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Down but not out! This is the theme of , a new award-winning short film that recorded Tommy Watson's inspiring journey from a homeless senior in high school to a top football player in America and a strong leader in education. Despite being in foster homes, living in nearly 30 different locations growing up, being homeless and without any parental supervision, protection or support, Watson beat the odds, and earned four college degrees, including a doctorate in education leadership.

During the COVID-19 pandemic and the transition to remote and hybrid learning, homeless students faced tremendous challenges as they strove to learn and achieve in school. "As a nation, we must do everything we can to ensure that all students - including students experiencing homelessness and housing insecurity - are able to access an excellent education that opens doors to opportunity and thriving lives," U.S. Secretary of Education Miguel Cardona said in a release. To support homeless students to achieve academic excellence, school leaders need funding, resources, and strategies.

As the number of homeless students grows every year across many public schools in the U.S., policymakers should increase awareness of how to better serve them. To help school leaders to better serve this disadvantaged student population, the Center for Public Education (CPE) of the National School Boards Association (NSBA) gathered information from federal agencies, state governments, and academic studies, and conducted research on the following questions:

Who are homeless students? (Definition of homeless students)

How many homeless students attend public schools?

Where do homeless students live and go to school?

What are some characteristics of homeless students?

How do homeless students perform academically?

What are some funding sources to support homeless students?

Who Are Homeless Students?

Homeless students are defined as students who lack a fixed, regular, and adequate nighttime residence, that is, students living in shared housing, hotels or motels, shelters, and unsheltered places (such as cars, parks, abandoned buildings), according to the McKinney-Vento Homeless Assistance Act. As a primary piece of federal legislation related to the education of children and youth experiencing homelessness, the Act authorizes the federal Education for Homeless Children and Youth (EHCY) Program. In 2015, the Act was reauthorized by Title IX, Part A, of the Every Student Succeeds Act (ESSA).

How Many Homeless Students Are Enrolled in Public Schools?

Since 2008, the number of homeless students identified by public schools each year has increased by more than 100%, from approximately 680,000 to 1,384,000 students in 2019 (Figure 1). In the 2016-17 school year, the number of homeless students exceeded 100,000 in California (262,935), New York (148,418), and Texas (111,177). At the same time, there were more than 50,000 homeless students In Florida (75,106) and Illinois (51,617).

Figure 1. Number and Percentage of Homeless Students in Public Schools

Source: Homeless students enrolled in public elementary and secondary schools, by grade, primary nighttime residence, and selected student characteristics: 2009-10 through 2016-17; National Center for Homeless Education (NCHE) (seiservices.com)

In Washington, D.C., and 12 states (New York, Louisiana, California, Oregon, Kentucky, Oklahoma, Washington, Missouri, Nevada, New Mexico, West Virginia, and Alaska), the percentages of homeless students enrolled in public schools were higher than the national average. As shown in Figure 2, the proportion of homeless students in Washington, D.C., reached 7.5% of its public schools' population. By contrast, in Rhode Island, New Jersey, and Connecticut, the percentage of homeless students was less than 1%.

Figure 2. Percentage of Homeless Students Enrolled in Public Elementary and Secondary Schools, by State or Jurisdiction: 2016-17

Source: Number and percentage of homeless students enrolled in public elementary and secondary schools, by primary nighttime residence, selected student characteristics, and state or jurisdiction: 2016-17

Among the 120 largest school districts in the U.S., New York City enrolled approximately 129,000 homeless students during the 2016-17 school year, and became the school district with the most homeless students. In the same school year, three school districts ― Los Angeles Unified (Calif.), City of Chicago (SD 299) (Ill.), and Clark County (Nev.) ― enrolled more than 10,000 homeless students, respectively. Percentagewise, in four public school districts (New York City, Santa Ana Unified and San Bernardino City Unified in California, and Mobile County in Alabama), more than 10% of the public school students were homeless.

Where Do Homeless Students Live and Go to School?

Geographically, three out of four homeless students live in cities (47%) and suburban areas (32%) (Figure 3). In the 2018-19 school year, approximately 77% of homeless students lived in doubled-up or shared housing (i.e., temporarily sharing the housing of other persons due to loss of housing, economic hardship, or other reasons such as domestic violence); 12% lived in shelters, transitional housing, or awaiting foster care; 7% lived in hotels or motels, and 4% unsheltered (e.g., living in cars, parks, campgrounds, temporary trailers ― including Federal Emergency Management Agency (FEMA) trailers ― or abandoned buildings).

Figure 3. Percentage of Public School Enrollment and Percentage of Homeless Students Enrolled in Public Schools, by School District Locale: 2016-17

Source: Number and percentage of homeless students enrolled in public elementary and secondary schools, by school district locale, primary nighttime residence, and selected student characteristics: 2016-17

In 11 states, more than 80% of homeless students lived in shared housing. In Mississippi, 92% of the state's 10,000 homeless students lived in shared housing because of economic hardship, domestic violence, or other reasons during the 2016-17 school year. The same situation was reported in other states:

Arkansas (88% of the state's 13,104 homeless students lived in shared housing).

Oklahoma (87% of the state's 27,096 homeless students lived in shared housing).

Alabama (86% of the state's 15,931 homeless students lived in shared housing).

Utah (86% of the state's 15,438 homeless student lived in shared housing).

While in many states, about 70% of homeless students live in shared housing, this is not the pattern in Massachusetts, Washington, D.C., New York, Pennsylvania, Wyoming, Nebraska, Minnesota, and Arizona. In Massachusetts, among the 20,872 homeless students, 45% lived in shelters, transitional housing, or were awaiting foster care placement during the 2016-17 school year.

Nationwide, only about 7% of homeless students live in hotels or motels, but 16 states reported rates higher than 10%. In Vermont, 20% of its 1,097 homeless students, and in Georgia, 18% of its 38,336 homeless students lived in hotels or motels in the 2016-17 school year.

Across the country, only about 4% of homeless students are unsheltered. However, in Kentucky, 12% of its 26,826 homeless students, and in Oregon, 10% of its 24,322 homeless students were reported living in cars, parks, campgrounds, abandoned buildings, and other unsheltered places during the 2016-17 school year.

Among the 120 largest school districts in the U.S., nine reported that over 90% of homeless students lived in shared housing in the 2016-17 school year. These districts were Milwaukee (Wis.), Jefferson Parish (La.), Jordan (Utah), Santa Ana Unified (Calif.), Loudoun County (Va.), San Bernardino City Unified (Calif.), Mobile County (Ala.), Long Beach Unified (Calif.), and Baltimore City (Md.).

During the 2016-17 school year:

In six large school districts, more than one third of homeless students reported living in hotels or motels. The districts were Gwinnett County (Ga.), Lewisville ISD (Texas), Virginia Beach City (Va.), DeKalb County (Ga.), Cobb County (Ga.), and Cumberland County (N.C.).

In Boston (Mass.), 83% of homeless students reported living in shelters, transitional housing, or awaiting foster care placement. In Philadelphia City (Pa.) and Omaha (Neb.), more than 40% of homeless students reported such living conditions.

In Texas, two school districts ― United ISD and San Antonio ISD ― reported that more than 30% of their homeless students were unsheltered.

What Are Some Characteristics of Homeless Students?

The number of homeless students has been growing every year in every grade level (Table 1). Between 2009 and 2017, the number of homeless students enrolled in public high schools increased by approximately 104,000; the number of homeless 12th-graders increased by 77%. During the same period, approximately 219,000 more young homeless students enrolled in pre-K to grade 5; prekindergarten experienced 50% increase in enrollment of homeless children.

Table 1. Homeless Students Enrolled in Public K-12, by Grade: 2009 vs. 2017

Source: Homeless students enrolled in public elementary and secondary schools, by grade, primary nighttime residence, and selected student characteristics: 2009-10 through 2016-17

Homelessness is a dramatic disadvantage for students, both physically and psychologically, but some homeless students experience additional hardships and challenges. In the 2016-17 school year:

Approximately 18% of homeless students were students with disabilities.

About 16% of homeless students were English language learners.

Nearly 9% of homeless students were unaccompanied homeless youth or youth who were not in the physical custody of a parent or guardian. This category includes youth living on their own and youth living with a caregiver who was not their legal guardian.

More than 1% of homeless students were migrant students, who were either migratory workers or the children of migratory workers who moved to obtain temporary or seasonal employment in agriculture or fishing.

During the same school year, nearly half of the homeless students with disabilities were in five states ― California (15%), New York (14%), Florida (6%), Texas (5%), and Illinois (4%); about two-thirds of homeless students who were English language learners participated in K-12 public education in three states - California (39%), New York (15%), and Texas (9%).

Among the migrant homeless students, 34% went to school in California, 11% in Washington, 7% in Oregon, and 7% in Texas.

At district level, approximately 10,000 unaccompanied homeless students attended schools in three districts ― New York City (6,380), City of Chicago (SD 299) (2,070), and Fairfax County in Virginia (1,087).

Between 2017 and 2019, the number of homeless students with disabilities increased by nearly 20,000; the number of homeless students who were English language learners increased by more than 10,000 (Figure 4). At the same time, the number of homeless students who were unaccompanied youth went up 6%, and migrant homeless students increased 5%.

Figure 4. Number of Homeless Students, by Student Characteristics: 2016-17 Through 2018-19

Source: National Center for Homeless Education (NCHE) (seiservices.com)

How Do Homeless Students Perform Academically?

Some research shows that only 64% of homeless students graduate from high school, compared to a national average of 78% for low-income students and 84% for all students. According to one report, students experiencing homelessness are 87% more likely to drop out of school than their stably housed peers. Other research states that without a high school diploma, youth are 4.5 times more likely to experience homelessness later in life.

The National Center for Education Statistics ( NCES) could not generate a national graduation rate of homeless students because not all states reported the public high school 4-year adjusted cohort graduation rate (ACGR) of homeless students. However, in general, the high school graduation rate of homeless students is much lower than that of their peers who are not homeless. Among the states that reported the statistics, in the 2018-19 school year:

In Kentucky, the graduation rate of homeless students was only 16%, while the state graduation rate was 91%.

In Minnesota and Washington, D.C., the 4-year ACGR was 49%. In other words, fewer than half of homeless students graduated from high school.

In 27 states, the 4-year ACGR was between 52-67%; at least one in three homeless students could not graduate from high school.

Evidence shows that homelessness is a serious negative factor that affects student achievement. According to a 2019 report about the homeless students in New York City, fewer than one in four (23%) met grade-level standards in English language art (ELA) in the 2016-17 school year, which was almost half the rate of housed students who scored proficient on the ELA assessment (43%). On the statewide math assessment, homeless students also scored proficient at half the rate of their housed classmates (20% vs. 40%).

In the same report, researchers suggested that among homeless students, those living in doubled-up housing were more likely to meet grade-level proficiency standards on their ELA assessment (26%), while those living in shelters were less likely to obtain a proficient score (17%). This trend was also found in the math assessment, in which 24% of homeless doubled-up students scored proficient compared to only 12% of students in shelters.

Chronic absenteeism is often reported as a factor in the low academic achievement of homeless students. Researchers from the University of Southern California examined how homelessness affects students' mathematics and attendance outcomes within the Los Angeles Unified School District. They found that students who experienced homelessness between fourth and eighth grade scored 0.13 standard deviations lower on math tests and missed additional 5.8 days of school than their peers who never experienced homelessness. "The average eighth-grader in the sample misses 7 days of school, thus homelessness adds almost six additional days absent in a 180-day school year (an 80% increase)" ( Gregorio et al., 2020).

What Are Some Funding Sources to Support Homeless Students?

"All students experiencing homelessness are eligible for Title I services even if they are not enrolled in Title I schools," according to the U.S. Department of Education ( ED). Recently, ED is encouraging states to complete their applications for "Round 2 of the American Rescue Plan Act of 2021's Homeless Children and Youth Fund (ARP-HCY), which will deliver a collective $600 million in additional support to students in dire need this summer and before the start of the school year."

According to ED, all public school districts must comply with the requirements of the McKinney-Vento Act to identify and serve school-age children and youth experiencing homelessness. Specifically, every state educational agency (SEA) must have an Office of the Coordinator of Education for Homeless Children and Youth, and the SEA must competitively award 75% of its annual allocation for homeless students to local educational agencies at least once every three years.

In 2020, two states - California and Texas - received more than $10 million for educating homeless students (Figure 5). Two states - New York and Florida - received $5-10 million for the education of homeless students. Nearly half of the country (24 states) received $1-5 million for the education of homeless students; most of the states are in the east coast, the Midwest, and the South. States in the West and the Northeast were more likely to receive less money for this category. This pattern is consistent with the density of homeless student population.

Figure 5. Grants from the U.S. Department of Education for Homeless Children and Youth Education, by State: 2020

Source: Fiscal Year 2019-FY 2021 President's Budget State Tables for the U.S. Department of Education

Conclusions

Homelessness has been steadily rising in major cities across the United States. Children under 18 comprise nearly a quarter of the homeless population ( Henry et al., 2017). Researchers predict that the economic fallout of the COVID-19 pandemic will likely result in more families facing homelessness, and consequently, large urban school districts across the country face the challenge of identifying and serving an increasing number of homeless students.

During the pandemic, many school districts struggled to serve homeless students. For example:

In New York City, the department of education announced that it would pay for summer school taxis for homeless students and those with disabilities after facing criticism from advocates.

In Indiana, an Indianapolis tutoring program ― School on Wheels ― tried to meet homeless students where they were, but the capacity of this program was limited. According to the Indiana Department of Education, approximately 16,380 Indiana students were experiencing homelessness, and the need for tutoring homeless students has been growing since 2018-19.

In Philadelphia, schools experienced a shortage of resources to serve homeless students because school leaders did not have accurate data about homeless students. Research shows that the number of Philadelphia high school students who are homeless may be four times higher than what has been reported.

In summary, providing homeless students with equal learning opportunities is not easy. According to ED, students experiencing homelessness have the right to enroll in school, even if they are missing paperwork that is normally required for enrollment, such as a birth certificate, proof of residence, previous school records, or immunization or other medical records. Homeless students have the right to enroll in their local school or stay in their school of origin, whichever is in their best interest. If attending their school of origin, they have the right to receive transportation to and from the school of origin.

Another big challenge is how schools can ensure that homeless students have equal access to online learning. According to NSBA, "Widespread home-based learning has highlighted a long-documented and persistent inequity of students that lack adequate broadband access." This digital divide, commonly known as the homework gap, impacts approximately 1.4 million students who live in shared housing, hotels, shelters, or even in unsheltered places.

Growing up in foster homes, crisis centers, motel rooms, living with family and friends and bouncing around from place to place, Tommy Watson said, "I had no control over my life, so I came to school and tried to control that." Down but not out - homeless students like Watson are resilient, hoping that education can change their lives. This hope should inspire school leaders and educators to make every effort to serve all homeless students.

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Homeless Students in Public Schools Across America: Down but Not Out

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Since 2008, the number of homeless students has increased by 100%. NSBA's Center for Public Education examines the data behind homeless students to better understand who they are so that policymakers can better serve them.

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It didn't feel like going to school, exactly, but it also didn't feel like just another morning at the homeless shelter where Lashay, 7, has been living since the pandemic hit and her parents lost their jobs.
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She shuffled her feet on the floor, then looked away from the screen of her Chromebook - which showed a pixelated teacher droning on about the flags of different countries - to survey the room. Seated nearby were seven other kids, spaced six feet apart at different tables, each one facing a laptop encircled by a tall, green, plastic shield. Each one wearing a mask. Each one trying to learn, despite everything.

The teacher on the screen told Lashay to pick a country, then draw its flag and list three facts about it.

"A-l-g-e-r-i-a," Lashay decided, even though she had never heard of it before. "And the first fact is that it's beautiful."

The eight children, gathered inside a converted living room area in the Serve Family Shelter in Prince William County, Va., represent a population of learners that educators and advocates say has been largely forgotten amid the devastation wrought across the country by the coronavirus pandemic.

The shift to online learning has drastically widened existing equity gaps in U.S. education, driving drops in attendance, college applications and academic performance among the nation's most vulnerable students: children who are low-income, Black or Hispanic, as well as those with learning disabilities and those whose first language is not English. All too often, homeless children - of whom there are 2.5 million every year in America - combine these factors.

The shuttering of schools nationwide in March immediately shattered any semblance of stability for millions of homeless children who depend on schools for food, emotional support, or even just a warm, uncomplicated place to think. Trying to learn inside shelters for the past nine months, students have faced spotty WiFi, crowded rooms, high noise levels and harassment from some peers who deduce, over Zoom, that they lack a home.

Lashay - and the seven children attending online school all around her - are actually among the luckier ones. The Serve Family Shelter, with 92 beds that make it among the largest family homeless shelters in Northern Virginia, received a $2.5 million investment two years ago from the Day 1 Families Fund, a program founded by Jeff Bezos and MacKenzie Scott that gives grants to nonprofit organizations fighting homelessness. (Bezos, Amazon's founder and chief executive, owns The Washington Post.)

By the time the pandemic arrived, enough money was left over from that windfall - in addition to money from Kaiser Permanente and the Cares Act - to fund the construction of a learning space, set up in a repurposed lounge-turned-children's play area and replete with strengthened WiFi, desk shields and headphones. The shelter also bought reams of personal protective equipment, extra Chromebooks (in case children mislaid their school-provided devices) and hired three teachers, as well as a professional cleaning team that visits regularly to wipe down the makeshift classroom.

More typical are the challenges at shelters like Doorways in nearby Arlington, where another 7-year-old was sitting inside a small bedroom, on the bed itself, with a school-provided iPad balanced on his lap. His mother, 43-year-old Liby, had shoved the bed against the wall so the only thing her son's teacher and fellow students could see, extending behind his head during virtual class, was a blank expanse of green wallpaper.

"I don't want his teacher to figure out where he's living," said Liby, who joined Doorways - a shelter for the homeless, as well as those who have suffered domestic violence and sexual assault - in January after splitting from her abusive ex-husband.

Unlike Serve, Doorways did not have millions in funding to draw on when it was suddenly forced to begin functioning as a schoolhouse, as well as a shelter.

Alexis Love, a client service counselor for Doorways, said she and other staffers pivoted as best they could. They boosted the WiFi, which was struggling to accommodate the unprecedented flood of simultaneous users, and they set aside a downstairs conference room as a "quiet place" where children could go do schoolwork.

The background hum of Doorways, which serves up to 22 people at a time - representing between seven and eight families - sometimes includes screaming babies.

"Most of the kids actually preferred to be in their room, though," Love said. "And our clients do have their own rooms - although the walls are thin, so you can hear people talking on the other side, which is definitely a challenge."

The advent of online learning means it is easier than ever for homeless children to slip through cracks in the educational system, sinking beneath the virtual radars of stressed and overworked teachers and administrators. Parents, many of whom are consumed by the hunt for employment and a stable home, are often unable to advocate for their children, or to devote time, attention and resources to their learning.

"Really it's been on parents who are supposed to be providing a virtual environment, so we knew nobody would be thinking about the kids here," said Michael-Sean Adams, who runs Serve.

School officials in Northern Virginia, and nationwide, have gone to great lengths to reach vulnerable, struggling and low-income children. They have expanded Internet into school parking lots, provided families with WiFi hotspots and hand-delivered needed devices to households, including Chromebooks and iPads. They have also provided free breakfasts and lunches to millions every week since the coronavirus shuttered schools back in March.

But homeless children pose a unique challenge. Their parents are sometimes unwilling or unable to communicate their circumstances. Some shelters, for example those catering to victims of abuse, take pains to hide their location. So, if a homeless child drops off the screen, it can prove impossible to track them.

For Lashay, trouble began in early 2020, when one of her parents was diagnosed with multiple sclerosis. The other was forced to cut back on work to care for her. Then the coronavirus began spreading in the United States, and in short order, Lashay's family lost their income, then their home.

Taped above the Serve fireplace is the slogan, "THE FUTURE OF THE WORLD IS IN THIS ROOM TODAY."

Lashay's eyes began to wander from her screen - and her right hand inched toward her colored marker. One of the hired teachers, Fairfax County Public Schools substitute teacher Amrata Sahasrabudhe, and her assistant, Devin Heilmeier, walked over.

Lashay noticed them approach.

"Can I please just finish this one?" she asked, pointing to a half-colored snowflake.

"Let's watch this video," Heilmeier replied, "and then you can finish that."

'I'm raising a leader'

At Doorways, Liby watched as her son clicked into the online portal for Arlington Public Schools.

She held herself ready to help in any way she could, even though English is not Liby's first language, and she has often struggled to navigate Arlington's seemingly endless, ever-changing, ceaselessly glitchy online learning portals. Recently, she'd started having nightmares that involved clicking through never-ending chains of nonfunctioning webpages.

And she'd developed a personal mantra: "I will make the best I can with what I have."

Liby spoke on the condition that The Post not use her last name, and not name her son, out of fear that her ex-husband would identify and locate her.

Not long after Liby checked into Doorways, the pandemic cost her a job waiting tables at a restaurant in downtown D.C. Then her son began learning online, and Liby's efforts to find new employment came to a complete halt.

Ever since March, her days have revolved around her boy: From 8:25 a.m. to 2 p.m., when he participates in online class, Liby is "just basically on call," she said. Her son is bright and loves school, but virtual learning has proved a constant challenge.

The 7-year-old interrupts every five minutes with some new problem: "Sometimes I have to help with math, sometimes he has to enter a password," Liby said. "Sometimes I have to talk to his teacher, like, 'What do you want him to do?' Because with a lot of kids talking over each other, it's hard for him to catch on."

But under her watchful eye, he has kept up his grades this year, at a time when so many students like him have slipped behind. The boy is reading at an advanced level and has continued to take fourth-grade level math courses, even though he's only in second grade.

In general, the 7-year-old doesn't get upset over much: He's very "coachable," Liby said, and used to adapting to new, sometimes difficult circumstances.

He hasn't complained at all, for instance, about the way her lack of employment has reshaped their lifestyle - the way they get their groceries from a food bank and the Arlington Food Assistance Center now, for example. Or the fact that, for a while, getting exercise meant doing yoga alongside his mom in the shelter parking lot.

Right now, the boy is "crazy about dinosaurs," Liby said. He won't stop talking about the family vacation they took to Jurassic World when he was 4. That was the one and only family vacation they ever took, Liby said, before her husband turned abusive and "everything started falling down."

Maybe, Liby tells herself, the boy is destined to become a world-famous paleontologist. She will sacrifice whatever she must to keep him learning.

"I always say, 'I don't have a son, I'm raising a leader,' " Liby said. "And this world, God knows, really needs leaders."

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What it's like to learn online from inside a homeless shelter

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It is easier than ever for homeless children to slip through cracks in the educational system.

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PHOENIX - By the time Aaliyah Ibarra started second grade, her family had moved five times in four years in search of stable housing. As she was about to start a new school, her mother, Bridget Ibarra, saw how much it was affecting her education.

At 8 years old, her daughter did not know the alphabet.

"She was in second grade and couldn't tell me any of the letters. I would point them out and she didn't know," Bridget Ibarra said. "She would sing the song in order, but as soon as I mixed them up, she had no idea."

"I just didn't know what letters were which," says Aaliyah, now 9. "I know them now."

The family's struggles coincided with the COVID-19 pandemic that forced Aaliyah to begin her school experience online. Unfamiliar with a computer, Aaliyah was regularly kicked out of the virtual classroom, her mother said. Teachers complained she was not looking at the screen and took too many breaks.

Zoom school was especially difficult for Aaliyah because she was homeless - and like thousands of students nationally, her school didn't know.

Homeless students often fell through the cracks during the tumult of the pandemic, when many schools struggled to keep track of families with unstable housing. Not being identified as homeless meant students lost out on eligibility for crucial support such as transportation, free uniforms, laundry services and other help.

Years later, the effects have cascaded. As students nationwide have struggled to make up for missed learning, educators have lost critical time identifying who needs the most help. Schools are offering tutoring and counseling but now have limited time to spend federal pandemic relief money for homeless students, said Barbara Duffield, executive director of SchoolHouse Connection, a national homelessness organization.

"There is urgency because of the losses that have occurred over the pandemic - loss in learning, the gaps in attendance and the health crisis," she said. Many education leaders, Duffield said, don't even know about federal money earmarked for homeless students - and the programs expire next year.

The number of children identified as homeless by schools nationwide dropped by 21% from the 2018-19 school year to the 2020-21 school year, according to federal data. But the decrease, representing more than 288,000 students, likely includes many kids whose homelessness was unknown to schools. Federal counts of homeless people living on the street or in shelters also appeared to decrease in 2021 due to pandemic disruptions, but by 2022, those numbers shot up to the highest in a decade.

In Bridget Ibarra's case, she chose not to tell the school her kids were homeless - and she says teachers, disconnected from students by a screen, never asked. She was worried if officials knew the family was staying in a shelter, and the school was obliged by law to provide transportation, the family would face pressure to enroll in a different school that was closer.

She knew how hard the disruptions were on her kids.

"I know they didn't enjoy moving as often as we did. They would say things like, 'We're moving again? We just moved!'" Ibarra said.

"When I moved, I missed my friends and my teacher," Aaliyah said.

The stigma and fear associated with homelessness also can lead families not to tell anyone they lack secure housing, Duffield said.

"If we don't identify children proactively, we can't ensure that they have everything they need to be successful in school and even go to school," she said.

Before the pandemic, Ibarra and her two children moved in with her brother in Phoenix because she was having trouble making ends meet. Then her brother died unexpectedly. At the time, Ibarra was pregnant with her third child and couldn't afford the rent with what she earned working at a fast-food restaurant.

The family spent the next six months at Maggie's Place, a shelter in North Phoenix that caters to pregnant women. The four of them, including Aaliyah's infant brother, moved next to Homeward Bound, an apartment-like shelter for families, where they were living when the pandemic hit a few months before Aaliyah started kindergarten.

Aaliyah's school, David Crockett Elementary, stuck with online learning her entire kindergarten year. Aaliyah and her older brother, joined by several other children, spent most of their school days on computers in a mixed-grade makeshift classroom at the shelter.

"It was like she wasn't even in school," Ibarra said.

While the shelter helped the family meet their basic needs, Ibarra said she asked the school repeatedly for extra academic help for her daughter. She blamed the struggles partly on online learning, but she also felt the school was giving all their attention to Aaliyah's older brother because he already was designated as a special education student with an individualized education program, or IEP.

The principal, Sean Hannafin, said school officials met frequently with the children's mom. He said they offered the support they had available, but it was hard to determine online which students had needs that required intervention.

"The best thing we could do was take that data and flag them for when we returned in person, because you need a certain amount of time to observe a child in a classroom," he said. "The online setting is not the place to observe."

A federal law aimed at ensuring homeless students have equal access to education provides rights and services to children without a "fixed, regular and adequate nighttime residence."

Many students aren't identified as homeless when their parents or guardians enroll them. At school, teachers, cafeteria staff, aides or bus drivers often notice other students whose well-being may need looking into. Students may have unwashed clothes, or many late arrivals or absences.

But with children learning online, teachers and staff often didn't see those things.

Overall, the drop in the student homelessness count began before the pandemic, but it was much steeper in the first full school year after COVID-19 hit. The percentage of enrolled students identified as homeless in the U.S. dropped from 2.7% in 2018-19 to 2.2% in 2020-21.

Over that timeframe, Arizona had one of the biggest drops in the number of students identified as homeless, from about 21,000 to nearly 14,000. But there were signs many families were in distress. KateLynn Dean, who works at Homeward Bound, said the shelter saw huge numbers of families dealing with homelessness for the first time during the pandemic.

Eventually, Bridget Ibarra had to enroll Aaliyah in a different school.

After getting kicked out of low-income housing last year when their property owner sold the building, the family lived with Ibarra's mother before finding another low-income unit in Chandler, more than 32 kilometers east of Phoenix.

Once the family moved, enrolling in school was far from easy. Aaliyah missed the first three weeks of the school year last fall because of delays obtaining transcripts, and Ibarra insisted she not start the year without a plan to address her delays in reading and writing. Aaliyah spent that time playing and sitting around the house.

"Honestly, Aaliyah said she didn't care how long, because she didn't want to go to that school anyway," her mother said. She said Aaliyah missed her friends and was tired of moving.

At Aaliyah's new school, Frye Elementary, Principal Alexis Cruz Freeman saw for herself how hard it was to keep in touch with families when children were not in classrooms. Several students disappeared altogether. But she said families have started reengaging with school. The state of Arizona reported more than 22,000 students were identified as homeless in the last school year - twice as many as the year before.

Ibarra said she tried to shield as much discomfort about their living situation from her kids as possible. It worked. Aaliyah doesn't remember much about the places they've stayed except the people that surrounded her family.

Aaliyah has gained ground academically at her new school, Cruz Freeman said. She still has trouble pronouncing and recognizing some words. But by the end of the school year, she was able to read a text and write four sentences based on its meaning. She is also performing at grade level in math.

The principal considers her a success story in part because of her mother's support.

"She was an advocate for her children, which is all that we can ever ask for," Cruz Freeman said.

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In US, Homeless Students' Education Took Hard Hit During Pandemic

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Youngsters face steep path to academic recovery

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Ensuring Homeless Students Are Seen During a Pandemic

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In Everett, Wash., Amy Perusse brought together a range of agencies to meet the needs of homeless students and their families.

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Family Gateway - Empowering children & families affected by homelessness

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Facts & Statistics About Homelessness- Family Gateway

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Learn more about homelessness by reading these facts and statistics provided by The Bassuk Center on Homeless and Vulnerable Children & Youth

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COVID has overwhelmed much of our safety net for youth and finding shelter space is harder now.

Do you know a homeless or at risk youth in Minneapolis, ST Paul or Anoka ?(share this on your social media)
Tell them about the YMCA's Communities Host Program where they can find safe, friendly and free shelter for up to a year at a time. HOW TO HELP OR GET HELP
* To sign up to be a host home or for more details about the program, call the YMCA at 612-208-7381.

* Homeless youth age 24 and under can receive services such as meals and housing referrals at the Link's drop-in center at Grace Lutheran Church, 7800 West County Road 42 in Apple Valley from 2-5 p.m. Monday-Friday.

About 6000 youth experience homelessness on any given night in our state.
Sad facts;
15% of homeless youth have traded sex for shelter and food.

Over 20% of homeless youth have been physically or sexually attacked while homeless.

Almost 1/3 of homeless youth have been sexually abused.

There are an estimated 553,742 people in the United States experiencing homelessness on a given night, This represents a rate of approximately 17 people experiencing homelessness per every 10,000 people in the general population.

Almost 40% of homeless youth have stayed in abusive homes because they had no where else to go.

Kids At Risk Action reports on the issues of child abuse & wellbeing

Learn about KARA's Financial Literacy Peer Groups for At Risk Youth

More resources below;

The Y's host program matches friendly families willing to share their safe homes with homeless youth as the Y staff helps these kids attain self-sufficiency.
It's a remarkable program.
So, if you share this with a homeless or at risk youth in your circle, you could change a life.

If you would consider sharing an available room in your home with a homeless youth in our community, you could change a life.
Contact Jesse Mamaril, Youth Support Program Manager 612-208-7381 hosthome@ymcamn.org Facebook: @ymcahosthome
KARA has been reporting and speaking on critical issues impacting abused and neglected children for many years.

This article submitted by long time CASA guardian ad Litem Mike Tikkanen

Share this important information with your social media and

#homeless #childwellbeing #childprotection #statistics #kara #kidsatrisk

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COVID has overwhelmed much of our safety net for youth and finding shelter space is harder now. Do you know a homeless or at risk youth in Minneapolis, ST Paul or Anoka ?(share this on your social media) Tell them about the YMCA's Communities Host Program where they can find safe, friendly and free shelter for up to a year at a time.

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Dominique Marshall moved a lot in her youth. She called many different places "home" over short periods of time when she was 17. She learned at a young age that the public school staff and liaisons she grew up around weren't adequately trained to recognize homeless students.

"I wasn't identified at the school I was at and because of that I didn't qualify for many services until I went to a shelter," Marshall, 23, says. "Even then, the liaison in Philadelphia didn't really have a conversation about what was going on."

The McKinney-Vento Act requires every school district to designate a liaison that identifies homeless students to help them receive needed services. Schools have to immediately enroll children who are homeless even if they don't have the typical paperwork. The students are also given school uniforms, if they are used, and transportation services.

Marshall had to advocate for herself. She stayed in a shelter for nearly a month through the Runaway and Homeless Youth program, a short-term transitional residential program, but she ended up couch surfing again at friends' and families' homes soon thereafter. It became difficult to find a job, and housing grants were unattainable. The 23-year-old later ended up having to drop out of college.

"I was also dealing with my own struggles - trauma as a child, becoming an adult, and being homeless," Marshall says. "Many times people look at homelessness as if you're just out in the streets, but it looks very different for everyone."
Finding Hidden Homelessness
Barbara Duffield, executive director of SchoolHouse Connection, a national nonprofit organization dedicated to overcome homelessness through education, says identifying children and youth who are homeless is a challenge. Hidden homelessness is one of the many reasons. These are people who are temporarily staying in someone's home and not receiving support.

"Most families and youth that are homeless aren't in shelters, they are not on the streets, they're going from place to place," Duffield says. "Identifying is so important because if we don't know who is experiencing homelessness, then we can't make sure they have the resources they need."

Darla Bardine, executive director of the National Network for the Youth, says it also makes it difficult to help this population because there is not one uniform federal definition or eligibility requirement when it comes to homelessness.

She says the Department of Housing and Urban Development (HUD) has the most narrow definition of all the federal agencies. It only includes people living in shelters, transitional housing, or on the streets or other outdoor locations.

This doesn't include people who are couch surfing or paying to stay in motels, for example. So, someone like Marshall, who spent most of her youth moving around, wouldn't be eligible for any housing assistance but would be eligible for homeless programs under the Department of Education.

"Their narrowness of the definition and eligibility requirements really excludes a lot of children, youth and families who are experiencing homelessness," Bardine says. "It is very much focused on chronically homeless single adults."

A legislation introduced in the U.S. House of Representatives would change the homelessness definition of HUD to align with those of other federal agencies so more children, youth and families can have access to housing assistance. It would also lead to more accurate data.

The HUD definition puts many vulnerable people at more risk. In 2019-2020, schools identified 1.28 million homeless students. Meanwhile, HUD identified 106,364 children under 18 and 45,243 young adults, 18 to 24. The HUD count is considered the official count of homelessness. Bardine says it is what Congress uses to make decisions about funding and policy regulation for homelessness in the United States.

Marshall's brother is on the autism spectrum, which makes it difficult for him to access services on his own. He had been staying at a family member's home when Marshall had to help him find a shelter so he could receive housing assistance.

"He ended up staying in an adult shelter and he was just about to turn 19 at the time," Marshall says. "He was with people twice his age and he had to stay there for a night to be able to qualify."

School isn't always a priority
Kedric Sledge, a school social worker at Fulton County Schools in Atlanta and a member of the National Board of StandUp for Kids, a non-profit addressing the youth homelessness crisis, says one of the biggest barriers he sees with homeless students is that school isn't their main priority. Students skip two or three days a week because they're more focused on making an income.

"They want to work first, and a lot of the time school comes second," Sledge says. "They just want to get those basic needs met - get money for hotels, get some food on the table, toiletries and things of that nature."

Myshelle Bey spent a majority of her youth homeless. She was kicked out of her grandmother's home when she became pregnant with her son at 18 and started staying in other people's homes. She had to put school on the back burner.

"I worked all the time, and at one point I had an overnight job, a day job and I was going to school," Bey says. "And I tried to make sure I was always busy and did not try to focus on the situation I was going through."

The school was aware that Myshelle Bey did not have a stable place to live. She says the school didn't offer many resources. And her grandmother, who struggled with drug addiction, did nothing to help.

"It was just very hard to deal with school, and the teachers weren't really understanding of that, they were just like 'you're supposed to be in school,'" Bey says. She is located in Boston.

She dropped out of high school and gave custody of her son to her mom.

Duffield says roughly 68% of students who experienced homlessness will graduate from high school. Others, housed children living in poverty, graduate high school about 80% of the time.

"We also know that lack of a high school or GED is the single greatest risk factor that is associated with continuing to be homeless as an adult," Duffield says. "Homelessness disrupts education, but education is critical to getting out of homelessness."

Bey completed her GED in 2019 and is currently getting her cosmetology license. The 27 year-old hopes to work in a hair salon while pursuing an associates degree.

Sledge says he is an advocate for vocational programs and HVAC training programs that can teach homeless students about the necessary skills they need to work in trading or welding. It allows students to learn how to do a job that can help them make money.

Job Corps, a program that offers free education and vocational training to young adults between 16 and 24 years old, is one of the programs Sledge is pushing for the most.

"They get housing for one, they are able to either choose a high school diploma or a trade when they are in Job Corp," Sledge says. "They get allowance - maybe about 25 dollars a week - and at least they get shelter and room and board."
Stigma Behind Homelessness
Many homeless children and youth also try not to be detected by the system because of the stigma behind homelessness.

Simeria Dewalt is a mother of four children between the ages 16-24 who were all in the public school system. She says her older children struggled academically when they first moved to the shelter. The embarrassment of not having a home hurt the most.

"They were more afraid of what people would think, and they would hide going into the shelter and coming out," Dewalt says. She lives in Elizabeth, N.J.

She says her older son started staying in other people's homes when he was 16 to avoid the shelter. And her daughter followed soon after and started staying in a group home when she was 14.

"It really means that the school district and the school staff need to be sensitive and also very proactive in doing outreach, not just using the word homeless for example," Duffield says.

Schools should train educators to notice signs of potential homelessness in students, she says. This tends to include students with frequent absences, students wearing the same clothing, students hoarding food or changing behavior like withdrawing or acting out.

Dewalt is a peer recovery specialist at Prevention Links, a nonprofit that provides free recovery services for people with substance abuse disorders. As a support specialist, she believes it would be beneficial for schools and shelters to have counseling sessions with homeless students to learn different ways to communicate with other students about their situation. She says many children, like her own, don't know how to deal with questions their friends may have at school.

She says also having participants who were homeless come in and share a success story might make students understand homelessness isn't permanent. Dewalt wants homeless students to understand that this is a situation many people go through and one that they can overcome.

"I was at one point suicidal, but I'm here today so [I know] it can get to the point where you feel like you want to break," Dewalt says. "But if you have someone to talk to, who is encouraging you, and uplifting you, then that may change."

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Homeless youth and children are wildly undercounted, advocates say.

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Dominique Marshall moved a lot in her youth. She called many different places "home" over short periods of time when she was 17. She learned at a young age that the public school staff and liaisons she grew up around weren't adequately trained to recognize homeless students.

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Endnotes

1. Bratt, R. G. 2002. Housing and Family Well-Being. Housing Studies 17(1): 13-26.

2. Aaronson, D. 2000. A Note on the Benefits of Homeownership. Journal of Urban Economics 47: 356-369.

3. National Coalition for the Homeless (NCH). 2008. NCH Fact Sheet: Homeless Family with Children. Accessed on Dec. 14, 2008 from: www.nationalhomeless.org/publications/facts/families.pdf.

4. Ibid.

5. U.S. Department of Education. 2002. Federal Register: 34 Cfr Part 200 Title I - Improving the Academic Achievement of the Disadvantaged; Final Rule. July 5, 2002.

6. National Center for Family Homelessness. 2009. America's Youngest Outcasts: State Report Card on Child Homelessness. Newton, MA: National Center for Family Homelessness.

7. Ibid.

8. Ibid.

9. Ibid.

10. Burt, M. Understanding Homeless Youth: Numbers, Characteristics, Multi-system Involvement, and Intervention Options, Testimony Given before the U.S. House Committee on Ways and Means, Subcommittee on Income Security and Family Support, June 19, 2007. 2007. Urban Institute. Accessed Aug. 11, 2009 from http://www.urban.org/UploadedPDF/901087_Burt_Homeless.pdf.

11. This is a technical term used by Ringwalt et al. 1998. See endnote 12 for the details.

12. Ringwalt, C. L.; Greene, J. M.; Robertson, M. J. 1998. Familial Backgrounds and Risk Behaviors of Youth with Thrownaway Experiences. Journal of Adolescence 21(3): 241-252.

13. Ibid.

14. Ray, N. 2006. Lesbian, Gay, Bisexual and Transgender Youth: An Epidemic of Homelessness. Washington, DC: National Coalition for the Homeless.

15. The United States Conference of Mayors. 2007. Hunger and Homeless Survey: A Status Report on Humger and Homelessness in America's Cities, a 23-City Survey, December 2007. Washington DC: The United States Conference of Mayors.

16. Joint Center for Housing Studies of Harvard University. America's Rental Housing: Homes for a Diverse Nation. 2006. Accessed June 8, 2009 from http://www.jchs.harvard.edu/publications/rental/rh06_americas_rental_housing.pdf.

17. U.S. Department of Housing and Urban Development. Affordable Housing. 2009. Accessed Sept. 1, 2009 from http://www.hud.gov/offices/cpd/affordablehousing/index.cfm.

18. Federal Interagency Forum on Children and Family Statistics. 2007. America's Children: Key National Indicators of Well-Being 2007. Edited By Federal Interagency Forum on Children and Family Statistics.

19. Ibid.

20. U.S. Department of Housing and Urban Development. Affordable Housing Needs 2005: Report to Congress. 2005. Accessed June 8, 2009 from http://www.huduser.org/publications/affhsg/affhsgneeds.html.

21. See endnote 18.

22. U.S. Department of Labor. The Employment Situation: May 2009. 2009. Accessed June 8, 2009 from http://www.bls.gov/news.release/archives/empsit_06052009.pdf.

23. The National Center on Family Homelessness. America's Youngest Outcasts. 2009. Accessed June 8, 2009 from http://www.homelesschildrenamerica.org/.

24. National Center for Children in Poverty, Columbia University Mailman School of Public Health. United States Demographics of Low-Income Children. 2009.

25. Bassuk, E. L.; Buckner, J. C.; Weinreb, L. F.; Browne, A.; Bassuk, S. S.; Dawson, R.; Perloff, J. N. 1997. Homelessness in Female-Headed Families: Childhood and Adult Risk and Protective Factors. American Journal of Public Health 87(2): 241-248.

26. The United States Conference of Mayors. 2007. Hunger and Homeless Survey: A Status Report on Hunger and Homelessness in America's Cities, a 23-City Survey, December 2007. Washington DC: The United States Conference of Mayors.

Kennedy, A. C. 2007. Homelessness, Violence Exposure, and School Participation among Urban Adolescent Mothers. Journal of Community Psychology 35(5): 639-654.

Rukmana, D. 2008. Where the Homeless Children and Youth Come From: A Study of the Residential Origins of the Homeless in Miami-Dade County, Florida. Children and Youth Services Review 30(9): 1009-1021.

Stainbrook, K. A.; Hornik, J. 2006. Similarities in the Characteristics and Needs of Women with Children in Homeless Family and Domestic Violence Shelters. Families in Society-the Journal of Contemporary Social Services 87(1): 53-62.

Tucker, J. S.; Wenzel, S. L.; Straus, J. B.; Ryan, G. W.; Golinelli, D. 2005. Experiencing Interpersonal Violence - Perspectives of Sexually Active, Substance-Using Women Living in Shelters and Low-Income Housing. Violence against Women 11(10): 1319-1340.

27. Rukmana, D. 2008. Where the Homeless Children and Youth Come From: A Study of the Residential Origins of the Homeless in Miami-Dade County, Florida. Children and Youth Services Review 30(9): 1009-1021.

28. Pavao, J.; Alvarez, J.; Baumrind, N.; Induni, M.; Kimerling, R. 2007. Intimate Partner Violence and Housing Instability. American Journal of Preventive Medicine 32(2): 143-146.

29. Covenant Housing Institute, C. H. 2009. Youth in Crisis. New York: Covenant Housing Institute.

30. Powers, J. L.; Eckenrode, J.; Jaklitsch, B. 1990. Maltreatment among Runaway and Homeless Youth. Child Abuse and Neglect 14: 87-98.

Ringwalt, C. L.; Greene, J. M.; Robertson, M. J. 1998. Familial Backgrounds and Risk Behaviors of Youth with Thrownaway Experiences. Journal of Adolescence 21(3): 241-252.

31. Powers, J. L.; Eckenrode, J.; Jaklitsch, B. 1990. Maltreatment among Runaway and Homeless Youth. Child Abuse and Neglect 14: 87-98.

32. Aratani, Y.; Cooper, J. 2008, August, 2008. The Effects of Runaway and Homeless Episodes on Educational Outcomes of Youth. Paper presented at the Annual Meeting in Boston for the Society of the Study of Social Problems, Boston, MA.

33. Whitbeck, L. B.; Hoyt, D. R.; Bao, W. N. 2000. Depressive Symptoms and Co-Occurring Depressive Symptoms, Substance Abuse, and Conduct Problems among Runaway and Homeless Adolescents. Child Development 71(3): 721-732.

Yates, G. L.; Mackenzie, R.; Pennbridge, J.; Cohen, E. 1988. A Risk Profile Comparison of Runaway and Non-Runaway Youth. American Journal of Public Health 78(7): 820-821.

34. Based on the author's analysis using NLSY 1997 sample. Runaway and homeless experiences were measured for the year 1998-2000 and the analysis excludes those who have run away from home in 1997 or earlier to insure the causality, and the behavioral health report was taken from 1997. Behavioral and Emotional Problems (Youth report) was created by summing the responses to the four questions for total possible score of 8 points. Higher scores suggest more frequent and/or numerous behavior problems. The age of NLSY97 used was limited to those who were age 14 or younger in 1997. The sampling weights were used for the analysis.

35. Bassuk, E. L.; Buckner, J. C.; Weinreb, L. F.; Browne, A.; Bassuk, S. S.; Dawson, R.; Perloff, J. N. 1997. Homelessness in Female-Headed Families: Childhood and Adult Risk and Protective Factors. American Journal of Public Health 87(2): 241-248.

Letiecq, B. L.; Anderson, E. A.; Koblinsky, S. A. 1998. Social Support of Homeless and Housed Mothers: A Comparison of Temporary and Permanent Housing Arrangements. Family Relations 47(4): 415-421.

Wood, D.; Valdez, R. B.; Hayashi, T.; Shen, A. 1990. Homeless and Housed Families in Los-Angeles - a Study Comparing Demographic, Economic, and Family Function Characteristics. American Journal of Public Health 80(9): 1049-1052.

36. Toohey, S. M.; Shinn, M.; Weitzman, B. C. 2004. Social Networks and Homelessness among Women Heads of Household. American Journal of Community Psychology 33(1-2): 7-20.

37. Tucker, J. S.; Kennedy, D.; Ryan, G.; Wenzel, S. L.; Golinelli, D.; Zazzali, J. 2009. Homeless Women's Personal Networks: Implications for Understanding Risk Behavior. Human Organization 68(2): 129-140.

38. Powers, J. L.; Eckenrode, J.; Jaklitsch, B. 1990. Maltreatment among Runaway and Homeless Youth. Child Abuse and Neglect 14: 87-98.

Ringwalt, C. L.; Greene, J. M.; Robertson, M. J. 1998. Familial Backgrounds and Risk Behaviors of Youth with Thrownaway Experiences. Journal of Adolescence 21(3): 241-252.

Tyler, K. A.; Hoyt, D. R.; Whitbeck, L. B.; Cauce, A. M. 2001. The Impact of Childhood Sexual Abuse on Later Sexual Victimization among Runaway Youth. Journal of Research on Adolescence 11(2): 151-176.

39. Whitbeck, L. B.; Rose, T.; Johnson, K. D. 2009. Social Networks: Friends and Families at Home and on the Streets. In Whitbeck, L. B. (Ed.), Mental Health and Emerging Adulthood among Homeless Young People (pp. 187-202). New York: Psychology Press.

40. Nesmith, A. 2006. Predictors of Running Away from Family Foster Care. Child Welfare 85(3): 585-609.

41. Ibid.

42. Kennedy, M. R. 1991. Homeless and Runaway Youth Mental-Health Issues - No Access to the System. Journal of Adolescent Health 12: 576-579.

Kushel, M. B.; Yen, I. H.; Gee, L.; Courtney, M. E. 2007. Homelessness and Health Care Access after Emancipation - Results from the Midwest Evaluation of Adult Functioning of Former Foster Youth. Archives of Pediatrics & Adolescent Medicine 161(10): 986-993.

43. Lee, B. A.; Greif, M. J. 2008. Homelessness and Hunger. Journal of Health and Social Behavio r 49(1): 3-19.

44. Ibid. One of the measurements for food insecurity was quality and whether respondents do not get type of food they prefer to eat.

45. See endnote 43.

46. Kelly, E. 2001. Assessment of Dietary Intake of Preschool Children Living in a Homeless Shelter. Applied Nursing Research 14(3): 146-154.

Smith, C.; Richards, R. 2008. Dietary Intake, Overweight Status, and Perceptions of Food Insecurity among Homeless Minnesotan Youth. American Journal of Human Biology 20(5): 550-563.

47. Drake, M. A. 1992. The Nutritional-Status and Dietary Adequacy of Single Homeless Women and Their Children in Shelters. Public Health Reports 107(3): 312-319.

Smith, C.; Richards, R. 2008. Dietary Intake, Overweight Status, and Perceptions of Food Insecurity among Homeless Minnesotan Youth. American Journal of Human Biology 20(5): 550-563.

48. Richards, R.; Smith, C. 2007. Environmental, Parental, and Personal Influences on Food Choice, Access, and Overweight Status among Homeless Children. Social Science & Medicine 65(8): 1572-1583.

Smith, C.; Richards, R. 2008. Dietary Intake, Overweight Status, and Perceptions of Food Insecurity among Homeless Minnesotan Youth. American Journal of Human Biology 20(5): 550-563.

49. Grant, R.; Shapiro, A.; Joseph, S.; Goldsmith, S.; Rigual- Lynch, L.; Redlener, I. 2007. The Health of Homeless Children Revisited. Advances in Pediatrics 51: 173-187.

50. Weinreb, L.; Goldberg, R.; Bassuk, E.; Perloff, J. 1998. Determinants of Health and Service Use Patterns in Homeless and Low-Income Housed Children. Pediatrics 102(3): 554-562.

51. Grant, R.; Bowen, S.; McLean, D. E.; Berman, D.; Redlener, K.; Redlener, I. 2007. Asthma among Homeless Children in New York City: An Update. American Journal of Public Health 97(3): 448-450.

52. Coker, T. R.; Elliott, M. N.; Kanouse, D. E.; Grunbaum, J. A.; Gilliland, M. J.; Tortolero, S. R.; Cuccaro, P.; Schuster, M. A. 2009. Prevalence, Characteristics, and Associated Health and Health Care of Family Homelessness among Fifth-Grade Students. American Journal of Public Health 99(8): 1446-1452.

Wood, D. L.; Valdez, R. B.; Hayashi, T.; Shen, A. 1990. Health of Homeless Children and Housed, Poor Children. Pediatrics 86(6): 858-866.

53. Noell, J.; Rohde, P.; Ochs, L.; Yovanoff, P.; Alter, M. J.; Schmid, S.; Bullard, J.; Black, C. 2001. Incidence and Prevalence of Chlamydia, Herpes, and Viral Hepatitis in a Homeless Adolescent Population. Sexually Transmitted Diseases 28(1): 4-10.

54. Thompson, S. J.; Bender, K. A.; Lewis, C. M.; Watkins, R. 2008. Runaway and Pregnant: Risk Factors Associated with Pregnancy in a National Sample of Runaway/Homeless Female Adolescents. Journal of Adolescent Health 43(2): 125-132.

55. Shinn, M.; Schteingart, J. S.; Williams, N. C.; Carlin-Mathis, J.; Bialo-Karagis, N.; Becker-Klein, R.; Weitzman, B. C. 2008. Long-Term Associations of Homelessness with Children's Well- Being. American Behavioral Scientist 51(6): 789-809.

Buckner, J. C.; Bassuk, E. L.; Weinreb, L. F.; Brooks, M. G. 1999. Homelessness and Its Relation to the Mental Health and Behavior of Low-Income School-Age Children. Developmental Psychology 35(1): 246-257.

Masten, A. S.; Miliotis, D.; Graham-Bermann, S. A.; Ramirez, M.; Neemann, J. 1993. Children in Homeless Families: Risks to Mental Health and Development. Journal of Consulting and Clinical Psychology 61(2): 335-343.

56. Anooshian, L. J. 2005. Violence and Aggression in the Lives of Homeless Children: A Review. Aggression and Violent Behavior 10(2): 129-152.

Buckner, J. C.; Bassuk, E. L.; Weinreb, L. F.; Brooks, M. G. 1999. Homelessness and Its Relation to the Mental Health and Behavior of Low-Income School-Age Children. Developmental Psychology 35(1): 246-257.

57. Anooshian, L. J. 2005. Violence and Aggression in the Lives of Homeless Children: A Review. Aggression and Violent Behavior 10(2): 129-152.

58. Whitbeck, L. B.; Hoyt, D. R.; Johnson, K. D.; Chen, X. 2007. Victimization and Posttraumatic Stress Disorder among Runaway and Homeless Adolescents. Violence and Victim 22(6): 721-734.

59. Yoder, K. A.; Whitbeck, L. B.; Hoyt, D. R. 2008. Dimensionality of Thoughts of Death and Suicide: Evidence from a Study of Homeless Adolescents. Social Indicators Research 86(1): 83-100.

60. Whitbeck, L. B.; Chen, X. J.; Hoyt, D. R.; Tyler, K. A.; Johnson, K. D. 2004. Mental Disorder, Subsistence Strategies, and Victimization among Gay, Lesbian, and Bisexual Homeless and Runaway Adolescents. Journal of Sex Research 41(4): 329-342.

61. Greene, J. M.; Ennett, S. T.; Ringwalt, C. 1997. Substance Abuse among Runaway and Homeless Youth in Three National Samples. American Journal of Public Health 87: 229-235.

62. Aaronson, D. 2000. A Note on the Benefits of Homeownership. Journal of Urban Economics 47: 356-369.

63. Rafferty, Y.; Shinn, M.; Weitzman, B. C. 2004. Academic Achievement among Formerly Homeless Adolescents and Their Continuously Housed Peers. Journal of School Psychology 42(3): 179-199.

64. Ibid.

65. Zima, B. T.; Bussing, R.; Forness, S. R.; Benjamin, B. 1997. Sheltered Homeless Children: Their Eligibility and Unmet Need for Special Education Evaluations. American Journal of Public Health 87(2): 236-240.

66. See endnote 63.

67. Rubin, D. H.; Erickson, C. J.; Agustin, M. S.; Cleary, S. D.; Allen, J. K.; Cohen, P. 1996. Cognitive and Academic Functioning of Homeless Children Compared with Housed Children. Pediatrics 97(3): 289-294.

68. See endnote 65.

69. See endnote 65.

70. See endnote 32.

71. Whitbeck, L. B.; Simons, R. L. 1990. Life on the Streets - the Victimization of Runaway and Homeless Adolescents. Youth & Society 22(1): 108-125.

72. Kaufman, J. G.; Widom, C. S. 1999. Childhood Victimization, Running Away, and Delinquency. Journal of Research in Crime and Delinquency 36(4): 347-370.

73. Baron, S. W. 2008. Street Youth, Unemployment, and Crime: Is It That Simple? Using General Strain Theory to Untangle the Relationship. Canadian Journal of Criminology and Criminal Justice 50(4): 399-434.

74. U.S. Department of Health and Human Services Administration for Children and Families. Youth Development Division. 2008. Accessed Aug. 2, 2009 from http://www.acf.hhs.gov/programs/fysb/content/youthdivision/index.htm#sub1.

75. Positive youth development is based on prevention science and focuses on protective factors that promote social, behavioral or cognitive competence and foster self-efficacy, resiliency, etc. For details, please see Catalano, R. F.; Berglund, M. L.; Ryan, J. A. M.; Lonczak, H. S.; Hawkins, J. D. 2004. Positive Youth Development in the United States: Research Findings on Evaluations of Positive Youth Development Programs. The ANNALS of the American Academy of Political and Social Science 591(1): 98-124.

76. National Alliance to End Homelessness. Runaway and Homeless Youth Act. 2009. Accessed Aug. 3, 2009 from http://www.endhomelessness.org/section/policy/legislature/rhya.

77. U.S. Department of Education. 2009. Guidance on McKinney-Vento Homeless Children and Youth Program Funds Made Available under the American Recovery and Reinvestment Act of 2009.

78. U.S. Department of Education. 2002. Federal Register: 34 Cfr Part 200 Title I - Improving the Academic Achievement of the Disadvantaged; Final Rule. July 5, 2002.

79. U.S. Department of Housing and Urban Development. Section 8 Rental Voucher Program. 2004. Accessed Aug. 1, 2009 from http://www.hud.gov/progdesc/voucher.cfm.

80. U.S. Department of Housing and Urban Development. HUD's Public Housing Program. 2007. Accessed Aug. 1, 2009 from http://www.hud.gov/progdesc/voucher.cfm.

81. See endnote 16.

82. U.S. Department of Health and Human Services. Chafee Foster Care Independence Program (Cfcip) State Fy 2008 Estimates. 2009a. Accessed Aug. 1, 2009 from http://www.acf.hhs.gov/programs/cb/laws_policies/policy/pi/2007/pi0705b1.htm.

U.S. Department of Health and Human Services. Education and Training Vouchers (ETV) States FY 2008 Estimates. 2009b. Accessed Aug. 1, 2009 from http://www.acf.hhs.gov/programs/cb/laws_policies/policy/pi/2007/pi0705b1.htm.

83. Patel, S.; Roherty, M. A. Medicaid Access for Youth Aging out of Foster Care. 2007. American Public Human Services Association. Accessed Aug. 13, 2009 from http://www.aphsa.org/Home/Doc/Medicaid-Access-for-Youth-Aging-Out-of-Foster-Care-Rpt.pdf.

84. Shinn, M.; Weitzman, B. C.; Stojanovic, D.; Knickman, J. R.; Jimenez, L.; Duchon, L.; James, S.; Krantz, D. H. 1998. Predictors of Homelessness among Families in New York City: From Shelter Request to Housing Stability. American Journal of Public Health 88(11): 1651-1657.

85. Busen, N. H.; Engebretson, J. C. 2008. Facilitating Risk Reduction among Homeless and Street-Involved Youth. Journal of the American Academy of Nurse Practitioners 20(11): 567-575.

86. Ensign, J.; Gittelsohn, J. 1998. Health and Access to Care: Perspectives of Homeless Youth in Baltimore City, USA. Social Science & Medicine 47(12): 2087-2099.

87. Cooper, J. L. 2008. Towards Better Behavioral Health for Children, Youth, and Their Families: Financing That Supports Knowledge. New York: National Center for Children in Poverty, Columbia University Mailman School of Public Health.

88. U.S. Department of Health and Human Services. Chafee Foster Care Independence Program: Program Description. Accessed Aug. 1, 2009 from http://www.acf.hhs.gov/programs/cb/programs_fund/state_tribal/jh_chafee.htm.

89. Hamm, L. A.; Holden, E. W. 1999. Providing WIC Services to Homeless Families. Journal of Nutrition Education 31(4): 224-229.

90. Gaetz, S.; O'Grady, B. 2002. Making Money: Exploring the Economy of Young Homeless Workers. Work Employment Society 16(3): 433-456.

91. Lenz-Rashid, S. 2005. Employment Experiences of Homeless Young Adults: Are They Different for Youth with a History of Foster Care? Children and Youth Services Review 28: 235-259.

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Homeless Children and Youth: Causes and Consequences

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Endnotes 1. Bratt, R. G. 2002. Housing and Family Well-Being. Housing Studies 17(1): 13-26. 2. Aaronson, D. 2000. A Note on the Benefits of Homeownership. Journal of Urban Economics 47: 356-369. 3. National Coalition for the Homeless (NCH). 2008. NCH Fact Sheet: Homeless Family with Children. Accessed on Dec.

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9 Challenges Our Students Face in School Today Part I: Poverty & Homeless Families

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Spread the loveSome students struggle with completing Math and English assignments, submitting homework on time, and staying focus in class. However, these struggles may be a part of a greater problem that is not clearly seen by parents, guardians, and educators.

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Originally posted on DailyMom.com.

The number of homeless children in the United States has grown in the last decade. More than 2.5 million children are homeless in the United States each year. That means one in every 30 children is homeless. This number has grown in the last decade as the number of families who are homeless has gone up. That increase is due to factors like increased poverty and a lack of affordable housing. Being homeless as a child can cause negative effects that last for the rest of someone's life. Homeless children face some alarming challenges to survive.

HOMELESSNESS AND HEALTH

A study conducted by researchers at Children's HealthWatch of Boston Medical Center found that experiencing homelessness before or right after birth put children at high risk for poor health. The same was true for children who were homeless for more than six months. This is because homeless pregnant women have less access to prenatal care, are likely to abuse drugs, and often face chronic health problems. Their babies are likely to have low birth weights. A third of homeless babies miss important vaccinations because their family does not have access to healthcare. The toll of poor health at such a young age has lasting effects.

As homeless children get older, they continue to face problems with poor health. Homeless children are more likely to experience illness and chronic health problems. They are also are risk for developing asthma or obesity. They typically miss vaccinations and lack basic health care. Poor health extends to mental health. Preschool aged homeless children are likely to suffer from anxiety, depression, or severe aggression. While homeless youth are twice as likely to be emotionally distressed than their peers who have housing, they're also twice as likely to have suicidal thoughts and attempt suicide.

HOMELESSNESS AND CHILD DEVELOPMENT

Children experiencing homelessness often have delays in child development. By the time homeless children are toddlers, they typically have delays in things like speech and toilet training. By the age of five, most homeless children have at least one major developmental delay. Many of these children have multiple developmental delays. The most common delays are with language skills, hand-eye coordination, and emotional or behavioral development.

More than a third of homeless children have emotional and behavioral problems. They generally cry more easily and overreact to small problems. Preschool-aged homeless children are likely to have such extreme emotional issues that they need professional help. Yet only about a third of children experiencing homelessness will receive some sort of professional intervention.

HOMELESSNESS AND LEARNING

Homeless children are more likely than their peers to have lower academic performance. They more frequently change schools, get expelled, and drop out of school. That is because many homeless children exhibit learning issues that make it harder for them to be successful in school. Homeless children experience delays that affect learning four times more than other children. They are also twice as likely as their peers to have a learning disability. They are also less likely than their peers to receive services that could correct many of these delays.

On top of all that, homeless children are generally more concerned about where they are going to sleep on any given night than they are about learning. When a child is worried about basic needs like food, shelter, and safety being met, they cannot focus on other, less pressing things like school work.

HOMELESSNESS AND FOSTER CARE

It is common for homeless children to be separated from their families. They are seven times more likely than other children to be placed in foster care. Twenty-two percent of homeless children will either be placed in foster care or live with relatives (compared to 3 percent of children who have housing). The stress and trauma caused by these separations can lead to attachment disorders, low self-esteem, and other mental health disorders.

The good news is that all is not lost for these children. A family being homeless does not necessarily mean those parents are not concerned about their children. It just means they are unable to provide housing. When homeless parents have a close relationship with their children and are involved in their education, they are more likely to be successful in school despite being homeless. Good relationships with other caring adults can also help homeless children to succeed in spite of the challenges they face. With early and consistent intervention, homeless children can overcome many of the problems caused by being homeless. The challenge is making sure children receive these interventions.

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Alarming Challenges Faced by Homeless Children - Children's HealthWatch

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Originally posted on DailyMom.com. The number of homeless children in the United States has grown in the last decade. More than 2.5 million children are homeless in the United States each year. That [...]

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Through the federal McKinney-Vento Homeless Assistance Act:

Students who are experiencing homelessness can remain in one school (including a preschool), even if their temporary living situation is located in another school district or attendance area, if that is in their best interest. Schools must provide transportation.

Students who are experiencing homelessness can enroll in school and begin attending immediately, even if they cannot produce normally required documents, such as birth certificates, proof of guardianship, immunization records, or proof of residency, or even if they have missed application or enrollment deadlines.

Students who are experiencing homelessness must be able to participate fully in school activities and access all programs and services for which they are eligible, including extracurricular activities, credit recovery, special education services, school nutrition programs, language assistance for English learners, career and technical education, gifted and talented programs, magnet schools, charter schools, summer learning, online learning, and before- and after-school care.

Every local educational agency, including charter schools that are local educational agencies, must designate a homeless liaison. Homeless liaisons have many critical responsibilities in the service of students experiencing homelessness, including identification, enrollment, ensuring access to early childhood education and other programs, and collaboration with community agencies.

What can I do if I believe one of my students is experiencing homelessness or is at risk of becoming homeless?
Teachers can play a critical role in the lives of students who are homeless. While McKinney-Vento liaisons bear the local-level legal responsibility for serving students experiencing homelessness, teachers are well-positioned to observe and respond to student needs. Some strategies for providing support include:

1. Learn more about the McKinney-Vento Act and connect with your local liaison.
If you believe one of your students needs support, contact your district's homeless liaison about next steps (you should be able to find the liaison's contact information on your district website or SEA website). Ask your liaison for local resources, and read more about McKinney-Vento provisions here.
2. Create a welcoming climate and build trust with all students.
Find time each week to check in with the student to assess unmet basic needs, offer encouragement, and recognize the child's talents and accomplishments. Pair new students with a "buddy" in the classroom or assign new students a "job" and encourage involvement in extracurricular activities. These personal relationships can be critical. Consider re-thinking morning meetings or circle times and instead of asking questions like "how was your weekend," ask questions like "what are you looking forward to at school today." Students who are in unsafe or unstable housing may feel uncomfortable or afraid to share about their evening or weekend. Create shared experiences for all students; instead of talking or writing about homes or neighborhoods, take students on walks around the school or playground so they can write or share about their common experience. Be sensitive to how families are discussed; consider saying things like "your grown ups" instead of "your parents."
3. Help to identify and support students experiencing homelessness.
Many students are uncomfortable telling people at school about their homelessness and asking for help. Be attentive to the stigma of homelessness and avoid using the word "homeless." Especially if you notice any of the warning signs listed above, use descriptive language and ask questions to better understand a student's housing situation. For example, ask students and families, "Where would you go if you couldn't stay here?" "What led you to move into this situation?" If appropriate, refer the child and his/her family for supportive services and housing assistance in your community.
4. Take a trauma-informed approach.
The experience of and events leading up to homelessness can expose students to violence, abuse, hunger, trafficking, and other traumatic experiences. Allow students to hold on to personal possessions in class, keeping in mind that any possession may be the child's only one. Provide well-defined transition procedures from one activity to another and give choices when appropriate to counter the loss of control experienced in their lives.
5. Stabilize basic needs and support full participation.
Make healthy snacks and/or hygiene supplies available. Ensure enrollment in the free meal program. (Homeless students are automatically eligible for free meals, and do not need to complete an application.) Ensure that the student has every opportunity to participate in school activities: contact the homeless liaison to find out how to provide school/project supplies, cover field trip fees, purchase uniforms, and meet other needs. Give students a clipboard to use as a "desk" when they leave school. Be sensitive to asking students to bring things from home, such as classroom treats or art supplies; make sure to have extras so all students can participate in celebrations or activities.

6. Ensure classroom policies and procedures set students up for success.

Disciplinary policies must take homelessness into consideration. Provide structure and adhere to a consistent daily routine and clear, concise rules. Plan assignments so children can keep up without having to take work home.
7. Reach out to parents/caregivers.
Because parents may not have regular access to a phone, create a communication plan. Send the family a "welcome" letter and/or invite them to visit the classroom. Ask if younger siblings need supportive services. Make sure parents know their family's rights.

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Tips for Teachers & Staff: How to Support Students Experiencing Homelessness

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For many students experiencing homelessness, school is the only place of stability in their lives. Teachers play a crucial role in creating a classroom environment that is safe and supportive for all students, especially those who are highly mobile and have experienced the trauma that often accompanies homelessness.

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Evictions, natural disasters, pandemic-related job loss, and increased family stress have the potential to cause unprecedented levels of child, youth, and family homelessness this school year. Here, we break down five facts every educator needs to know about child and youth homelessness and action steps for supporting students as they return to the classroom. For more awareness and training resources, click here .

To learn more about how you can support students experiencing homelessness this school year, review the educators' resources here.

1. Homelessness is in Your School And School District, Even If You Can't See It.

Family and youth homelessness is often hidden. Many communities lack shelters for families and youth, and families and youth may fear shelter - especially during COVID-19. For these reasons, homeless families and youth are much more likely to stay temporarily with other people, or in motels, than in shelters. These situations are often unstable, and sometimes unsafe. Of 1.4 million children and youth experiencing homelessness reported by school districts in 2018-2019, 77% were staying with others due to lack of alternatives when they were first identified, while only 12% were in shelters. The prevalence of youth homelessness is the same in urban, rural, and suburban areas .

Schools provide the education, safety, stability, and services necessary for children and youth experiencing homelessness to cope and avoid homelessness as adults. However, in order to benefit from targeted educational protections and services, children and youth must first be identified as experiencing homelessness. Every educator has a role to play in identifying students experiencing homelessness .

2. There is No Educational Equity Without Addressing Homelessness in Schools.

Student homelessness is an equity issue intrinsically tied to challenges, traumas, and outcomes of our most underserved students. Students of color, pregnant and parenting students, and LGBTQ students are significantly more likely to experience homelessness. In high school , Black students are 2.25 times more likely to experience homelessness, and Hispanic students are 2 times more likely to experience homelessness, than their white peers. Heightened racial violence also contributes to loss of trust with public schools, exacerbating challenges in re-engaging students who are homeless. Students with disabilities and English learners are also disproportionately represented among students experiencing homelessness. For many students, these experiences and identities intersect; once they become homeless, they face unique barriers to enrolling, attending, and succeeding in school.

We cannot achieve education's promise of "opportunity for all" without prioritizing children and youth who experience homelessness, and educators must implement federal protections for homeless students with a trauma-informed and anti-racist approach.

3. It Takes More than Housing to Solve Homelessness.

Homelessness is an indicator of many vulnerabilities, inequities, and traumas that a child might experience. Contributing factors include job loss and underemployment, evictions and lack of affordable housing, natural disasters, domestic violence, international violence, addiction, mental illness, low educational attainment, generational poverty, and systemic racism. For youth who experience homelessness on their own, abuse, neglect, abandonment, and family conflict are causal factors.

Educators can respond to child and youth homelessness by understanding the full range of traumatic events that lead to and accompany loss of housing, and adopting a trauma-informed approach to identification and services. At the same time, a comprehensive approach to community partnerships - including housing and emergency rental assistance , but also health care, counseling, transportation, nutrition, credit accrual, mentorship, and more - are needed to ensure that students experiencing homelessness and their families are supported in their education, which they ultimately will need to obtain and sustain housing.

4. Under Federal Law, State and Local Education Systems Have a Legal Obligation to Provide Children and Youth Experiencing Homelessness Education and Supportive Services - and with Passage of the American Rescue Plan Act, There Are Unprecedented Resources To Do So.

The McKinney-Vento Act provides rights and services to children and youth experiencing homelessness, including immediate enrollment, school stability, transportation, and more. Under the Act, every local educational agency is required to designate a liaison for homeless children and youth. The local educational agency liaison coordinates activities to ensure that homeless children and youth are identified, enrolled in school, and have the opportunity to succeed academically.

Both the American Rescue Plan Act Elementary and Secondary School Emergency Relief fund (ARP ESSER) and American Rescue Plan Act Homeless Children and Youth fund (ARP HCY) the basics of the McKinney-Vento Act's protections provide unprecedented funding to support the identification, enrollment, and school success of children and youth experiencing homelessness, supporting this work. Educators should make sure they understand , and reach out to their local homeless education liaison and/or state coordinator to learn about additional training opportunities.

5. You Can Support The Unique Needs of Your Students Experiencing Homelessness Whether You Are An Early Childhood, Elementary, Middle, High School, or Higher Education Educator.

From prenatal to postsecondary, homelessness jeopardizes the health and development of children and youth. Public schools report homelessness in every grade , including preschool; the percentage of homeless students enrolled in each grade has remained stable over the last five years. Schools also have reported increasing numbers of unaccompanied youth (youth not in the physical custody of their parent or guardian) across grades. At every grade level, educators can provide age-appropriate support for children, youth, and families. The McKinney-Vento Act requires specific attention to young children, including ensuring that they are enrolled in Head Start, Early Head Start, early intervention, and preschool programs administered by the LEA . It also requires action to support high school students to prepare for college, and receive assistance obtaining documentation for the Free Application for Federal Student Aid (FAFSA) . By supporting the full continuum of learning, educators can help ensure the lifelong success of children and youth who experience homelessness.

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Five Facts Educators Need to Know About Student Homelessness - And Actions to Take

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Evictions, natural disasters, pandemic-related job loss, and increased family stress have the potential to cause unprecedented levels of child, youth, and family homelessness this school year. Here, we break down five facts every educator needs to know about child and youth homelessness and action steps for supporting students as they return to the classroom.

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53 Proven School Fundraising Ideas - Raise Money for Your School

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Although they often do, schools should not underestimate the value of fundraising. Fundraising can help schools offer scholarships and new programs, maintain academic excellence, and complete major projects. Having a well-planned and well-executed fundraising strategy can make all the difference between thriving and simply surviving for most schools.

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Types of Interactions Between Health and Homelessness

In examining the relationship between homelessness and health, the committee observed that there are three different types of interactions: (1) Some health problems precede and causally contribute to homelessness, (2) others are consequences of homelessness, and (3) homelessness complicates the treatment of many illnesses. Of course, certain diseases and treatments cut across these patterns and may occur in all three categories.

Health Problems That Cause Homelessness

Certain illnesses and health problems are frequent antecedents of homelessness. The most common of these are the major mental illnesses, especially chronic schizophrenia. As mentally ill people's disabilities worsen, their ability to cope with their surroundings-or the ability of those around them to cope with their behavior-becomes severely strained. In the absence of appropriate therapeutic interventions and supportive alternative housing arrangements, many wind up on the streets. Another contemporary example of illness leading to homelessness is AIDS. As the disease progresses and leads to repeated and more serious bouts with opportunistic infections, the individual becomes unable to work and may be unable to afford to continue paying rent. Other health problems contributing to homelessness include alcoholism and drug dependence, disabling conditions that cause a person to become unemployed, or any major illness that results in massive health care expenses.

One type of health problem in this category-about which the committee heard much during several site visits-is accidental injury, especially jobrelated accidents. Although such programs as Workers' Compensation were designed to prevent economic devastation as a result of workplace casualties, they often fall far short of what is optimal for many reasons, including lack of knowledge of the program by the employee, low levels of benefits under the program, and lack of benefits for "off the books" work and migrant farm labor. A case study illustrates the point:

Samuel Anderson arrived in New York City in 1985 from his native Oklahoma. He is 24 years old, educated through the 11th grade, and says he left his rural surroundings because there was no opportunity to work, ". . . there was no job with something ahead of it." He feels that his chances will be best in the "biggest town I know of." In New York, he is studying for a graduate equivalency diploma and supports himself as an evening security guard. His wages are enough to pay for a rented room in the borough of Queens. Five months after starting work, he scuffles with intruders and suffers gunshot wounds in his right leg and hand (he is right-handed). Mr. Anderson spends 2 weeks in the hospital after losing four pints of blood through his wounds. A vascular surgeon and a neurosurgeon repair his shattered hand during a 4-hour microsurgical procedure. In the meantime, his room in Queens (he is in a hospital in the borough of Manhattan, some distance away) is rented to someone else because of his absence and the concurrent lack of rent payment. After discharge from the hospital, he spends a few nights in a hotel. When his money runs out, he sleeps in a city park, finally coming to a shelter.

In addition to accidents, various common illnesses such as the degenerative diseases that accompany old age can also lead to homelessness:

James Barnam, now 62 years old, has worked regularly since age 17, but has never found a job with secure employee benefits. He has lived a marginal existence: adequate funds for food and a room in a single room occupancy hotel, but certainly not enough for savings. He is fired from his long-held kitchen job because he cannot see the food stains on the dishes; after working 2 days as a messenger, he is let go because items were delivered to incorrect addresses. Mr. Barnam has eye cataracts, a frequent accompaniment of older age and treatable with ambulatory surgery for those patients with health insurance. Mr. Barnam's marginal income entitles him to Medicaid benefits, but he is unable to negotiate the public welfare system and has no one to guide him through forms, appointments, and examinations. Upon losing his hotel room, Mr. Barnam goes to a shelter for homeless men after he is discovered at a bus station by outreach workers. However, even there, his health problem remains troublesome: he almost loses his bed because he fails to sign a daily bed roster he cannot see.

In each of these cases, employment was not secure, and the man lacked a network of family or friends. The fact that health problems precipitated homelessness underscores the relationships among health status, employment, social supports, and access to affordable housing.

Health Problems That Result from Being Homeless

Homelessness increases the risk of developing health problems such as diseases of the extremities and skin disorders; it increases the possibility of trauma, especially as a result of physical assault or rape (Kelly, 1985). It can also turn a relatively minor health problem into a serious illness, as can be seen by the case of Doris Foy:

Doris Foy's varicose veins occasionally result in swollen ankles. When homeless, she sleeps upright, and her legs swell so severely that tissue breakdown develops into open lacerations. She covers these with cloth and stockings-enough to absorb the drainage but also to cause her to be repugnant to others because of the smell and unsightly brown stains. She is eventually brought to a clinic by an outreach worker. When the cloth and the stockings are removed from the legs, there are maggots in the wounds. She is taken to the emergency room of a hospital, where her wounds are cleaned.

Other health problems that may result from or that are commonly associated with homelessness include malnutrition, parasitic infestations, dental and periodontal disease, degenerative joint diseases, venereal diseases, hepatic cirrhosis secondary to alcoholism, and infectious hepatitis related to intravenous (IV) drug abuse.

Homelessness as a Complicating Factor in Health Care

For even the most routine medical treatment, the state of being homeless makes the provision of care extraordinarily difficult. Even the need for bed rest is complicated, if not impossible, when the patient does not have a bed or, as is the case in many shelters for the homeless, must leave the shelter in the early morning. Diabetes, for example, usually is not difficult to treat in a domiciled person. For most people, daily insulin injections and control of diet are adequate. In a homeless person, however, treatment is virtually impossible: Some types of insulin need to be refrigerated; syringes may be stolen (in cities where IV drug abuse is common, syringes have a high street value) or, sometimes, the homeless diabetic may be mistaken for an IV drug abuser; and diet cannot be controlled because soup kitchens serve whatever they can get, which rules out special therapeutic diets. The following case illustrates the various problems involved in treating a homeless man with another common chronic medical problem, hypertension:

Tyrone Harrison is black, 26 years old, and homeless because he cannot find a job. He wants to work in the shelter kitchen and waits 3 hours for a preemployment physical examination. He is friendly and describes himself as "very healthy." His blood pressure is 180/120. His smile disappears and he feels "cut down." Because he is homeless, he must deal with his illness, private and asymptomatic, in the public spaces of the shelter. He refuses to talk about high blood pressure with the fellows in the dormitory-it diminishes his macho image. He tells the nurse that his blood pressure reading must be a mistake. Three weeks later, after six contacts with the medical outreach worker, he confides that his cousin had been a dialysis patient because of hypertensive kidney disease. Weeks later, after several more visits to the medical team, Tyrone consents to medication for his persistently elevated blood pressure. His 2-week supply of pills are stolen 4 days later. An argument erupts in the dormitory and, in accord with routine regulations, Tyrone is put out of the shelter for 2 weeks. On his return to the shelter, his blood pressure is uncontrolled because he had no medication.

The cases described above exemplify not only how homelesshess complicates treatment but how burdens are placed on various parts of the social system and on the homeless persons themselves. Because he lacked any form of health insurance, Samuel Anderson did not receive rehabilitation therapy for his right hand, and as a result developed stiffness and had significant loss of fine and gross motor skills; he had to apply for permanent disability benefits. Doris Foy was admitted to the hospital, because the treatment for her leg ulcers, which consisted of elevating her leg and taking prescribed antibiotics, is impossible for a homeless patient. Not only does her hospital stay make a bed unavailable for someone else who might possibly be in more serious need of inpatient treatment, but it also means that the hospital will not be reimbursed for her treatment because under the present system of utilization review, cellulitis with leg ulcers is judged to be treatable on an outpatient basis, and therefore, inpatient treatment for this condition may not be covered by Medicaid.

General Health Problems of Homeless Adults

Although homeless people are susceptible to the same range of diseases that occurs in the general population, the conditions discussed below appear to be especially prevalent among homeless people. Tables 3-1 through 3-6 delineate the prevalence of various acute, chronic, and infectious diseases among homeless people. A section providing a key to the abbreviations and some other explanatory notes follows the text (pp. 69-71). These tables were developed by the Social and Demographic Research Institute (SADRI) of the University of Massachusetts, Amherst, and are based on the reports from 16 of the Johnson-Pew Health Care for the Homeless (HCH) projects during their first year of full operation (Wright et al., 1987b). The prevalence rates are given both for the total number of people seen and for those seen more than once (Tables 3-1, 3-3, and 3-5). This group of tables is divided further by sex, ethnic group, and age (Tables 3-2, 3-4, and 3-6). The comparable prevalence rates for the domiciled general population are available from the National Ambulatory Medical Care Survey (NAMCS) of 1979, a study of a random sample of adult patients' visits to doctors' offices throughout the United States conducted by the U.S. Department of Health and Human Services (1979). It should be noted that the SADRI data are for homeless people who sought health care from facilities available to them; therefore, they may not be truly representative of all homeless people. Because the NAMCS figures are derived from doctors' offices-not hospital emergency rooms, clinics, outpatient departments, and so on-the sample is not weighted for people in the lowest socioeconomic groups. The two data sets also differ in age, gender, and ethnicity (older white women were more commonly involved in the NAMCS data, whereas nonwhite men were more prominent in the SADRI data). Although comparisons between these figures are inexact, they do provide general measures of the severity and frequency of certain medical conditions seen among the homeless as compared with those among the general patient population seen in doctors' offices.

Traumatic Disorders

Contusions, lacerations, sprains, bruises, and superficial burns are more commonly reported in the homeless population (TRAUMA in Tables 3-1 and 3-2). Results of a 1983 study indicated that approximately 30 percent of 524 homeless people treated in San Francisco over a 6-month period presented because of trauma-related injuries (Kelly, 1985). Homeless people are at high risk for traumatic injuries for a number of reasons. They are frequently victims of violent crimes such as rape, assault, and attempted robbery. In addition, primitive living conditions result in unusual risks; for example, the use of open fires for warmth predisposes them to potential burns.

Most of the findings in the literature, including those from the national HCH program, describe inner city homeless people. It is not known whether these observations can be extrapolated to the homeless people in rural areas. For example, during visits to rural areas of Alabama and Mississippi, committee members commented on the relative infrequency of traumatic disorders.

Disorders of Skin and Blood Vessels

Pustular skin lesions secondary to insect bites and other infestations are common among homeless people (SERSKIN in Tables 3-1 and 3-2). In addition, venous stasis of the lower extremities (i.e., poor circulation because of varicose veins) caused by prolonged periods of sitting or sleeping with the legs down predisposes homeless people to dependent edema (swelling of the feet and legs), cellulitis, and skin ulcerations. Although there is reason to speculate that venous valve incompetence would develop more frequently in homeless patients and lead to chronic phlebitis, data are meager. The term "peripheral vascular disease" (PVD in Tables 3-3 and 3-4) is frequently used to connote venous stasis; there is no clear evidence that arterial vascular disease is more prevalent in this population than in a nonhomeless population. Recurrent dermatitis (MINSKIN in Tables 3-1 and 3-2), which is possibly related to inadequate opportunities to bathe or shower and which is associated with infestations with lice and scabies, is prevalent among the homeless population. This form of dermatitis is frequently confused with bacterial cellulitis, since they both present with red, warm, tender skin lesions. This confusion may lead to inappropriate management. Moreover, homeless people do have an increased frequency of bacterial cellulitis and other pustular skin lesions. Finally, homeless people are at high risk of developing subcu-Collecting taneous abscesses, but this may be related in part to an increased prevalence of needle-stick infections from drug abuse.

Respiratory Illnesses

Acute nonspecific respiratory diseases (MINURI and SERRI in Tables 3-1 and 3-2) are commonly reported in populations of homeless people in shelters. Living in groups, crowding, environmental stresses, and poor nutrition may predispose homeless people to infections of the upper respiratory tract and lungs.

Tuberculosis has become a major health problem among homeless people (TB in Tables 3-5 and 3-6). Characteristically, this has been a disease associated with exposure, poor diet, alcoholism, and other illnesses that can lead to decreased resistance in the host. Substance abusers and the elderly are at high risk for developing tuberculosis. Immigrants from Third World countries also have an increased risk of infection (U. S. Department of Health and Human Services, 1980; Brickner et al., 1985). In a study of tuberculosis among homeless people in New York City in 1980 (Sherman, 1980), based on tuberculin skin test reactivity and subsequent case findings, 191 people were initially screened. Of these, 98 had positive skin tests and 13 had positive sputum cultures for Mycobacterium tuberculosis. Forty-four required either prophylaxis or treatment according to recommendations of the American Thoracic Society. Compared with nonhomeless populations, these homeless individuals had a very high frequency of skin test reactivity and positive cultures. Whether homelesshess alone led to the high prevalence of tuberculosis or whether multiple other predisposing factors were equally important is not obvious from the results of this single study. However, other studies performed in New York City and Boston between 1982 and 1986 confirm earlier observations and support the findings that homeless people have a greater prevalence of tuberculosis (Glickman, 1984; Centers for Disease Control, 1985; Barry et al., 1986; Brickner et al., 1986; Narde et al., 1986). Because tuberculosis is spread by personal contact, these infections pose a potential public health problem to occupants of shelters and to the general population.

Chronic Diseases

The proportion of adults seen more than once in the HCH clinics who suffer from various chronic illnesses (e.g., hypertension, diabetes, and chronic obstructive pulmonary disease) is high-41 percent-compared with 25 percent in domiciled outpatients described in the NAMCS data (Tables 3-3 and 3-4). The high prevalence of hypertension can be explained partially by age, race, and alcohol consumption; but homelessness makes the long-term dietary and pharmacological management of hypertension extremely difficult.

Similarly, compliance with recommended treatment regimens for cardiovascular and renal diseases, as well as metabolic disorders such as diabetes, is notoriously difficult for homeless people. For these reasons, many homeless people are referred to hospitals for inpatient care for the treatment of disorders that in nonhomeless people could be managed on an Outpatient basis.

Miscellaneous Health Problems

Foot problems occur with a greater frequency among homeless people. These include superficial fungal infections and calluses, corns, and bunions that are apparently the result of trauma from ill-fitting shoes. Homeless people suffer from many dental problems. Reports of poor oral hygiene, cavities, gingival disease, and extractions with no prosthetic replacements appear to be extremely common among homeless people (TEETH in Tables 3-3 and 3-4). These problems are also common among indigent patients in general who have limited or no access to dental care. Finally, various illnesses associated with increased mortality are related to environmental exposure, such as hypothermia and frostbite or hyperthermia (Olin, 1966; Brickner et al., 1972; Alstrom et al., 1975). These life-threatening problems are especially prevalent among alcoholic homeless people and those who abuse other drugs.

Mental Illness, Alcoholism, Drug Abuse, and Comorbidity of Homeless Adults

Mental Disorders

Many homeless adults suffer from chronic and severe mental illness. The visibility of mentally ill people has led to the creation of a stereotype for the entire homeless population; the earlier stereotype of the homeless alcoholic has been replaced in recent years with that of the mentally ill homeless person (Stark, 1985, 1987). One of the first reports describing the high prevalence of mental illness among the homeless appeared in 1978, when Reich and Segal wrote about the Bowery in New York as a "psychiatric dumping ground." They asserted that large numbers of psychiatric patients were being discharged from the mental hospitals and ending up on the streets, a theme that has since been echoed widely in the media and professional literature.

Not only can homelessness be a consequence of mental illness, but a homeless life may cause and perpetuate emotional problems. To sort out these variables, it is necessary to distinguish among the various categories of psychiatric disorders. The major mental illnesses, principally schizophrenia and the affective disorders (bipolar and major depressive disorders), are unlikely to result from the trauma of homelessness. Rather, they cause a level of disability and impaired social functioning in some people that, in the absence of adequate treatment and support, may lead to homelessness, which will then exacerbate these conditions (Fischer and Breakey, 1986).

Personality disorders are not considered "major" mental illnesses because reality awareness is maintained; nevertheless, these disorders are manifested by a person's long-standing inability to deal with the routine demands of living (e.g., as a parent, worker, or independent citizen). Deeply ingrained maladaptive behavior patterns, which usually begin during childhood or adolescence, interfere with a person's capacity to relate to others, limit a person's potential, and often provoke counterreactions from the environment. Personality disorders should not be seen primarily as a consequence of homelessness. Rather, because they impair a person's ability to cope with the demands of life and the expectations of society, they may contribute to the factors that cause certain people to become homeless.

Other psychiatric illnesses, such as the anxiety and phobic disorders and milder depressive reactions, can either be contributing factors in causing homelesshess or, more commonly, result from the stress of homelesshess. Becoming homeless is a psychologically traumatic event that commonly is accompanied by symptoms of anxiety and depression, sleeplessness, and loss of appetite. Sometimes, homeless people try to "medicate" these feelings away with alcohol or drugs.

Dementia is a progressive deterioration of mental faculties resulting from degenerative brain disorders, such as Alzheimer's disease; recently, it has been observed among some people with AIDS. It can also be caused by repeated small cerebral hemorrhages or traumas from diseases such as untreated hypertension or uncontrolled epilepsy; it is also a relatively common consequence of chronic alcoholism. Certain types of dementia, therefore, would be expected to occur more commonly in homeless people.

In interpreting research data on the psychiatric disorders suffered by homeless people, distinctions among the different diagnostic categories are important. Crude data, such as a history of psychiatric hospitalization (see Table 3-7), are of limited value in defining the prevalence of psychiatric disorders or in predicting needs for mental health services. Estimates of the prevalence of current major mental illness range from 25 to 50 percent of individual homeless adults (Bachrach, 1984). The most frequently reported figure-both in the literature and in the committee's site visits- was approximately one-third. In addition, during those site visits, members of the committee occasionally received reports of homeless people who manifested symptoms that might indicate the presence of mental retardation or other developmental disabilities. However, no studies of this problem could be located, so it is impossible to identify the extent to which mental retardation is present among homeless people.

Some researchers have used screening instruments, such as the Brief Symptom Inventory, the General Health Questionnaire, or the Center for Epidemiological Studies Depression Scale, to measure psychiatric disorders among the homeless. These include studies done in St. Louis (Morse, 1986) and Detroit (Mowbray et al., 1985) and one statewide sample of Ohio (Roth et al., 1985). Invariably, authors who use these instruments report rates of psychological distress in homeless people that are higher than those found in other population groups. These screening instruments provide nonspecific measures of psychological distress and not diagnosis. They are therefore of limited value in describing the nature of mental health problems and predicting the needs of homeless people for services.

Several studies have sought to clinically examine homeless individual adults in shelters (see Table 3-8). Two recent studies reported a high prevalence of substance abuse (alcohol and other drugs) and major psychiatric disorders among this population. Arce et al. (1983) examined homeless people in Philadelphia and diagnosed major mental illness in 40 percent of those studied. When substance abuse, personality disorders, and organic disorders were included among the diagnoses, the figure rose to 78 percent of those studied. Bassuk et al. (1984), in a similar study in Boston, reported major mental illnesses (mania, depression, schizophrenia) among 39 percent of those studied; when substance abuse and personality disorders were included among the diagnoses, the figure rose to 90 percent.

Reports of findings such as these have stimulated strong criticisms in some circles. Some critics object to emphasizing the psychopathology of homeless people as an explanation for their homelessness, noting that failure to provide community-based care and appropriate housing are the crucial factors; they are concerned about "blaming the victim" instead of focusing public attention on the societal problems and political choices that are responsible for the increase in homelessness. Methodological critics point to the lack of standardized clinical diagnostic methods and samples restricted to a single shelter, so that the subjects may not represent the overall homeless population.

One study that addresses both methodological objections is that of Farr et al. (1986), who interviewed a sample of homeless men from various settings in the skid row area of Los Angeles. Trained interviewers, using the diagnostic interview schedule developed for the National Institute of Mental Health (NIMH) (Robins et al., 1984), gathered data on 379 subjects. By this method they determined that at the time of the examination, 60 percent of the homeless men met the criteria for one or more current (within the past 6 months) mental disorders or substance abuse disorders. Of the total sample, 11.5 percent met the diagnostic criteria for schizophrenia, 20 percent met the criteria for major affective disorders, and 3 percent displayed severe cognitive impairment suggestive of dementia; 17 percent met the criteria for antisocial personality disorder, and 31 percent apparently abused alcohol or other drugs. Many respondents met the criteria for the diagnosis of more than one type of serious disorder. When added together, the total percentage of homeless people who apparently suffer from any mental illness or substance abuse problem was 83 percent, a figure similar to those found in the studies by Arce et al. (1983) and Bassuk et al. (1984). Several years earlier, using the same diagnostic method, a randomly selected sample of domiciled people in Los Angeles was surveyed as part of the NIMH Epidemiological Catchment Area (ECA) program (Regier et al., 1984). Farr and colleagues (1986) found that, compared with domiciled men in the catchment area study, homeless people were given a current diagnosis of schizophrenia 38 times more frequently, major affective disorders 4 times more frequently, antisocial personality disorders 13 times more frequently, dementia 3 times more frequently, and substance abuse disorders 3 times more frequently.

A study of men at a mission shelter in Baltimore also used the diagnostic interview schedule (Fischer et al., 1986). As in Los Angeles, data from an ECA program sample of a domiciled population were available for comparison. Disorders in all categories occurred with greater frequencies in the 51 homeless men. Overall, 24 of the men (47 percent) had some current (within 6 months) mental or substance abuse disorder; 4 percent of the total sample suffered from major mental illnesses, and 20 percent suffered from alcohol or drug abuse problems. Using virtually identical standardized diagnostic procedures-but very different sample populations-these two 1986 studies (Farr et al. and Fischer et al.) demonstrated a high overall prevalence of psychiatric disorders in homeless men. It is not clear why the prevalence of specific major mental illnesses (schizophrenia, major affective disorder) was so much lower in the sample of Baltimore mission users compared with that in the sample of homeless people studied in Los Angeles-and elsewhere ( Table 3-8). Differences in sampling strategy are the most likely explanation.

Although there is a substantial proportion of women in the homeless population, there are no data on the psychiatric diagnoses of randomly sampled homeless adult women. There is an impression, however, supported by nonspecific indicators of mental health status, that larger proportions of individual homeless women than homeless men are mentally disturbed. Researchers in New York City's shelter system (Crystal and Goldstein, 1984) reported that indicators of psychiatric disorder, such as history of hospitalization or current symptoms, were reported by 37 percent of women but by only 21 percent of men. Similar findings have been reported for homeless people from Milwaukee, Phoenix, and Boston (Brown et. al., 1983; Rosnow et al., 1985; Schutt and Garrett, 1986). Unless a woman has a very severe mental disorder, it is probably easier for her to remain within the family network or, failing that, to find some kind of housing. Therefore, it may be the more dysfunctional, alienated, or disorganized woman who becomes homeless.

Women who are heads of households and who are homeless with their children represent a segment of the homeless population that is growing both in numbers and in proportion. These women have a markedly different psychiatric profile than individual homeless adult women. Bassuk and colleagues (1986) have examined homeless mothers with families in approximately two-thirds of the family shelters in Massachusetts. Substance abuse was relatively rare, but this may be an underestimate since the study was limited to shelters and did not include hotels and motels. Of the mothers, 3 percent were schizophrenic, major affective disorders were found in 10 percent, and personality disorders were diagnosed in 71 percent. The children manifested considerable emotional and intellectual impairment. The authors stressed that measures to help such families, if they are successful, must attend to these psychiatric issues.

Clinicians who work with homeless people in primary health care clinics confirm the high frequency of psychiatric disorders in their patients. Brickner and coworkers (1985), in listing the common health problems encountered in a primary care program serving homeless people in shelters in New York City, placed alcoholism and then psychiatric disorders at the top of the list. The Health Care for the Homeless program's service data, pooled from sites in major cities across the country, show that, whatever the presenting problem, the primary care practitioners also frequently observed a mental or emotional disorder. The authors estimated that 30 to 40 percent of patients have psychiatric disorders (Wright and Weber, 1987). Clinicians were twice as likely to record a psychiatric diagnosis in white patients than in black or Hispanic patients. There was also a higher prevalence of almost every category of physical illness in patients with psychiatric diagnoses than in those without.

Mental disorders are very frequent in homeless populations generally and among homeless people who seek health care. In both groups mental disorders are found that can be considered both a cause and a consequence of homelessness.

Clinical Problems in Providing Mental Health Care for the Homeless

The central problem for homeless people with mental illnesses is the lack of community-based treatment facilities and adequate housing. In addition, the special characteristics of this patient group present particular challenges for treatment. These patients often have already had negative experiences with mental health care, often in understaffed, underfunded institutions, and are determined not to accept further treatment. Some have had unpleasant adverse reactions to antipsychotic medications or remember having been abused in the mental health care system; some homeless people lack insight into the reality of their illness and their need for ongoing treatment, but others who are aware of their problems simply do not believe that they will receive appropriate treatment if they accept an offer of care. In most cases, they lack the support of friends or family, are suspicious of authority figures (including providers of treatment), and are slow to develop a trusting therapeutic relationship. As is the case with the homeless in general, their material resources and access to public support programs are extremely limited (see Chapter 4).

From the perspective of mental health service providers, homeless patients are often perceived as less desirable or less rewarding. They may be slow to accept a therapist's sincere efforts to help, but quick to express their negative feelings about the mental health service system. A therapist may be frustrated by failures of homeless patients to keep appointments; and clinics may be unwelcoming to dirty, disheveled, or disorganized patients who frighten away others.

The treatment and rehabilitation of a severely mentally ill homeless person requires the marshaling of major financial and professional resources. Treatment requires enormous patience; considerable clinical skill; and the capacity to mobilize an array of treatment, residential, and rehabilitation resources to meet the needs of a particular patient (Breakey, 1987).

Although ambulatory treatment for mentally ill patients is preferred in most cases, hospital admission may be necessary for treating some patients with severely distressing and disabling symptoms, or for the protection of others if a person is violent. Psychiatric treatment providers are frequently frustrated in their efforts to help the most severely disturbed because of the lack of access to inpatient treatment facilities. The committee received reports from several cities and states that stated that because the supply of psychiatric beds is limited, some poor patients have great difficulty gaining access to voluntary inpatient care; occasionally there may even be a waiting period of several days at a public hospital for emergency involuntary psychiatric admission.

Consent for outpatient or inpatient treatment often can be obtained from a homeless patient relatively easily. For hospital care, voluntary admission is greatly preferred over involuntary commitment and facilitates the development of a constructive doctor-patient relationship. When a patient is unwilling to accept treatment but is clearly dangerous to himor herself or others, civil commitment procedures are available. However, problems arise when a patient is ill and behaves in a manner that is self-jeopardizing or is offensive, embarrassing, or frightening to others. Because these people are not unequivocally dangerous to themselves or others, they cannot be involuntarily committed.

Another problem confronting clinicians is a person who is neither offensive not dangerous but who is resistant to treatment because of delusions arising from the mental illness itself. Mental health workers may believe that medication and supportive care could substantially help a mentally ill person cope, but the patient is legally entitled to refuse treatment.

Mentally ill homeless people have attracted considerable attention from the news media. One of a series of articles in The New York Times in late 1986 called attention to a successful new approach to outreach, treatment, and rehabilitation (Goleman, 1986). The program was described by the journalist as "a partnership between modern psychiatry and older humanitarian traditions." Its various elements-persistent outreach, medication, professionally supervised supportive housing, disability benefits, preparation for employment, and so forth-certainly seem to have helped "Timothy":

A Year on the Road Back

Jan. 23, 1985. Mental health workers find Timothy huddled in a pile of garbage in a stairwell on West 68th Street. He says the Mafia is after him and laughs oddly. From his confused account, it appears that he has been hiding in garbage for at least two months. He resists efforts to move him to a shelter, preferring the stairwell.

March 4. After several false starts, Timothy is finally brought into the office of Project Reachout for treatment. One drug, then another is tried. He is put on a regimen of Prolixin, an anti-psychotic drug that diminishes agitation and delusions.

March 11. Meanwhile, a psychiatrist records improvement in Timothy's mental condition; his thinking is clearer, he is more alert, feeling better about himself. The patient starts to take showers.

March 19. For the first time, Timothy expresses interest in washing his clothes.

April 10. He agrees to leave the stairwell behind, accepting a tiny hotel room from the project.

May 19. He starts working in the kitchen at Fountain House, an organization that helps chronic schizophrenics to take part in society again.

Sept. 10. After project workers apply in his behalf, he receives his first Government disability payment.

Sept. 25. He begins work as a messenger at Manufacturers Hanover Trust bank offices. A project worker initially accompanies him to take over if he fails.

Oct. 29. He moves into a room of his own at the St. Francis Residence. There is a cable hookup for the color television he hopes to get. The room is newly painted. On the floor by the closet is a blue plastic bucket containing three pairs of filthy shoes and six umbrellas, mementos of his street days.

Alcoholism and Alcohol Abuse

In whatever setting homeless adults are studied, alcoholism is the most frequent single disorder diagnosed. (The exception is women who are homeless with their families.) Severe and intractable alcohol disorders have historically been thought to be especially prevalent among homeless people. Early accounts often attributed the high frequency of alcohol problems among homeless men to their inherent shiftlessness and failure to obtain gainful employment. Anderson (1923) asserted that "practically all homeless men drink when liquor is available. The only sober moments for many hoboes and tramps are when they are without funds." In 1946, Straus used prevalence figures from the studies that were available then and estimated that, overall, 80 percent of homeless men could be considered alcoholic. More recent studies, however, suggest that this perception may be stereotypical rather than real. It is now estimated that approximately 25 to 40 percent of homeless men suffer from serious alcohol problems, and that this level has been reasonably consistent over time (Mulkern and Spence, 1984; Stark, 1987; Schutt and Garrett, in press). This is nevertheless a high figure when compared with that in the general population, in which the most frequently reported figures are 11 to 15 percent for men and 2 to 4 percent for women. The prevalence of alcoholism for domiciled adults in the epidemiological catchment areas studied by NIMH is 12 percent for men and 2 percent for women (J. E. Heizer, Department of Psychiatry, Washington University School of Medicine, personal communication, 1988).

The emergence of a new homeless population further calls into question the meaning of previous findings. Current descriptive studies reveal a population that is younger and more heterogeneous than skid row populations. It includes (1) higher proportions of women and minority group members, such as blacks and Hispanics; (2) alarming numbers of families with young children; and (3) an increased proportion of people with mental illnesses and histories of drug abuse. Despite these changes, serious alcohol problems are common among homeless adults and remain important in understanding this population (see Table 3-9).

Current studies also document the fact that homeless people with alcohol problems are more often physically disabled than homeless people without such problems. As a consequence, they are more likely to use health care services (Fischer, 1987; Fisher and Breakey, 1987; Koegel and Burnam, 1987a,b). Wright and Weber (1987) have identified specific disorders that occur more frequently among homeless alcoholics than other homeless people; these include acute disorders, such as trauma, serious skin problems, and severe upper respiratory infections, along with chronic disorders such as cardiac disease, hypertension, and active tuberculosis.

What is the relationship between homelessness and serious alcohol problems? Observers have indicated that many homeless adult individuals who suffer from alcoholism and alcohol abuse are undomiciled to begin with because of their drinking. In a study of homeless male alcoholics in Baltimore, 59 percent reported that drinking caused them to become homeless (Fischer and Breakey, 1987). Others may have become "environmental alcohol abusers" (Shandler and Shipley, 1987), adapting to a homeless subculture that encourages drinking. For homeless individuals, drinking is often seen as the way to make it through a day (Morgan et al., 1985) or to forget failure (Wiseman, 1987).

In the past, many alcoholics lived in SRO housing. For example, a 1979 study of 2,110 SRO housing residents in New York City indicated that 25 percent were alcoholics (Kasnitz, 1984). With the decline in the number of SRO units nationwide (see Chapter 2), many alcoholic single men and women have become homeless. Today many of the country's emergency shelters will not accept anyone who has been drinking. Instead, many homeless alcohol abusers sleep on the streets.

In sum, the causal relationships between problems with alcohol and homelessness are complex, and precise knowledge of them may not be possible or even as therapeutically relevant as one might hope. There is a large general literature on treating people who have problems with alcohol, even though the scientific evaluation of treatment in this area is relatively recent. Effective approaches to this population might have to include several elements, for example, detoxification, convalescence, and entry into specialized alcohol-free living environments combined with supportive treatment programs.

Detoxification is the indispensable first step in treatment; access to detoxification needs to be widely and readily available. Experience suggests that many people entering detoxification facilities will progress no further, and that a small number of people account for the majority of admissions. It is not always possible, however, to predict who will progress further with treatment; a common clinical experience is that, after multiple short-term admissions, some people elect to continue, and eventually they achieve genuine gains.

In recent years disagreement has arisen over the optimal structure of detoxification programs. Traditionally, detoxification has been undertaken in an inpatient medical setting. More recently, nonmedical detoxification programs have arisen (see, e.g., Annis et al., 1976). The latter have attracted much attention because of their markedly lower cost and reportedly equivalent effectiveness (McGovern, 1983). Ideally, a mixture of both would be available. There is little doubt that many people seeking detoxification can be handled in a nonmedical program (Shaw et al., 1981). However, withdrawal from alcohol in people with serious concurrent medical or psychiatric disorders is best undertaken in a hospital setting; many homeless people fall into this category.

After detoxification, some people are unable or unwilling to take advantage of the currently available rehabilitation alternatives, which at present require entry into a specialized alcohol treatment system. Some of these difficulties could be resolved if there were an intermediate stage in the treatment process between detoxification and specialized treatment (Blumberg et al., 1973; Shandler and Shipley, 1987). The goal of such a convalescent stage would be to facilitate complete recovery from the physical and mental ravages of the individual's last period of alcohol intake. A safe setting, perhaps best outside of, but closely connected to, a medical facility, could provide protection, adequate nutrition, rest, and an opportunity to assess the future realistically. Extended medical and psychiatric evaluations, which are problematic in detoxification settings, could be performed, and consequent therapeutic measures could be proposed.

Specialized treatment and active rehabilitation for alcohol-related problems are complex (a forthcoming Institute of Medicine study will explore this subject in detail). Some homeless people with alcohol-related problems may eventually enroll in specialized treatment. However, access to such specialized treatment is far from universal, and the shortage of facilities is serious. Furthermore, there is an extreme shortage of the specialized housing arrangements that are needed to support rehabilitation efforts. Residential opportunities are essential to enable the alcoholic homeless person to get away from the streets, where inducements to resume drinking are ever present.

Illnesses Associated with Abuse of Drugs Other Than Alcohol

There are few concrete data describing the extent of drug abuse among homeless individuals. Most studies about the homeless combine alcohol and drug abuse together under the heading of substance abuse. Those that separate the two provide some minimal information about illicit drug use. Estimates of homeless individual adults with drug problems range from a low of 10 percent reported by users of Johnson-Pew clinics nationwide (Wright and Weber, 1987) to 33.5 percent for individuals living in shelters and on the streets in Boston (Mulkern and Spence, 1984) (see Table 3-10).

Data from the Johnson-Pew HCH projects in 16 cities show that age, ethnicity, and drug abuse are correlated (Wright, 1987). The strongest correlate of drug abuse is age. As with the general domiciled population, rates of illicit drug abuse are highest among younger HCH clients and fall off with increasing age, especially after the age of 50. This is almost the opposite of alcohol abuse, which is found to be least prevalent among younger homeless people.

One of the problems associated with drug abuse is AIDS and AIDS related complex (AIDS/ARC in Tables 3-5 and 3-6). Whether this is more commonly encountered among homeless people who abuse drugs compared with the remainder of the drug-abusing population is not clear. Nevertheless, as the clinical syndromes associated with AIDS increase in the general population, especially among those who abuse parenteral drugs, it will be an increasing problem among the homeless as well.

Working from a series of assumptions and data from the 16 cities of the Johnson-Pew HCH projects, Wright and Weber estimated the prevalence of AIDS and AIDS-related complex at about 185 per 100,000 homeless persons in those cities. Meaningful comparisons to the rates of AIDS in each of those urban centers are not available, but one reference point is the rate for the U.S. population as a whole, viz. approximately 144 per 100,000 in 1986 (Wright and Weber, 1987).

Other illnesses more commonly encountered in patients who abuse parenteral drugs are hepatitis, skin infections, abscesses, thrombophlebitis, bacterial endocarditis, and tuberculosis. Other, more exotic infections that are not frequent in the United States are more common among drug abusers, such as malaria, which can be transmitted among patients who share needles. SADRI specially analyzed its main data base, which consisted of all clients with two or more visits who abused drugs, and found that some disorders were more common among drug abusers than among non-drug abusers. To some extent, however, the differences could be ascribed to various demographic characteristics, specifically, age and the presence of other disorders such as alcohol abuse or mental illness. Using this series of multivariant analyses, which controlled statistically for age, sex, ethnicity, and family status and for alcohol abuse and mental illness, the following disorders were found more commonly among homeless people who were drug abusers: AIDS, liver disease, cardiac disease, peripheral venous stasis disease, and chronic disorders such as diabetes and diseases of the liver and genitourinary tract. Although the exact relationship between homelessness and drug abuse and these illnesses is unclear, most of the findings are not surprising. AIDS and liver disease, for example, are associated with an increased frequency of hepatitis exposure among drug abusers.

Comorbidity

Finally, a point must be made about the comorbidity caused by mental illness, alcoholism and alcohol abuse, and illicit drug abuse. There is a growing concern among those who work with homeless people about clients with dual and multiple diagnoses (further exacerbated by a higher prevalence of many acute and chronic physical illnesses). For example, the HCH data point to correlations among drug abuse, alcohol abuse, and mental illness. Among drug abusers, 42 percent of the men and 41 percent of the women who visited HCH projects and gave evidence of that diagnosis could also be classified as mentally ill; 59 percent of the male clients and 46 percent of the female clients who abused drugs also evidenced a problem with alcohol (Wright, 1987). In another recent study drawn from a broad geographic base, the Veterans Administration Homeless Chronically Mentally Ill program reported that of the homeless for whom evaluations were performed, 32 percent had combined diagnoses of alcohol and drug abuse. Sixty-four percent had been hospitalized for any treatment for mental illness, alcoholism, or drug abuse. Because this latter figure is less than the sum of the prevalence rates for homeless veterans seen for each diagnosis (33 percent reported being hospitalized for psychiatric illness, 44 percent for alcoholism, and 14 percent for drug abuse), it appears that many of these hospitalizations were for dual or multiple diagnoses (Rosenheck et al., 1987).

There are two major problems that relate specifically to homeless people with multiple diagnoses. During the site visits, it was repeatedly emphasized to the committee members by those who work with the homeless that homeless people with dual and multiple diagnoses are among the most difficult to entice into treatment. Second, when outreach efforts are successful, there often are no appropriate programs into which such homeless people can be enrolled. Each separate diagnosis correlates to a specific treatment modality and treatment system. These programs frequently exclude those with secondary and tertiary diagnoses of other illnesses. It is rare to find programs that will address a combination of diagnoses on other than the most episodic of terms.

Health Problems of Homeless Families, Children, and Youths

Perhaps the most distressing and dramatic health problems caused by homelesshess are those experienced by homeless families with children. Although the adult members of homeless families appear to be in better health than homeless single adults, they are still in poorer health than the general population. Using data from the HCH projects in 16 cities, Wright and Weber (1987) described 1,417 adult family members who were seeking health care; they represented 15 percent of the total adult population of the 16 programs. The authors concluded that in comparison with the NAMCS population, ''homeless adult family members are . . . much more ill on virtually all indicators than the general ambulatory population." With regard to a specific subpopulation of homeless adults in families, the Coalition for the Homeless (1985) has identified the following problems among homeless pregnant women: lack of prenatal care, poor nutrition, and low birth weight of the infants. In a study comparing homeless women living in New York City welfare hotels with women living in low-income housing projects, Chavkin et al. (1987), using data drawn from birth certificates for single births, determined that pregnant homeless women were more likely not to receive prenatal care, were more likely to have babies of low birth weight, and had higher infant mortality rates. With regard to mental illness, although many homeless mothers have emotional problems, most do not suffer from a major mental illness (e.g., schizophrenia). Furthermore, in contrast to adult homeless individuals, a relatively small percentage of homeless mothers had ever been hospitalized for psychiatric reasons (Bassuk et al., 1986).

Wright and Weber (1987) found that various chronic physical disorders are nearly twice as common among homeless children as among ambulatory children in the general population. Illnesses such as anemia, malnutrition, and refractory asthma were many times more common among homeless children. Acker et al. (1987) concluded that more than 50 percent of homeless children had immunization delays. Although there is no precise information indicating that homeless children are more vulnerable to contracting such illnesses as diphtheria, tetanus, measles, or polio, existing epidemiologic data suggest that they are a high-risk group. Using data from the HCH projects, Wright and Weber (1987) reported that the rate of chronic physical disorders is nearly twice that observed among the children in the NAMCS population in general. Whether geographic mobility and residential instability will make these children a greater health risk to the general population is unknown, but it is a potential public health problem of concern.

While access to food-or, more appropriately, adequate and appropriate nutrition-is a problem for homeless people of all ages, it is an especially critical issue for children and youths. Many welfare hotels where homeless families reside do not provide cooking facilities or refrigerators:

For a hot meal, families must either violate safety codes by "smuggling" a hot plate into their room or use the little money they have to eat in a restaurant. This means that families usually rely on canned goods, dry cereals and other non-perishable items for nourishment. Lack of refrigeration is particularly problematic for mothers with infants who must devise other methods for keeping milk or formula cold, such as using toilet tanks as coolers. (Gallagher, 1986)

Acker et al. (1987) compared 98 children up to 12 years old who were living in New York City welfare hotels with 253 domiciled poor children who presented at the Bellevue Hospital pediatric outpatient clinics. Homeless children between the ages of 6 months and 2 years were at higher risk for iron deficiency, leading the authors to conclude that "this may indicate the presence of other nutritional deficiencies and should be the subject of further investigation."

In addition to physical health problems, homeless children appear to suffer greater emotional and developmental problems. Kronenfeld and colleagues (1980), in their report on children living at the Urban Family Center, a residential facility for homeless families on public assistance in New York City, found that homeless children were having serious problems in school. Children living in this facility were usually 2 or more years behind their age-appropriate grade level in reading and mathematics, often had discipline problems, and were frequently truant.

Bassuk and colleagues (1986, 1987, 1988) described serious developmental, emotional, and learning problems in a population of homeless children residing in family shelters in Massachusetts. They reported that of the preschoolers tested on the Denver Developmental Screening Test, 47 percent manifested serious developmental delays in at least one of the four areas tested (language skills, gross motor skills, fine motor coordination, and personal/social development). One-third of the children manifested more than two developmental lags. In this study, the schoolage children were depressed and anxious; half of them required further psychiatric evaluation. Many had severe learning difficulties: 43 percent had already failed to complete a grade and 25 percent were in special classes. It is difficult to determine the extent to which homelessness per se was the principal variable accounting for each of these findings, but a comparison to poor, domiciled children documented that homelessness makes a major contribution (Bassuk and Rosenberg, 1988).

With regard to homeless youths and adolescents, Wright and Weber (1987) reported that substance abuse, sexually transmitted diseases, and pregnancy were more prevalent among the homeless adolescents seen in the HCH projects than among the same age group in the domiciled population reported in the NAMCS study. The three studies on runaway and throwaway youths discussed in Chapter 1 (Shaffer and Caton, 1984; Greater Boston Adolescent Emergency Network, 1985; Janus et al., 1987), while not specifically examining the general health of this population, reported that the youths that they interviewed were not in poorer health than adolescents in general. However, as with the HCH project population, the major exceptions were pregnancy and sexually transmitted diseases. Both sets of findings might be attributed to the fact that these teenagers tend to be more sexually active at a younger age, even prior to becoming homeless. Given that AIDS is a disease that can be transmitted through sexual contact, the staff of the Larkin Street Youth Center in San Francisco expressed serious concern to the committee members during the site visit to that facility that AIDS may spread among runaway youths.

Summary

Homeless people experience a wide range of illnesses and injuries to an extent that is much greater than that experienced by the population as a whole. First of all, health problems themselves, directly or indirectly, may cause or contribute to a person's becoming or remaining homeless. The leading example is major mental illness, especially schizophrenia, in the absence of treatment facilities and supportive housing arrangements. Second, the condition of homelessness and the exigencies of life of a homeless person may cause and exacerbate a wide range of health problems. Just as ill health can cause homelessness, so can homelessness cause ill health. Examples of this include skin disorders and the sequelae of a traumatic injury. Finally, the state of being homeless makes the treatment and management of most illnesses more difficult even if services are available. Examples of this can be found for alcoholism and nearly any chronic illness, such as diabetes or hypertension. As with all other aspects of the problems of homeless people, data on their health problems and health care needs are partial, fragmentary, and incomplete. Still, enough is known about the health problems of homeless people to provide basic descriptive information and draw inferences for the purposes of programmatic intervention.

Key to Abbreviations and Explanatory Notes for Tables 3-1 to 3-6

The data in the tables indicate the percentage of the various subgroups within the client population who have been diagnosed with the various disorders listed. Thus, in Table 3-1, 23.6 percent of all adult clients ever seen (in 16 cities through the end of June 1986; N = 23,745 adult clients) have had a minor upper respiratory infection. Among clients (same cities and time frame) seen more than once ( N = 11,886), the percentage with a minor upper respiratory infection is 33.2 percent, and so on through the tables. The rates of occurrence are given for adult clients only in 16 cities and are for the total number of people seen and for those seen more than once. This latter group is then divided further by sex, ethnic group, and age. In all tables, "NA" indicates that the data are not available at this time.

In Tables 3-2, 3-4, and 3-6, age groups are as follows: I = 16-29; II = 30-49; III = 50-64; IV = 64+. The last (rightmost) columns of numbers in Tables 3-2, 3-4, and 3-6 show the data for adult respondents in urban areas from the National Ambulatory Medical Care Survey (NAMCS) done in 1979 (U.S. Department of Health and Human Services, 1979).

Explanations or the abbreviations and terms used in Tables 3-1 to 3-6 are as follows:

INF

Infestational ailments (e.g., pediculosis, scabies, worms)

NUTDEF

Nutritional deficiencies (e.g., malnutrition, vitamin deficiencies)

MINURI

Minor upper respiratory infections (common colds and related symptoms)

SERRI

Serious respiratory infections not classified elsewhere (e.g., pneumonia, influenza, pleurisy)

MINSKIN

Minor skin ailments (e.g., sunburn, contact dermatitis, psoriasis, corns, calluses)

SERSKIN

Serious skin disorders (e.g., carbuncles, cellulitis, impetigo, abscesses)

SPR

Sprains and strains

BRU

Bruises, contusions

LAC

Lacerations, wounds

ABR

Superficial abrasions

BURN

Burns of all severity

ANYCHRO

Any chronic physical disorder

ENDO

Endocrinological disorders (e.g., goiter, thyroid, pancreas disease)

DIAB

Diabetes mellitus

ANEMIA

Anemia and related disorders of the blood

NEURO

Neurological disorders, not including seizures (e.g., Parkinson's disease, multiple sclerosis, migraine headaches, neuritis, neuropathies)

SEIZ

Seizure disorders (including epilepsy)

EYE

Disorders of the eyes (e.g., cataracts, glaucoma, decreased vision)

EAR

Disorders of the ears (e.g., otitis, deafness, cerumen impaction)

CARDIAC

Heart and circulatory disorders, not including hypertension and cerebrovascular accidents

CVA

Cerebrovascular accidents/stroke

COPD

Chronic obstructive pulmonary disease

GI

Gastrointestinal disorders (e.g., ulcers, gastritis, hernias)

TEETH

Dentition problems (predominantly caries)

LIVER

Liver diseases (e.g., cirrhosis, hepatitis, ascites, enlarged liver or spleen)

GENURI

General genitourinary problems common to either sex (e.g., kidney, bladder problems, incontinence)

MALEGU

Genitourinary problems found among men (e.g., penile disorders, testicular dysfunction, male infertility) (Note: Data on MALEGU shown in the table are for men only in all cases.

FEMGU

Genitourinary problems found among women (e.g., ovarian dysfunction, genital prolapse, menstrual disorders)

PREG

Pregnancies (Note: Data on FEMGU and PREG shown in the table are for women only in all cases.)

PVD

Peripheral vascular diseases

ARTHR

Arthritis and related problems

OTHMS

All musculoskeletal disorders other than arthritis

AIDS/ARC

Acquired immune deficiency syndrome, AIDS-related complex

TB

Active tuberculosis infection, any site

PROTB

Prophylactic anti-TB therapeutic regimen

ANYTB

Either TB or PROTB or both

VDUNS

Unspecified veneral disease, herpes

ANYSTD

VDUNS, SYMPH, or GONN, or any combination

INFPAR

Infectious and parasitic diseases (e.g., septicemia, amebiasis, diphtheria, tetanus)

ANYPH

AIDS, ANYTB, ANYSTD, INFPAR, SERURI, INF, or SERSKIN, or any combination of these

References

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1

Unless otherwise noted, all case studies in this chapter are drawn from a background paper prepared for this report, "Homelessness: A Medical Viewpoint," (Vicic and Doherty, 1987) by William Vicic, M.D., and Patricia Doherty, R.N., of St. Vincent's Hospital Medical Center, New York City. The names, of course, are fictitious; the circumstances and clinical details are real and are drawn from Dr. Vicic's and Ms. Doherty's professional experiences working with the homeless.

2

In several site visits, committee members heard repeated reference to the high prevalence of sexual assaults against homeless women. One shelter staff member commented: "It's not a question of whether a homeless woman will be raped, but simply a question of when."

3

Bassuk et al. (1986) pointed out that this is "a diagnosis of social dysfunction" and that such a diagnosis might exaggerate the degree of psychopathology in this population. It is best utilized as a measure of functional impairment and as an indication of the extent of the need for help.

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Homeless people are at relatively high risk for a broad range of acute and chronic illnesses. Precise data on the prevalence of specific illnesses among homeless people compared with those among nonhomeless people are difficult to obtain, but there is a body of information indicating that homelessness is associated with a number of physical and mental problems. This is evident not only in recent data from the Social and Demographic Research Institute but also in individual published reports in the medical literature.