- AAP —
- American Academy of Pediatrics
- ACE —
- adverse childhood experience
- NYC —
- New York City
Family homelessness in the United States became an egregious problem in the 1980s and was the reason that I, as a young pediatrician, discovered the importance of advocacy. In my hometown, New York City (NYC), because of increasing income inequality, neighborhood gentrification, and poor housing policies nationally and locally (all leading to dramatically decreased availability of affordable housing for low-income families), there was a growing number of children living in so-called “welfare hotels.” This number increased from 5000 each night in 1983 to 12 000 each night in 1988.1 Because many of these families were sheltered in hotels in midtown Manhattan, my program at Bellevue Hospital Center provided many of these children with health care within our hospital as well as in a clinic that we ran in one of the biggest hotels. I became active in my American Academy of Pediatrics (AAP) chapter and started the Committee on Homeless Families in New York Chapter 3. My colleagues and I learned how to collaborate with community-based advocacy organizations to fight for better treatment of homeless families in the shelter system as well as for better housing policies, at least in NYC. The result of those efforts by many advocates was that by 1990–1991, the number of children without a home being sheltered each night was back down to ∼5000.1 The nightmarish conditions of the lawless hotels were gone, and instead, safer and better-resourced, city-run shelters housed these families.
Today, however, there are more homeless families in NYC than ever, with 22 000 children in 15 000 families being housed in city shelters for families each night.1 Across the country during the year 2016, according to the US Department of Housing and Urban Development, 293 000 children were living in shelters for some of the year, and ∼118 000 children were living in shelters on any 1 day.2 Although 90% of homeless families in the United States are sheltered, ∼10% are living unsheltered in cars, on the street, and in other areas not meant for human habitation. In addition to those families being counted as homeless, many other families are doubled up with friends or relatives in conditions not conducive to a child’s optimal health and development. Various estimates reveal that there are 3 to 10 times as many children living in doubled-up households as in shelters. In their 2014 report, America’s Youngest Outcasts, the National Center on Family Homelessness estimated that 2.5 million US children (1 in 30) experienced homelessness (including being doubled up and living in temporary motels) for at least part of the year.3
In this month’s issue of Pediatrics, Stewart et al4 report on an increase in emergency department visits after Massachusetts tightened its shelter eligibility policy for homeless families (presumably to discourage families from seeking shelter and to cut costs), perhaps leading to families coming to emergency departments to qualify as “homeless.” It appears that even governments known for their programs for poor and low-income families are making it harder for families to find shelter when they are evicted or lose doubled-up housing with friends and families.
Children who are homeless have been shown to have significant health problems as well as problems with behavior and academic achievement. For example, 1 study from Los Angeles shelters done in the 1990s revealed that 78% of school-aged children who were homeless had mental health, behavioral, or academic issues.5 In studies from shelters in NYC, immunization delays, iron deficiency anemia, and poor growth have been documented.6,7 High rates of asthma and obesity as well as high rates of psychiatric, behavioral, or developmental problems have been documented in other studies.8 At least some of the academic problems are related to the disruption of school attendance. Young children are particularly vulnerable to the conditions of long-term housing instability and homelessness. In 1 study in an NYC shelter hotel, three-quarters of the preschool-aged children had language delays and emotional problems.9 It is also likely that many children who are homeless experience multiple adverse childhood experiences (ACEs) because there is a high incidence of domestic violence, maternal depression, other maternal mental health disorders, and other ACEs in the homeless family population.10 All of this leads to the child experiencing chronic toxic stress, which potentially leads to lifelong physical, emotional, and economic hardships. Although homelessness is not 1 of the standard 10 ACEs, it is certainly experienced as one by children because a shelter is definitely not a home.
The McKinney-Vento Act, first passed in 1987 (as the McKinney Act) and amended multiple times, is the major federal legislation in which the emergency issues of homelessness are addressed. It has a major focus on adult homelessness but does have important provisions for children and families, especially concerning child nutrition and education. Nevertheless, advocacy is still needed to make sure that states and local communities are following these regulations, including the right of children who are homeless to attend preschool and school. The Homelessness Prevention and Rapid Re-Housing Program, funded by the American Recovery and Reinvestment Act of 2009 at the level of 1.5 billion dollars, provided funds for families to help with rent payments and gave assistance for paying security deposits and utility bills. There was also funding for eviction prevention services, credit counseling, and help for those who were currently experiencing homelessness to find both short-term and permanent housing. The program ended in 2012, and funds are no longer available.
Low-income families simply cannot afford available housing without help. Poor and low-income families in 2012 spent approximately half of their income on rent, which crowds out funds for other basics, such as food, clothes, and health care.10 The federal housing programs are extremely problematic because there is a fixed number of housing vouchers, public housing units, and low-income housing tax credit–built units. The waiting lists for these programs are often completely closed. Only approximately one-quarter of families who are eligible receive these housing options. In 2012, almost 5 million families were on waiting lists for housing vouchers that pay the proportion of the family’s rent that is >30% of the family income. Advocacy for increasing the number of vouchers for a majority of families with children is a critical priority.
The AAP encourages pediatricians to take an active role in the health care of children in homeless families, including ensuring behavioral health and nutrition, leading efforts for programs that ameliorate the conditions in shelters, and advocating for policies to make adequate housing more available and secure for low-income families.11 The AAP calls on the federal government to resurrect programs like the Homelessness Prevention and Rapid Re-Housing Program as well as dramatically increase access to housing choice vouchers for families with children. Cities and states with large numbers of homeless families must also implement housing solutions on a scale that meets the need. For example, cities such as New York, Los Angeles, and Boston must increase the number of newly constructed or rehabbed housing units that are deeply subsidized for low-income families and track their success on a yearly basis. Of course, this problem, like so many others that children face, is primarily due to family poverty. Ultimately, we need to raise children out of poverty if we want to give them a real home, not just a shelter.
- Accepted August 30, 2018.
- Address correspondence to Benard P. Dreyer, MD, Department of Pediatrics, New York University School of Medicine, 462 First Ave, NBV 8E-11, New York, NY 10016. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-1224.
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- Council on Community Pediatrics
- Copyright © 2018 by the American Academy of Pediatrics