versions, one intended for preschoolers and the other for school-age children. Both versions of the CBCL are comprised of specific syndrome scales as well as composite "internalizing" and "externalizing" global scores.³ The internalizing dimension of the CBCL assesses observable behaviors that are indicative of anxiety and depression as well as withdrawn behavior and somatic complaints. The externalizing dimension is derived from items that assess delinquent and/or aggressive behavior in older kids and attention problems and aggressive behavior in younger children. Raw scores on the syndrome and global scales can be converted into T-scores with the mean set to 50. Higher scores are indicative of more problematic behaviors.⁴

    Bassuk and Rosenberg (1990) published the first study comparing homeless and housed children in which the CBCL was employed. Homeless children were enrolled from emergency shelters in Boston during 1985 and a comparison group of families living in low-income housing were interviewed a year later. Bassuk and Rosenberg (1990) used the CBCL to assess children ages 6 to 16 in their study and found that 39 percent of the 31 homeless children and 26 percent of the 54 housed children scored in the clinical range. This difference did not reach statistical significance, most likely a function of the relatively small sample size. Homeless girls had higher scores than homeless boys and older homeless youths (ages 12–16 years) were more likely to score in the clinical range than younger children (ages 6–11 years). A widely used self-report measure of depression, the Children’s Depression Inventory (CDI), was also part of the assessment protocol in this study and homeless children averaged 10.3 on this measure compared to 8.3 for the housed children. While this difference was also not statistically significant, such levels on the CDI are of some clinical significance and represent depressive symptoms of moderate severity.

    In Philadelphia during the late 1980s, Rescorla, Parker, and Stolley (1991) conducted a study involving 83 homeless children between the ages of 3 and 12 years who were living in 1 of 13 shelters throughout the city and compared them to 45 children whose families were randomly selected from the waiting room of a pediatric clinic. The children were given an assessment battery that included the CBCL and various measures of cognitive abilities (IQ) and reading achievement. The authors compared preschool and school-age children separately. Across the various indices of intelligence and achievement, homeless children in both age groups scored lower than the clinic group although only some of the differences reached statistical significance. If the study had had a greater sample size, it would have found more differences between the two groups reaching statistical significance. Similarly, on the CBCL, homeless children in both age groups had more elevated indices of internalizing and externalizing problems compared to the clinic enrolled children, with differences particularly acute among the preschool-age children.

    The authors did not use multivariate statistics to control for potential imbalances on other explanatory variables and collected very little data on the mothers of children in these two groups, making it hard to discern how well the two groups were matched. Thus, it is not possible to determine to what extent the differences found between homeless and housed children is a function of housing status or other family/mother factors that are associated with both vulnerability to becoming homeless and child outcomes. Despite the difficulty of making causal inferences about whether housing status or other unmeasured variables accounted for the differences seen between the homeless and clinic children in this study, the absolute scores that Rescorla et al. (1991) reported for the homeless children on measures of intelligence, achievement, and problem behaviors are the most problematic that can be found in the published literature. Indices of IQ and achievement were a good one standard deviation below the national average (e.g., 85 instead of the norm of 100) and CBCL scores, on average were in the high 50s, with internalizing and externalizing CBCL scores at 59 for the homeless preschool group (the borderline clinical range begins at 60).

    In a study conducted in the early 1990s in New York city involving 82 homeless and 62 housed children ages 3 to 5 and their mothers, Schteingart, Molnar, Klein, Lowe, and Hartmann (1995) found that the two groups had equivalent scores on both the internalizing and externalizing dimensions of the CBCL as well as on a measure of developmental status. In multivariate analyses, maternal depressive symptoms predicted internalizing CBCL scores, but housing status did not. Overall, CBCL scores for this group of low-income preschool-age children were in the low 50s, indicating slightly more problem behaviors than would be expected based on the instrument’s standardization group.

    A study with similar no difference findings involved 145 homeless and 142 housed school-age children in Madison, Wisconsin. Using the teacher-report version of the CBCL, Ziesemer, Marcoux, and Marwell (1994) found that both groups scored appreciably higher than test norms on the total problem behaviors index (T-scores of about 58 on average for the homeless and 60 for the housed children). Also, the two groups were comparable on a measure of self-esteem and academic functioning. The authors stressed that broader issues of poverty, rather than homelessness per se, accounted for these results (Ziesemer, et al., 1994).

    Several years after her Boston study, Ellen Bassuk and colleagues mounted a “second generation” study of 220 homeless and 216 housed single parent, female-headed families, which took place in Worcester, Massachusetts. These families were enrolled into this longitudinal study and received their initial (baseline) interview between1992-95. The findings to follow predominantly come from the data collected during this cross-sectional phase of the study. Homeless mothers were enrolled from nine of Worcester’s emergency shelters while the comparison group consisted of low-income, never homeless, mothers who were receiving public assistance in the form of Aid to Families with Dependent Children (AFDC). The CBCL was administered to the mothers of both preschool-age (2-½ – 5 years old) and school-age (6–17 years old) children and data for the two age groups were analyzed separately due to different assessment protocols for these two cohorts.

    As reported in Bassuk, Weinreb, Dawson, Perloff, and Buckner (1997), for the preschool children, scores on both the internalizing and externalizing dimensions of the CBCL were slightly higher for homeless children compared to their housed peers (52.5 vs. 49.9 on the internalizing dimension and 54.8 vs. 51.2 for the externalizing score). Only the difference in externalizing scores was statistically significant between the two groups. Approximately 12 percent of children in both groups were in the clinical range on the internalizing score and 15 percent in both groups on the externalizing dimension. This compares to about 10 percent in the general population based on CBCL test norms. Importantly, the two best predictors of children’s CBCL scores were a measure of mother’s psychological distress and a measure of her parenting practices (negative parenting practices were associated with more elevated CBCL externalizing scores).⁵ Housing status (whether the child was homeless or housed) was also predictive of externalizing scores, but to a lesser degree.

    Among school-age children ages 6 to 17 years in the Worcester study, Buckner, Bassuk, Weinreb, and Brooks (1999) found a similar pattern of findings; although homeless children in this older age group were evidencing more problem behaviors than their low-income housed counterparts.⁶ On the internalizing dimension of the CBCL, the 80 homeless school-age children scores averaged 56.1 compared to 50.2 for their 148 housed peers. About 47 percent of the homeless school age children were in the borderline-clinical or clinical range on the internalizing subscale of the CBCL as compared to 21 percent of the youths in the housed group and 16 percent in the general population. Controlling for other explanatory variables such as negative life events, abuse history, mother’s distress, and social support, housing status remained a significant predictor (Buckner, et al., 1999).

    On the externalizing dimension of the CBCL, homeless children also were reported to have elevated behavior problems compared to the general population but their scores were only slightly higher than the housed poor comparison group (53.7 vs. 51.4). Supporting the CBCL internalizing dimension finding, homeless youths were also more symptomatic on self-reported measures of depression and anxiety. For instance, CDI scores for homeless youths averaged 10.9 versus 9.2 for housed children.⁷ This difference in CDI scores was not statistically significant, and both levels indicate depressive symptoms of moderate severity. Among school-age children in the Worcester study there was some evidence of a link between homelessness and mental health/behavioral problems. This link was not evidenced among preschool children, however.

    Among homeless school-age children, there was some indication that a “dose-response” relationship existed between length of time in shelter and children’s internalizing CBCL scores (Buckner et al., 1999). Such problem behaviors appeared to gradually increase the longer a child had been homeless and peak at about 15 weeks and then were less for those children who had been homeless a longer duration (e.g., 18-45 weeks). While this curvilinear (rainbow-shaped) trend was rather apparent in the data, the finding was a tentative one as it involved a cross-sectional comparison of separate children who had been homeless for different lengths of time. Stronger evidence for such a dose-response curve could be had if a group of children were repeatedly measured during their shelter stays and the same trend was noted in their individual “change trajectories.” The meaning of this curvilinear trend, if valid, is not clear. It could suggest that children habituate some to shelter conditions over time and have fewer internalizing problems once they get used to living there. It might also be the case that after several months of observation, shelter staff pick up on the problems of some children and take measures to ameliorate their distress. It might also be the case that mothers’ perceptions of their children’s behavior changes over time as they become more accustomed to living in a shelter.

    Buckner and Bassuk (1997), assessed the mental health of homeless and housed youths in the Worcester study using a diagnostic instrument. Both parent and self-report versions of the Diagnostic Interview Schedule for Children (DISC Version 2.3) were administered to 94 children 9 to 17 years of age (and their mothers) in the Worcester study.⁸ To meet criteria for a disorder, a child needed to fulfill the specific DSM-III-R criteria and have impairment in functioning as a result of that disorder. About 32 percent of youths in each of the homeless and housed groups (i.e., the proportions were nearly identical in the two groups) met criteria for one or more disorders in the past 6 months (Buckner and Bassuk, 1997). This compares to a rate of 19 percent that has been reported for children of similar age in the general population (Shaffer, Fisher, Dulcan et al., 1996). The most prevalent disorders for these low-income children were anxiety, mood, and conduct problems. Differences found between homeless and housed youths on the CBCL (Buckner et al., 1999), were not apparent when examining these youths in terms of diagnostic criteria, whether looking across all assessed disorders or only those pertaining to disorders of an internalizing (e.g., depressive and anxiety disorders) nature.⁹ The more important finding was that these low-income children had much higher prevalence rates of mental health problems than has been found among youths of similar age in the general population (32% versus 19% prevalence rate for meeting criteria in the past 6 months for at least one disorder that was causing impairment).

    The Worcester study also involved a longitudinal component in which followup data were collected on study participants at 12 and 24 months following their baseline interviews. Among children in the school-age cohort, the longitudinal interviews found all formerly homeless children now living in permanent housing. At followup, the impact of this homeless experience seemed to have dissipated, whereas other negative life events, particularly exposure to violence in the home or community, was much more associated with mental health symptoms (Buckner, Beardslee, and Bassuk, 2004). Unpublished results from the Worcester study’s preschool cohort showed a similar pattern with initial differences between homeless and housed children at baseline assessment converging at followup when most children were living in permanent housing.

    An entirely separate study to the Worcester investigation, but somewhat similar in its methodology, is that of Masten, Miliotis, Graham-Bermann, Ramirez, and Neemann (1993). They interviewed 159 homeless children ages 8 to 17 years who were living in a large emergency shelter in Minneapolis during the summer of 1989 and compared them to 62 low-income children of similar age living in permanent housing. The CBCL and CDI were their principal outcome measures. On the internalizing CBCL score, homeless children scored 52.2 on average compared to 49.4 percent for the housed group. Twenty-seven percent of homeless youths had T-scores of 60 and higher (borderline clinical range and above) compared to 17 percent of housed youths and 16 percent in the general population based on the tests normative data. On the externalizing dimension, homeless youths had scores that averaged 56.0 (40% had a T-score of 60 or higher) versus 53.4 for housed youths (with 30% having a T-score of 60 or higher). For homeless youths, these internalizing scores are lower than those reported by Buckner et al. (1999) in the Worcester study but about the same for externalizing scores. Controlling for other explanatory variables, Masten et al. (1993) did not find that housing status was a significant predictor of either internalizing or externalizing CBCL scores. Scores on the CDI were equivalent between the two groups and of similar magnitude in severity (mild to moderate) to what was found by Buckner et al. (1999) in the Worcester study.

    In summarizing their findings with an eye toward the bigger picture, Masten et al. (1993) described a “continuum of risk.” By this they meant that behavior problems seemed to be more severe according to how much “risk” children had experienced. Based on indices of adversity such as stressful life events, homeless children in the Minneapolis study had the most risk, followed by low-income housed children who, in turn, looked worse off than children from more advantaged backgrounds. This continuum-of-risk concept is an appropriate summary of the Worcester study’s findings, with both homeless preschool and school-age children experiencing the most adversity and having more problem behaviors.

• Developmental Status

  • Among infants and preschool age children, assessing cognitive and motor development in relation to specific developmental milestones is useful in understanding a child’s “developmental status” and whether the child appears to have developmental delay(s) in one or more realms. For instance, a child who is not walking by the age of 2 or not speaking simple sentences by the age of 3 may be delayed in this sphere of development compared to the majority of children of similar age. Three studies examined young homeless children on this dimension. Two of the studies, Wood et al. (1990) in Los Angeles, and Bassuk and Rosenberg (1990) in Boston used the Denver Developmental Screening Test (DDST), whereas the third study, Garcia Coll, Buckner, Brooks, Weinreb, and Bassuk (1998), which involved the infant and toddler cohort from the Worcester study, used the Bayley Scales of Infant Development (“Bayley”). As the name implies, the DDST is an easy-to-use screening instrument for identifying developmental delays in children. The Bayley is the gold standard measure of developmental status in infants and young children and requires specialized training to administer. The DDST is a set of questions asked of a parent or guardian about the child (usually with the child present), whereas the Bayley is administered by a trained tester via direct observation and interaction with the child.

     Both the Los Angeles and Boston studies found that homeless preschool children were experiencing a greater proportion of developmental delays than the comparison groups of poor housed children. In the Wood et al. (1990) study, 15 percent of homeless children were found to have one developmental delay and 9 percent had two or more. These rates are significantly higher than that found in the general child population.¹⁰ The most common type of delay was in language. Bassuk and Rosenberg (1990) found much higher rates of developmental delay in their Boston study, with 54 percent of homeless children evidencing at least one delay versus 16 percent for children in the housed comparison group. Developmental tasks in the areas of language and social behavior were the two areas in which homeless children were having the most difficulty. In contrast to these two studies, Garcia Coll et al. (1998) found no differences between homeless and low-income housed infants/toddler’s developmental status on the Bayley. In fact, homeless children looked slightly better on both the mental and motor development subscales of this instrument (scores of 105 in both realms vs. about 101 for the housed comparison group). Moreover, scores on the Vineland Screener (a measure of adaptive behavior that asks a parent about a child’s communication, daily living, socialization, and motor skills) were almost identical. These low-income infant and toddlers’ scores were in the low-normal to normal range based on normative data for this instrument.

• Health Outcomes

  • The early studies of homeless children that assessed health outcomes found a higher prevalence of health-related problems compared to low-income housed children or children in the general population. For instance, Alperstein et al. (1987) in a study of outpatient medical records in a New York City pediatric clinic, compared 265 homeless children under the age of five in New York City with poor housed children attending the same clinic. Homeless children were behind in their immunizations and had elevated blood lead levels compared to housed children. Homeless children also had higher rates of hospital admissions and reports of child abuse/neglect. The two groups were comparable in terms of height, weight, and free erythroprotoporphyrin (FEP) levels (a measure of iron deficiency).

    Miller and Lin (1988) conducted a survey in King County, Washington, involving a representative sample of 82 homeless families living in emergency shelters. A total of 158 children ranging from 1 month to 17 years of age were assessed, and the investigators compared their findings on these homeless children to normative data in the general population. Although Miller and Lin (1988) found that the majority of children were described as in “good” or ”excellent“ health, the proportion whose health was described as ”fair“ or “poor” was 4 times that of the general U.S. pediatric population (13% vs. 3.2%) and 2 times higher than low-income children (13% vs. 6.5%). Homeless children in this study were also found to lack a regular health care provider (true for 59%), use emergency rooms a rate 2 to 3 times higher than in the general population, and were more likely to lack standard immunizations and preventative health care.

    Another health outcome study took place in Los Angeles and involved a comparison of 196 homeless families to 194 stably housed poor families (Wood et al., 1990). Children in both groups had compared global ratings of their health status (i.e., excellent, good, fair, poor) and similar rates of symptoms (e.g., fever, cough, vomiting, diarrhea) indicative of an illness during the past month. However, these rates were 2 to 5 times higher than those reported in the general child population. Children in both groups had poor dietary intakes and problems with obesity. Homeless children were more likely than housed children to have experienced an episode of hunger in the past month (21% vs. 7%).

    The only second generation study involving health outcomes is that of Weinreb, Goldberg, Bassuk, and Perloff (1998), which was part of the Worcester study that took place during the mid 1990s. They compared 293 homeless children ranging from 2 months to 17 years of age to 334 low-income housed (never homeless children). Their results are fairly consistent with prior studies, although the study is more rigorous because they used multivariate analyses to statistically control for imbalances between the two groups in order to better isolate genuine differences between the two groups. Eighty-eight percent of the homeless children and 94 percent of low-income housed children were reported to be in “good” to “excellent” health, while about 12 percent of the homeless children and 6 percent of the housed children’s health were rated as “fair or poor.” Overall, the difference in health ratings between the two groups was statistically significant at the p <.05 level. Rates of acute illnesses in the past month were generally comparable between the two groups although homeless children had higher rates of ear infections and asthma. Homeless children had higher service use rates, including visits to an emergency room and outpatient clinic visits.

• Education-related Outcomes

  • When the crisis of family homelessness emerged in the 1980s, most school systems were unprepared to deal with the complex needs of homeless children. Many homeless children were denied access to education with school districts claiming that families living in shelter did not meet permanent residency requirements and, therefore, were not eligible for enrollment (Rafferty, 1995). The most frequent impediments to adequate education for homeless children were residency, guardianship, immunization requirements, availability of records, and transportation to and from school (Stronge, 1992). It is not difficult to imagine that if homelessness causes children to miss school, such absence will likely be detrimental to their academic performance.

    Part of The Stewart B. McKinney Homelessness Assistance Act, which Congress passed in 1987, was the establishment of the Education of Homeless Children and Youth (EHCY) program to ensure that homeless children had the same access to public education as all other children. Since then, the EHCY program has provided formula grants to state educational agencies to review and revise policies that may act as barriers to school enrollment and attendance as well as to fund direct services such as transportation and tutoring. Anderson, Janger, and Panton (1995) conducted a national evaluation of the EHCY program and found that over 85 percent of homeless children and youth were regularly attending school, indicating a marked improvement in school access compared to pre-EHCY program attendance rates.

    Studies of homeless children that were conducted prior to and shortly after the creation of the EHCY program have consistently documented disrupted school attendance and academic underperformance. For instance, Bassuk and Rubin (1987) reported that 43 percent of students living in Massachusetts shelters had repeated a grade, 25 percent were in special classes, and 42 percent were failing or doing below-average work. Masten et al. (1993) found that 64 percent of the homeless children they surveyed in Minneapolis in 1999 had changed schools in the past year, significantly higher than the 40 percent rate experienced by housed poor children. In a separate study of 73 homeless children ages 6 to 11, Masten and colleagues determined that academic achievement scores were lower on average than would be expected among children in the general population (Masten, Sesma, Si-Asar, Lawrence, Miliotis, and Dionne, 1997).

    Zima, Wells, and Freeman (1994) reported that 16 percent of their sample of school-age homeless children in Los Angeles had missed more than 3 weeks of school over the past 12 weeks. Thirty-nine percent exhibited reading delays and almost half were at or below the 10th percentile on a measure of receptive vocabulary. Zima and colleagues also found a high level of unmet need for special education evaluations (and perhaps special education programs) based on the high proportion of children with a probable behavioral disorder, learning disability, or mental retardation (Zima, Bussing, Forness, and Benjamin, 1997).

    In a longitudinal study in New York City, Rafferty, Shinn, and Weitzman (2004) compared the academic achievement scores of 46 youths who had a history of homelessness with 87 housed (never homeless) adolescents at three time points during the early to mid-1990s. They found an apparent detrimental effect of homelessness on achievement scores over the short term but not 5 years later. A subtest of the Wechsler Intelligence Scale for Children-Revised was equivalent between the two groups. Youths who had previously been homeless had more school mobility and grade retention than their housed peers (Rafferty et al., 2004).

    Between 1990-92, Rubin, Erickson, San Agustin, Cleary, Allen, and Cohen (1996) conducted a comparative study of homelessness and poor housed children ages 6 to 11 in New York City to examine the relation among housing status, cognitive functioning, and academic achievement. Similar to other studies, they reported that homeless children had missed more days of school in the past year and were more likely to have repeated a grade compared to low-income housed children. Controlling for sociodemographic variables, Rubin et al. (1996) did not find differences between the two groups on measures of verbal and nonverbal intelligence. However, academic achievement scores (reading, spelling, math) were worse for homeless children compared to their housed counterparts, adjusting for demographic factors. Rubin et al. (1996) reported that the effect of housing status on reading achievement was mediated by the number of school changes a child had experienced in the previous 2 years, whereas housing status was linked to spelling achievement through having repeated a grade.

    In contrast to some of these studies, Buckner, Bassuk, and Weinreb (2001) found no evidence of higher school absenteeism or lower academic achievement scores among homeless school age children in the Worcester study as compared to low-income housed children. Children in each group had missed an average of 6 days of school in the past year and scores on a composite measure of academic achievement were identical for both groups (92.8 with 100 the average in the general population). IQ scores were also equivalent in the two groups (92.5 for homeless children vs. 93.5 for housed youths with a score of 100 the norm). Rates of school suspension, grade retention, and special classroom placement were actually higher in the housed comparison group. The only notable difference in the “expected” direction was that homeless children had been enrolled in more schools in the past year (a median of 2 vs. 1 for housed school-age children).

    It is likely that the lack of differences in the Worcester study between homeless and housed school-age children on school and education-related variables had to do with successful implementation of the EHCY program in that city. For the most part, data collection for the other investigations cited above occurred prior to the full implementation of EHCY programs in cities in which these studies were conducted. Since EHCY programs target likely mechanisms by which homelessness could adversely impact academic achievement—namely school access and school attendance—it is not surprising that subsequent studies of homeless children that took place after EHCY programs had been actively implemented (such as in Worcester) would find fewer differences between homeless and housed children on measures of school-related problems and achievement. The findings offer encouraging evidence that it may be possible to eliminate education-related problems for homeless children if barriers to accessing education can be removed.¹¹

    A summary of all the studies described above is presented in Table 1-1. The “Findings” column of this table gives a simplified synopsis of the results of the study in terms of how homeless children looked on the main outcome measure(s) compared to housed children and children in the general population. As can be seen by reading down this column, past studies that can speak to the matter of if and how homelessness has an impact on children are decidedly mixed in their findings, particularly when comparing homeless to low-income housed children.¹² In virtually all instances, these two groups of low-income children look worse on various outcome measures compared to children in the “general population” (i.e., for whom the tests were normed). However, overall it appears that homelessness is associated with worse outcomes, particularly those pertaining to health and education-related measures. Study results in the areas of mental health, problem behaviors, and developmental status are somewhat less consistent, both within and across investigations. The magnitude of severity of problems found among homeless (and low-income housed) children tend to be in the mild to moderate range.

    Table 1-1. Summary of published homelessness studies 1987-2004 by domain

    Mental health/behavior problems

    Publication	Location	Sample	Age	Outcomes	Findings	Comments
    Bassuk and Rubin (1987)	Massachusetts	156 homeless children	0-18 years	CBCL, CDI	Hom > GP	First study to involve homeless children
    Bassuk and Rosenberg (1990)	Boston	134 homeless children 81 housed children	0-18 years	CBCL, CDI, etc.	Hom > Hou > GP	Mostly the same homeless sample as Bassuk and Rubin (1987)
    Rescorla et al. (1991)	Philadelphia	83 homeless children 45 housed/clinic children	3-12 years	CBCL, etc.	Hom > Hou > GP	Homeless children much worse on CBCL than housed peers
    Masten et al. (1993)	Minneapolis	159 homeless children 62 housed children	8-17 years	CBCL, CDI	Hom = Hou > GP	Multivariate analyses controlled for other explanatory variables
    Zima et al. (1994)	Los Angeles	169 homeless children	6-12 years	CBCL, CDI	Hom > GP
    Ziesemer et al. (1994)	Madison, WI	145 homeless children 142 housed children	School-age	CBCL-Teacher	Hom = Hou > GP	Teacher version of CBCL used, not parent version as in the other studies
    Schteingart et al. (1994)	New York City	82 homeless children 62 housed children	3-5 years	CBCL	Hom = Hou > GP	Multivariate analyses controlled for other explanatory variables
    Bassuk et al. (1997)	Worcester, MA	77 homeless children 90 housed children	2-5 years	CBCL	Hom > Hou > GP	Multivariate analyses. Difference between Homeless/housed on CBCL-Externalizing only
    Buckner et al. (1999)	Worcester, MA	80 homeless children 148 housed children	6-17 years	CBCL, CDI, etc.	Hom > Hou > GP	Multivariate analyses. Difference between Homeless/housed on CBCL-Internalizing only
    Buckner and Bassuk (1997)	Worcester, MA	41 homeless children 53 housed children	9-17 years	DISC (DSM-III-R diagnoses)	Hom = Hou > GP	Children age 9 and older in Worcester study. Only study to report DSM diagnoses

    Developmental-related problems

    Publication	Location	Sample	Age	Outcomes	Findings	Comments
    Bassuk and Rosenberg (1990	Boston	134 homeless children 81 housed children	0-5 years	DDST	Hom > Hou > GP	DDST is a brief screening instrument
    Wood et al. (1990)	Los Angeles	194 homeless children	0-5 years	DDST	Hom > GP	Housed children were not assessed
    Garcia Coll et al. (1999)	Worcester, MA	127 homeless children 91 housed children	0-3 years	Bayley	Hom = Hou = GP	Bayley is the “gold-standard” measure of Developmental status

     

    Health-related problems

    Publication	Location	Sample	Age	Outcomes	Findings	Comments
    Alperstein et al. (1987)	New York City	265 homeless children 1600 housed children	0-5 years	Miscellaneous	Hom > Hou> GP
    Miller and Lin (1988)	King County, WA	158 homeless children	0-17 years	Miscellaneous	Hom > GP
    Wood et al. (1990)	Los Angeles	194 homeless children 193 housed children	0-5 years	Miscellaneous	Hom > Hou > GP
    Weinreb et al. (1998)	Worcester, MA	293 homeless children 334 housed children	0-17 years	Miscellaneous	Hom > Hou > GP	Multivariate analyses.

    Education-related problems

    Publication	Location	Sample	Age	Outcomes	Findings	Comments
    Bassuk and Rubin (1987)	Massachusetts	156 homeless children	0-18 years	Attendance, etc.	Hom > GP
    Rescorla et al. (1991)	Philadelphia	83 homeless children 45 housed/clinic children	3-12 years	WRAT-Reading	Hom > Hou > GP	Homeless children worse in reading achievement than housed peers
    Masten et al. (1993)	Minneapolis	159 homeless children 62 housed children	8-17 years	Changes in school	Hom > Hou
    Masten et al. (1997)	Minneapolis	73 homeless children	6-11 years	WIAT-S, etc.	Hom > GP	Compared to children for whom the test was normed, homeless children scored lower in achievement
    Ziesemer et al. (1994)	Madison, WI	145 homeless children 142 housed children	School-age	CBCL-Teacher	Hom = Hou > GP	Ratings of academic performance using teacher version of CBCL
    Zima et al. (1994; 1997)	Los Angeles	169 homeless children	6-12 years	Attendance, reading delays, unmet need for special ed., etc.	Hom > GP	Homeless children have elevated rates of academic problems, unmet need for special education, etc.
    Rubin et al. (1996)	New York City	102 homeless children 178 housed children	6-11 years	WRAT-R	Hom > Hou > GP	Multivariate analyses. No differences between homeless and housed on IQ measure
    Buckner et al. (2001)	Worcester, MA	80 homeless children 148 housed children	6-17 years	Attendance, WIAT-S, KBIT-Non-verbal	Hom = Hou = GP	Multivariate analyses. No differences between homeless and housed on any measure, including IQ
    Rafferty et al. (2004)	New York City	46 formerly homeless children 87 permanently housed children	11-17 years	Changes in school, WISC-R Similarities, Reading achievement	Hom > Hou	No differences on IQ measure
    Key: Hom = Homeless group; Hou = Low-income housed comparison group; GP = Children in the general population; “>” means “greater problems than” CBCL = Child Behavior Checklist; CDI = Children’s Depression Inventory; DISC = Diagnostic Interview Schedule for Children; DDST = Denver Developmental Screening Test; Bayley = Bayley Scales of Infant Development; WRAT-R = Wide Range Achievement Test – Revised; WIAT-S = Wechsler Individual Achievement Test- Screener; KBIT – Kaufman Brief Intelligence Test; WISC-R = Wechsler Intelligence Scale for Children-Revised.

     

    The notion of a continuum of risk is a useful in describing how results tend to fall out when comparing homeless to low-income housed children as well as children in the general population. That is, compared to children in the general population, low-income housed children appear to be doing worse on most outcome measures with homeless children looking the most problematic. (In the next section a range of different factors are discussed that might account for the lack of dependable findings in studies that have compared homeless to housed children.) In addition to the table, Figure 1-1 provides a means by which to summarize both the intentions and the findings of the studies discussed in this section. It is intended as an explanatory device: The figure does not portray actual findings from any particular study and the quantitative values suggested by the lines on the y axis should not be taken literally. The figure portrays the continuum-of-risk concept mentioned by Masten et al. (1993), which is a consistent pattern of results across studies involving homeless and low-income housed children. In the figure, an “average degree of problem severity” is assigned to each of three different grouping of children: children in the general population, housed children living in poverty, and homeless children. Each group’s level of “problem severity” is apportioned to up to three different sources or risk. Children in the general population have just one source of risk (“normative stressors”), those who are from low-income families living in housing have two sources of risk (normative stressors plus “non-homeless, poverty-related” stressors) and homeless children have three sources (normative, poverty-related, and “homelessness-specific” stressors).

    Figure 1-1: Continuum-of-Risk Concept

    

     

    To interpret this graph, assume that the y axis refers to values indicative of a problem of some sort, with higher values indicating greater severity. The graph illustrated a finding that is typical across the studies reviewed earlier, namely that the degree of problem severity is highest for homeless children, followed by low-income housed children, with children in the general population (based on test norms) scoring lowest. The continuum-of-risk notion posits that those with exposure to greater risk have heightened problems, with homeless children experiencing the most risk, hence more severe problems followed by poor housed children, followed by children in the general population. An implicit assumption is that all three groups of children share some common risk factors that are not related to poverty. These are labeled problems attributable to “normative risk factors” and assigned equal values in all three groups. Children in the low-income housed and homeless groups share in common a set of “poverty-related” risk factors. These would be mostly environmental and family variables that children from more advantaged backgrounds are rarely or never exposed to. Furthermore, these poverty-related risk factors are not related to homelessness. Equal values are assigned to both the low-income housed children and homeless children, but no value to children in the general population. Lastly, a value of risk exposure is assigned to the group of homeless children that represents their exposure to risks that are “homelessness-related.” Of course, only children in the homeless group receive such exposure.

    Some of the studies reviewed earlier reveal a pattern of results that match up nicely to this figure. For instance, those studies listed in Table 1-1, in which the finding “Homeless Group > Housed > General Population” seems to fit a pattern of findings consistent with the continuum-of-risk notion.¹³ As described earlier, a goal of many of the studies, especially those involving both homeless and housed children and multivariate statistics, was to determine whether homeless children had heightened problems; and, if so, whether these could be attributed to homelessness or if it were simply the case that homeless children got a higher dose of poverty-related risk exposure than the low-income housed group. So, for example, Buckner et al. (1999) found that homeless school-age children had more internalizing mental health problems than their low-income housed counterparts. Furthermore, through the measurement and statistical control of other risk factors (such as negative events, chronic strains, abuse history, mother’s mental health), the study determined that homelessness, per se, seemed to be playing a role in these elevated internalizing problems. Put another way, it was unlikely that this was a spurious association between housing status and internalizing problems brought about by homeless children having been exposed to more poverty-related (non-homeless) risks than the low-income housed group. This is one of the few studies that has found both an elevated problem severity in homeless children and has been able to convincingly demonstrate that this heightened degree of problem severity is likely the result of homelessness-related stressors and not non-homeless poverty-related factors.

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