Post-traumatic stress disorder in extremely poor women: implications for health care clinicians.

OBJECTIVES: To identify childhood antecedents for lifetime post-traumatic stress disorder (PTSD) and to determine how this diagnosis relates to health and service use among extremely poor women. METHODS: We conducted a secondary data analysis of 425 women in the Worcester Family Research Project, a case-control longitudinal study of 220 sheltered homeless and 216 extremely poor housed (never homeless) women in Worcester, Massachusetts. RESULTS: We found that extremely poor women with lifetime PTSD were more likely to have grown up in family environments of violence, threat, and anger than those without PTSD. The strongest risk factor for PTSD was childhood sexual abuse with threat. Low-income women with lifetime PTSD had more bodily pain, even when controlling for other health and demographic factors. Women with PTSD experienced more chronic health conditions and had more problematic relationships with their health care providers and perceived more barriers to care. CONCLUSION: Many low-income women have difficulty using medical care appropriately because of childhood histories of physical and sexual abuse, the subsequent development of post-trauma responses, and structural barriers to care. Given these factors, it is critical that health care clinicians routinely screen for histories of violence and PTSD and develop treatment plans that ensure safety, link current symptoms with prior experiences, and provide support as necessary. A team approach coordinated by a case manager may be the best strategy. Without routine screening for PTSD and sensitive treatment, many extremely poor women will receive compromised health care and may even be retraumatized.

Homelessness and its relation to the mental health and behavior of low-income school-age children.

This study examined the relationship between housing status and depression, anxiety, and problem behaviors among children age 6 and older who were members of low-income, single-parent, female-headed families. Participants were 80 homeless and 148 never homeless children living in Worcester, Massachusetts. Children in both groups had recently been exposed to various severe stressors. Mother-reported problem behaviors were above normative levels for both homeless and poor housed youths but self-reported depression and anxiety were not. Controlling for other explanatory variables, housing status was associated with internalizing problem behaviors but not with externalizing behaviors. Among homeless youths, internalizing behavior problems showed a positive but curvilinear relationship with number of weeks having lived in a shelter. Housing status was not associated with self-reported depression and anxiety. Findings are discussed in terms of their implications for programmatic interventions and in light of recent welfare reform.

Prevalence of mental health and substance use disorders among homeless and low-income housed mothers.

OBJECTIVE: This study compared the prevalence of DSM-III-R disorders among homeless and low-income housed mothers with the prevalence of these disorders among all women in the National Comorbidity Survey. METHOD: The authors used an unmatched case-control design for assessing 220 homeless and 216 housed mothers receiving public assistance. RESULTS: Homeless and housed mothers had similar rates of psychiatric and substance use disorders. Both groups had higher lifetime and current rates of major depression and substance abuse than did all women in the National Comorbidity Survey. Both groups also had high rates of posttraumatic stress disorder and two or more lifetime conditions. CONCLUSIONS: The prevalence of trauma-related disorders among poor women was higher than that among women in the general population. Programs and policies designed for low-income mothers must respond to the high prevalence of DSM-III-R disorders.

The developmental status and adaptive behavior of homeless and low-income housed infants and toddlers.

OBJECTIVES: This study describes the development status of 127 homeless and 91 low-income housed infants and toddlers. METHODS: The Bayley Scales of Infant Development and the Vineland Screener were used to gather data. RESULTS: There were no differences between homeless and low-income housed children. However, younger children in both groups performed better than the older children on most summary scores. CONCLUSIONS: Homeless and low-income housed children did not differ in their cognitive and motor skills. However, older children scored lower than younger children on most measures of development status, suggesting that the cumulative effects of poverty may increase with time.

The plight of extremely poor Puerto Rican and non-Hispanic white single mothers.

Using data from a case-control study of family homelessness in Worcester, Massachusetts, this analysis compares the economic, psychosocial and health characteristics of 159 Puerto Rican and 170 Non-Hispanic White poor, single mothers. When compared to Non-Hispanic Whites, the Puerto Rican mothers had more children, less education, fewer work experiences, fewer social supports, and more English language problems. Although the absolute rates were high in both groups, Puerto Rican mothers had experienced less violence and suffered fewer mental health problems, with the exception of major depression, than Non-Hispanic Whites. In addition, Puerto Rican mothers were less likely to use traditional health services. These findings suggest that to escape poverty, Puerto Rican mothers need a unique combination of educational opportunities (including English as a Second Language), job training, and child care.

Responding to the needs of low-income and homeless women who are survivors of family violence.

Americans have started to recognize interpersonal violence as a major health care issue. Increasingly, clinicians are beginning to recognize both the high rate of victimization among extremely poor women and its health consequences. However, most clinical responses focus on the immediate effects of child abuse, partner abuse, and rape. The long-term medical and mental health consequences and the relationship between early victimization and adult problems are still largely ignored. This article focuses on medical and mental health needs of extremely poor women survivors of interpersonal violence. It begins by documenting the extent and nature of violence against low-income women. Special attention is focused on the long-term sequelae of childhood abuse and on identifying and managing complex trauma responses in these women. The article concludes by discussing obstacles to care and the necessity of advocating for increased resources to respond to women living in extreme poverty.

Determinants of behavior in homeless and low-income housed preschool children.

OBJECTIVES: To describe the characteristics of homeless and low-income preschool-aged children, and to identify family and environmental determinants of their behavior. METHODS: An unmatched case-control design was used to recruit a sample of sheltered homeless families and a comparison group of low-income housed families who were never homeless in Worcester, Massachusetts. Seventy-seven sheltered homeless and 90 low-income housed mothers with preschool-age children were assessed using a comprehensive interview protocol. Information about mothers' housing, income, service use, par-enting practices, and children's father was obtained. Data about children's background, health, and life events were included. Standardized instruments were administered to assess mothers' mental health and their children's behavior. Comparisons of homeless and low-income housed families were used to describe the sample of 167 preschoolers. Multiple linear regression was used to examine the association of various stressors, such as homelessness, and family factors with their behavior. RESULTS: Although homeless preschoolers were significantly more likely to have experienced stressful life events, undergone a care and protection investigation, and been placed in foster care when compared with low income preschoolers, differences in adverse behaviors were minimal. Although homeless children scored higher than housed children on the internalizing, externalizing, and total problem score on the Child Behavior Checklist (CBCL) (52.5 vs 49.9, 54.8 vs 51.2, and 54.4 vs 51.1, respectively), approximately equal numbers of children from both groups scored in the clinical range. With regard to determinants of behavior, mothers' emotional status was one of the strongest independent predictors of negative behavioral outcomes on both subscales. Foster care placement and death of a child's friend were predictors of adverse internalizing behavioral outcomes on the CBCL. After controlling for housing status, parenting practices, child's age, child's history of physical abuse, and specific life stressors predicted adverse externalizing behavioral outcomes. For both subscales, housing status and behavior were only marginally associated in the multivariate model. CONCLUSIONS: Both homeless and low-income children experienced significant adversity in their lives, with homeless preschool children facing more stress. However, differences in behavior as measured by the CBCL were minimal. Mothers' emotional status, in addition to various stressors, strongly predict children's negative outcomes for both CBCL subscales. These findings emphasize the importance of preventive family-oriented interventions that address the needs of preschoolers and their mothers.

Mental disorders and service utilization among youths from homeless and low-income housed families.

OBJECTIVE: To assess the mental health of homeless and poor housed youths, using the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule for Children (DISC) Version 2.3, and to examine mental health service use. METHOD: As part of a comprehensive study of homeless and housed families Worcester, MA, data were collected on 41 homeless and 53 poor housed (never homeless) youths aged 9 to 17 using both the parent and youth versions of the DISC. RESULTS: On the basis of the parent version of the DISC, current (6-month) prevalence rates of DSM-III-R disruptive behavior, affective, and anxiety disorders were comparable in homeless and housed youths but higher than rates found among youths in the NIMH-sponsored Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, which used the same diagnostic measure. Approximately 32% of the combined sample of homeless and housed youths had a current mental disorder accompanied by impairment in functioning. Mental health service use in the preceding 6 months among youths who had one or more current disorders and associated impairment ranged from 20% to 35%. A subgroup of youths with one or more current disorders and poor global functioning had never received treatment. CONCLUSIONS: This sample of homeless and housed youths was found to have high rates of current mental disorders. Use of mental health services by children with mental health needs was low, particularly for youths with poor overall functioning.

Homelessness in female-headed families: childhood and adult risk and protective factors.

OBJECTIVES: To identify risk and protective factors for family homelessness, a case-control study of homeless and low-income, never-homeless families, all female-headed, was conducted. METHODS: Homeless mothers (n = 220) were enrolled from family shelters in Worcester, Mass. Low-income housed mothers receiving welfare (n = 216) formed the comparison group. The women completed an interview covering socioeconomic, social support, victimization, mental health, substance use, and health domains. RESULTS: Childhood predictors of family homelessness included foster care placement and respondent's mother's use of drugs. Independent risk factors in adulthood included minority status, recent move to Worcester, recent eviction, interpersonal conflict, frequent alcohol or heroin use, and recent hospitalization for a mental health problem. Protective factors included being a primary tenant, receiving cash assistance or a housing subsidy, graduating from high school, and having a larger social network. CONCLUSIONS: Factors that compromise an individual's economic and social resources are associated with greater risk of losing one's home.

The characteristics and needs of sheltered homeless and low-income housed mothers.

OBJECTIVE: To compare characteristics of homeless and low-income housed mothers across economic, psychosocial, and physical health domains. DESIGN: Case-control study. SETTING: Community of Worcester, Mass. PARTICIPANTS: A cross-sectional sample of 220 sheltered homeless mothers and 216 low-income housed (never homeless) mothers receiving welfare. MAIN OUTCOME MEASURES: Income, housing, life events, social support, history of abuse and assault, and mental and physical health. RESULTS: Comparison of homeless and housed mothers revealed some important similarities and differences. The proportion of homeless mothers with annual incomes of less than $7000 was 46% vs 17% for housed mothers (P<.O1). Homeless mothers experienced more residential instability than the housed mothers (3.8 moves vs 1.8 moves; P<.001) and had smaller support networks (P<.001). More homeless mothers reported severe physical and sexual assault over the lifespan than housed mothers (91.6% vs 81.1 %; P<.003). No significant differences were found between the groups in mental and physical health. However, the lifetime prevalence of major depressive disorder, posttraumatic stress disorder, and substance use disorders was overrepresented compared to the general female population. Both groups had lower physical functioning compared to the general population and a higher prevalence of chronic health conditions. CONCLUSIONS: Sheltered homeless mothers had fewer economic resources and social supports and higher cumulative rates of violent abuse and assault over their lifespans than their housed counterparts. However, both groups faced extreme adversity that compromised family well-being. Practitioners and social policymakers need to be cognizant of the multiple economic, psychosocial, and physical health needs of these mothers in providing treatment and developing program interventions.

Social and economic hardships of homeless and other poor women.

Homeless women generally face the same social and economic problems as do men but in an intensified form due to the social marginalization of women and the responsibilities of parenthood, often borne by women alone. Remedies that entail changes in public policy and the enhancement of social-support networks are discussed.

Homeless pregnant women: two generations at risk.

The impact of pregnancy on the course of homelessness and the adverse effects of homelessness on pregnant women and their babies are explored. Recommendations for policy to address the urgent needs of this population are offered, and components of an innovative three-site demonstration program are described.

Mental health issues affecting homeless women: implications for intervention.

A review of the relevant literature is followed by an exploration of the complex relationship, especially for women, between homelessness and mental health. Various mental health and gender-related concerns that have implications for the design of interventions for homeless women are explored.

Lithium intoxication: a coordinated treatment approach.

This case illustrates the clinical features of lithium intoxication and the problems in treating it that may arise as a result of lithium's effects on the kidney. It also demonstrates the difficulties that can develop when a delicate physiologic balance is inadvertently disrupted by nonpharmacologic interventions such as seclusion and consequent restriction of access to food and water. Patients with lithium-induced urine-concentrating defects are especially at risk for dehydration, and care must be taken to ensure adequate fluid and salt intake. This case also shows how intense negative feelings evoked by chronically mentally ill patients can adversely affect their psychiatric and medical care. While such feelings are inevitable, their impact may be lessened by improved communication and coordination between the medical and psychiatric systems of care and by the presence of psychiatrists in the general medical hospital.