The Journal for Nurse Practitioners
Volume 4, Issue 2 , Pages 109-113, February 2008

Mental Illness in Homeless Families

  • Roxanne Amerson

      Affiliations

    • Roxanne Amerson, MSN, RN, BC, is a lecturer in the School of Nursing at Clemson University. In conjunction with national ethical standards, the author reports no relationships with business or industry that represent a conflict of interest.

Article Outline

Abstract 

The article discusses the factors influencing mental illness in homeless families. High rates of domestic violence, substance abuse, depression, and poverty are identified as contributing factors. Social isolation and rejection by peers are commonly seen in children of homeless families. Nurse practitioners who provide health promotion, risk reduction strategies, and disease management in the community should adapt care interventions to take into account these contributing factors. Guidelines established by the National Health Care for the Homeless Council are used to adapt care for the unique needs of a homeless family at risk of or currently experiencing mental health issues.

Keywords:  Family care , guidelines for homeless care , homeless families , mental illness in the homeless

 

It is estimated that 800,000 persons are homeless every day with 200,000 of them being children.1 As much as 2.3 to 3.5 million persons are homeless at some point during an average year with approximately 33% of them being represented by families with children. The purpose of the article is to discuss the factors related to mental illness in homeless families. Understanding the mental health issues that are associated with this population is essential for nurse practitioners and health care workers who provide health promotion, risk reduction strategies, and disease management in the community. Health care interventions should be adapted to take into account the factors that lead to homelessness and the resulting effects on mental health that may occur. Adapting nursing practice to meet the unique needs of this subgroup is consistent with one of two overarching goals of Healthy People 2010: to eliminate health disparities among different populations.

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Family Health Issue 

The Federal Bureau of Primary Health defines homeless as “an individual without permanent housing who may live on the streets; stay in a shelter, mission, single-room occupancy facility, abandoned building or vehicle; or in any other unstable or non-permanent situation.”1 Many homeless people indicate their residency status as “doubled-up,” meaning they are living with friends or family as a result of being unable to maintain their own home. Homeless persons who have been incarcerated or released from a hospital without a stable home environment are especially at high risk of returning to a homeless status.

Many of the demographics of the homeless population are consistent with the characteristics of populations who are experiencing health disparities. These demographics include sex, ethnic, and socioeconomic characteristics. Families with children represent the greatest increase in the homeless population with single women heading the majority of families.2, 3, 4 In the United States a typical homeless family consists of a mother, approximately 30 years of age, with 2 to 3 children. Ethnic categories indicate 58% are African American, 22% are white, and 15% are Latino.2 Most of the women were involved in physically and sexually abusive relationships.2, 3, 5, 6, 7 Depression and post-traumatic stress disorder are common in homeless women as well.4, 5, 7 A history of substance abuse is frequently a contributing factor in many homeless families.2, 3 Of course, issues related to poverty such as lack of affordable housing, limited education levels, and the inability to earn wages that will support the needs of a family contribute to the increasing homeless levels.2, 3

Children of homeless families are at risk of a number of mental health issues. Research indicates that children who are exposed to violence and aggression experience higher rates of social isolation and relationship problems.5 Children of women who are victims of domestic abuse have higher rates of depression and behavior problems with school and peer situations. The exposure to violence in the home increases the chance that children will model this aggressive behavior in their relationships with peers or future spousal relationships. When homeless children age 6 to 17 years are compared with their peers, higher rates of mental disorders exist.3 As a result of the increased mobility of homeless families, children have limited or no access for referrals that might usually occur through a family practice or school setting.8 The lack of close family and friends for homeless families further reduces the availability of support systems outside the immediate family.2

School performance is greatly influenced by the lack of a stable home environment. Homeless children experience higher rates of developmental delays in language and reading skills.7 Students living in unstable home environments score lower on achievement tests and are less likely to be promoted to the next grade.2 As many as 30% of homeless children may not attend school, and only 42% of children who do attend school read at the expected level for their age.6 In a nonrandomized study by Morris and Butt2 with 34 homeless families, 3 important themes were identified that contributed to parents' homelessness and their perceptions of their children's academic and behavioral problems in school. The first theme posed that unstable relationships associated with addiction issues and frequent domestic violence were precipitating factors to homelessness. The second theme indicated parents frequently deny or blame others for the child's school problems. The final theme revealed that parents saw themselves as good parents and felt that the teacher should handle problems within the school room with little or no involvement from the parent. Many of the parents did not see absenteeism as an important problem. Although evidence shows that children of homeless families are at a greater risk of academic failure, parent perceptions may not truly recognize the implications.

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Current Knowledge of the Issue 

Most of the available literature on mental illness in homeless families was conducted through research studies at homeless shelters in the United States.6 Those studies found high rates of behavioral and emotional problems in these families. In a nonrandomized study conducted in the United Kingdom with 113 homeless families, it was found that 85% became homeless as a result of violence issues with 54% as a result of spousal separation.6 That study also found that 49% of the mothers experienced psychiatric disorders. The study indicated a need for a coordinated effort to address housing, social services, education, and health services for the displaced family. A later study evaluated the effect of a family support worker with 29 homeless families living in a hostel.8 The families did feel that they benefited from the service. Findings from that study suggest the need for improved interventions to support positive parenting and continued involvement from the family support worker even after a family is re-housed in the community.

A comparison of 2 nonrandomized studies of homeless mothers from 1993 and 2003 (N = 220 in the 1993 study and 148 in the 2003 study) provided a look at the changing needs of homeless families in the United States.4 In 2003, homeless mothers were slightly older in age, had older children, and expressed greater amounts of poverty. Women in 2003 were more likely to have a high school education. Rates of sexual abuse were high in both samples. Most disturbing was the 4-fold increase in women experiencing acute and chronic mental health problems such as depression and post-traumatic stress disorder. In addition, these women were receiving less mental health services than in previous years.

A qualitative study conducted with a convenience sample of 34 homeless families indicated that parents did not recognize the connection between their behavior choices and the current effects of their homeless situation on the behavioral problems associated with their children.2 That study indicated a need to further investigate the phenomenon of educational resilience in homeless children. Implications for school nurses include working with a multidisciplinary team to design workable programs to empower parents to become active and responsible in the success of their children in the academic setting. In addition, staff development needs to be conducted with professionals that work with homeless children to understand the unique needs. Parenting classes may be helpful in addressing many of the emotional responses of being homeless.

A nonrandomized study conducted with 93 homeless families in a mid-size Northwestern city found that 88% of homeless parents were victims of violence.5 High numbers of participants reported violence as an adult, violence as being beaten up, and violence experienced as a child. The greater the mother's experience with violence as an adult, the more likely they were to report behavioral problems with their children. Maternal violence and poverty contributed to the child's aggression. Those same children were more likely to experience social isolation and peer rejection. The findings suggest that withdrawal is a consequence of social rejection which is triggered by aggressive behaviors. This excessive aggression may be the result of the culminating effects of stressors in the lived experience of homeless children. Mothers that have experienced family violence may communicate mistrust and negative beliefs about others to their children, who in turn associate these negative feelings with their peers. Efforts to address the violence and aggression should focus on building resilience in children who have been exposed to violence and finding individual resources to help a child cope with violence in a positive manner.5

Harpaz-Rotem et al7 interviewed a convenience sample of 195 mothers who were veterans of the US armed forces. Results indicated that a significant risk factor for increased mental health issues in children was associated with the mother's own emotional problems and a history of incarceration. A child's low self-esteem or being a witness to violence significantly increased the degree of emotional problems. The greater the psychiatric symptoms experienced by the mother, the more anxiety or depression that was experienced by the child. That study also found that children of homeless mothers were less likely to be enrolled in school.

As one can see, emotional problems clearly exist in significant numbers for homeless families, especially for women and children. A review of the literature failed to identify studies that address the issue of homeless fathers and their children. Although the presence of fathers in homeless families is occasionally noted in the literature, most studies appear to have focused on the woman as the head of the family. While studies have documented the presence of a number of contributing factors, many fail to address clear and distinct interventions to address the mental health issues that exist for mothers and children. Academic failure presents a real and significant risk for homeless children. More studies need to be conducted to evaluate the efficacy of specific strategies to help these at-risk youths. If health providers do not address homeless children' academic and emotional needs, the chances of breaking the cycle of family violence and poverty are doomed for failure.

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Implications for Nursing Practice 

Providing access to health care is essential to decreasing health disparities for the homeless population. Statistics show that homeless families face considerable challenges related to mental health. Unfortunately, elimination of disparities will not occur until health policies change in a manner that will provide health care for all. In the meantime, The National Guidelines Clearinghouse has placed 8 guidelines on its website to help health practitioners care for homeless patients. These guidelines were developed by the National Health Care for the Homeless Counsel.1 Although the guidelines were established with the intent of being used by family physicians, it is appropriate that nurse practitioners should incorporate these guidelines into their own clinical practice. Although these guidelines relate to specific diseases and general care, the suggestions could prove helpful as nurse practitioners care for homeless families at risk of or currently experiencing mental illness.

1.Build trust. Do not require a patient to disrobe for a comprehensive physical examination on the first visit. Many women and children have been victims of sexual assault or abuse in the past. Instead, defer nonurgent genital examinations until a level of trust has been established.

2.Provide access to care. After clinic hours may be more conducive to homeless families' schedules. Although they may be homeless, the parent may actually be working at a minimum-wage job that does not offer flexibility in scheduling. Also attending school is an important challenge for children; thus, health care appointments outside of school hours might decrease absenteeism.

3.Recognize the nomadic lifestyle. Inquire whether the family has a secure place to maintain medications. Acknowledge and accommodate medication regimes that do not require refrigeration. It is helpful to give patients a wallet-sized card with pertinent medical information that they can provide new health care providers.

4.Adapt medication regimes. It is important to assess the availability of water. Medications that require specific amounts of water may not be a good choice, if a patient does not have convenient access to water supplies. Medications with diuretic effects pose a problem if a person has limited access to bathroom facilities. Sedating medications can put the person or family at risk when they are sleeping on the streets or even in shelters. Limiting medications supplies may be important if addiction is a problem. It is also important to recognize drugs that could be sold on the street for a profit.

5.Provide patient education. Because of the tendency for present orientation, it is critical to focus on immediate concerns instead of future consequences. Helping patients to establish a plan for emergencies can decrease the number of emergency department visits. Instead of focusing on cessation techniques, stress harm reduction approaches. For example, reducing the number of cigarettes smoked versus quitting smoking.

6.Screen and care for children and adolescents. Homeless children experience poor health outcomes and lack consistent medical care. Every visit should be used to conduct screenings for developmental delays, depression, sexual or physical abuse, oral screenings, and immunizations. The visit with the nurse practitioner may prove to be an opportunity to educate the parent in learning new and effective parenting skills.

7.Coordinate with ancillary care. Following up with a social worker or case manager may provide the most effective outcomes for homeless families. The complex issues of the homeless families require ongoing coordination for addiction, housing, and school attendance issues.

8.Accommodate for diet. Homeless families rarely have a choice about diet. Although diet may not directly link to mental illness, it is important to recognize that poor performance in school by homeless children may be related to an inadequate diet. Frequently, obesity is a problem in homeless children which reflects the high-fat content of many shelter foods. Obesity only adds one more factor to lower self-esteem in a child that is already experiencing a self-identity crisis.

Implications for research for the nurse practitioner should include studies evaluating the efficacy of interventions related to the emotional effects of homeless. Interventions should be aimed at promoting healthy peer relationships, coping strategies for exposure to violence, and succeeding in academic endeavors for homeless children. Parental interventions need to focus on improving parenting skills, maintaining a stable home environment, and managing current mental health disorders. Specific interventions need to assist parents to recognize the long-term effects of violence and addiction. In addition, nurse practitioners need to be prepared to provide mental health counseling for both parents and children experiencing homelessness.

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Conclusion 

Nurse practitioners will encounter homeless populations in a variety of health care settings. Families may present as victims of domestic violence through the emergency department or as patients seeking routine health care at community clinics. Regardless of the method of entry to the health system, nurses need to be knowledgeable of the complex issues that contribute to homelessness and the risk of mental illness that exists both for the parents and the children. Nurse practitioners who understand and adapt their practice to incorporate the unique aspects of the homeless have a better chance of providing health care that can achieve successful outcomes and decrease health disparities. Knowledge is power and leads to empowerment of homeless families to make changes that will lead to success for themselves and their children.

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References 

  1. Montauk SL . The homeless in America: adapting your practice . Am Fam Physician . 2006;74(7):1132–1138
  2. Morris R , Butt R . Parents' perspectives on homelessness and its effects on the educational development of their children . J Sch Nurs . 2003;19(1):43–50
  3. Morris R , Strong L . The impact of homelessness on the health of families . J Sch Nurs . 2004;20(4):221–227
  4. Weinreb LF , Buckner JC , Williams V , Nicholson J . A comparison of the health and mental health status of homeless mothers in Worcester, Mass: 1993 and 2003 . Am J Public Health . 2006;96(8):1444–1448
  5. Anooshian LJ . Violence and aggression in the lives of homeless children . J Fam Violence . 2005;20:373–387
  6. Cumella S , Grattan E , Vostanis P . The mental health of children in homeless families and their contact with health, education and social services . Health Soc Care Community . 1998;6(5):331–342
  7. Harpaz-Rotem I , Rosenheck RA , Desai R . The mental health of children exposed to maternal mental illness and homelessness . Community Ment Health J . 2006;42(5):437–448
  8. Tischler V , Karim K , Rustall S , Gregory P , Vostanis P . A family support service for homeless children and parents: users' perspectives and characteristics . Health Soc Care Community . 2004;12(4):327–335

PII: S1555-4155(08)00003-2

doi:10.1016/j.nurpra.2008.01.001

The Journal for Nurse Practitioners
Volume 4, Issue 2 , Pages 109-113, February 2008

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