标题：Physical and Mental Health, Cognitive Development, and Health Care Use by Housing Status of Low-Income Young Children in 20 American Cities: A Prospective Cohort Study
摘要：Objectives. We assessed the independent effect of homeless and doubled-up episodes on physical and mental health, cognitive development, and health care use among children. Methods. We used data from 4 waves of the Fragile Families and Child Wellbeing Study, involving a sample of 2631 low-income children in 20 large US cities who have been followed since birth. Multivariate analyses involved logistic regression using the hybrid method to include both fixed and random effects. Results. Of the sample, 9.8% experienced homelessness and an additional 23.6% had a doubled-up episode. Housing status had little significant adverse effect on child physical or mental health, cognitive development, or health care use. Conclusions. Family and environmental stressors common to many children in poverty, rather than just homeless and doubled-up episodes, were associated with young children's poor health and cognitive development and high health care use. Practitioners need to identify and respond to parental and family needs for support services in addition to housing assistance to effectively improve the health and development of young children who experience residential instability, particularly those in homeless families. Approximately 2 million Americans experience homelessness each year. 1 Families with children are estimated to make up 34% of the homeless population (i.e., 23% children and 11% adults) on any given night. 2 A substantial portion of homeless children have physical, developmental, behavioral, and emotional problems. Homeless children commonly experience acute and chronic health problems such as asthma, 3 – 6 ear infections, 6 lead toxicity, 7 , 8 immunization delays, 9 nutritional deficits including overweight and obesity, 4 , 10 , 11 developmental or growth delays, 12 , 13 and problems in cognitive functioning. 14 Children in homeless families also have a high current prevalence of mental health problems, ranging from 12% to 47% depending on the age of the children, assessment measures, and geographic area. 4 , 15 – 19 The literature has provided solid evidence that the extent of health and mental health problems among homeless children is greater than that among the general population of children. However, the evidence is mixed as to whether homeless children differ from housed low-income children on health, developmental, and mental health outcomes. Some studies have found that homeless children are more likely than low-income stably housed children to have fair or poor health status, 6 severe health problems, 3 delayed developmental status, 12 disruptive behavior disorders, 18 and, among boys, internalizing and externalizing behavior problems. 17 A review of the studies on the cognitive functioning of homeless children and adolescents concluded that homeless children tend to have lower intellectual functioning than those who are domiciled. 20 Other studies have reported that both groups of children have high rates of developmental, behavioral, and emotional problems, and they do not differ significantly from each other. 15 , 21 – 23 A review of published studies between 1987 and 2004 stated that the detrimental impact of homelessness measured as a stay in a family shelter on children's health tends to be in the mild to moderate range. 24 Although previous studies of the health status of homeless children and families have added greatly to knowledge of this population's needs, they have had several limitations. With a few exceptions, 25 , 26 most studies in this area have relied on cross-sectional designs, which makes determining the causal relationships between homelessness and health outcomes difficult. Little is known about whether homeless families differ from housed low-income families before homeless episodes. Studies have typically been based on a sample from a single geographic area and have often used a small convenience sample. In addition, variations in the age of the sample, settings from which the study participants were recruited (e.g., shelters, clinics, schools), and assessment measures make it difficult to compare and generalize the findings. Last, many studies currently available relied on decade-old or even older data, which do not reflect the recent trends in homelessness and health. 25 , 27 We built on previous studies using public-release data from the Fragile Families and Child Wellbeing Study (FFS). First, the sample was recruited in 20 large US cities and included children in families who have experienced homelessness and others who were at risk. Second, unlike in studies based on families staying in shelter settings, we counted as homeless a family living in temporary housing, in a shelter, or in a place not meant for human habitation (e.g., the streets, abandoned buildings, and automobiles). In addition to measures of homelessness, the data include information on doubling-up episodes, an additional important measure of precarious housing status. Third, the data include a wide range of health-related measures and control variables, including individual and household characteristics. Finally, the use of longitudinal data enabled us to compare children's health status over time by homeless and doubled-up episodes, adjusting for many potential confounders. We examined the extent of homelessness and doubling up and health and health care use by housing status among low-income children in 20 large US cities. We also investigated the extent to which homelessness and doubling up explain differences in health and mental health, cognitive development, and health care use of children, controlling for a wide variety of individual and familial characteristics.
