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dimension of the CBCL assesses observable behaviors that are indicative of anxiety and depression as well as withdrawn behavior and somatic complaints.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.