On one morning, about a year ago, I walked into a room to see two brothers whom I have seen in my clinic for several years, 3-year-old Ari and 4-year-old Ryan. (I’ve changed their names to protect their privacy.) Their mom was worried about their behavior. She said that they had a hard time listening, couldn’t sit still, and fought with each other constantly. The two boys were running and jumping all around and ended up fighting several times during their appointment.
Their family had been moving around for as long as I had known them, staying with family members and friends, in their car, or in a hotel room. Even though their mother had a steady job, she had not yet been able to make enough to get their own home, which was something she talked about wanting every time I saw them. On this morning, their mom talked about how tired and stressed she felt from her full-time job, taking care of her boys under someone else’s house rules, and knowing she would eventually have to move yet again.
While their mom’s concerns at this visit were not new, Ari and Ryan did seem more agitated than in the past: full of nervous energy and more emotionally fragile than I would expect children their age to be. It was clear that both boys were feeling their mother’s mounting anxiety and were struggling with the stress.
As a pediatrician in the San Francisco Bay area for over 20 years, I have focused on working with families who experience unstable housing. Families like the ones I work with are often left out of conversations about the housing crisis. However, the best data we have, collected by the US Department of Education, suggests that millions of children in the United States are homeless every year; in the 2018–19 academic year, nearly 1.4 million, or one in 30, school-age children met the federal McKinney-Vento Act’s definition of homelessness. And this unfathomable number is actually an undercount, since it does not include young children ages 0–5 who have not yet enrolled in school, which is half of all homeless children. In fact, the age at which a person is most likely to stay in a shelter is between birth and 1 year old. It also does not include children who experienced homelessness during the summer when school was out, and children who did not inform anyone in the school about their housing challenges. Ari and Ryan, who are not yet enrolled in school, are not on any housing agency or school’s radar.
Homelessness can damage kids’ physical health and hinder their ability to do well in school. But one of the most profound and long-lasting impacts I’ve observed is on children’s mental health. Ari and Ryan should be focusing on their development: learning how to interact with other children, negotiate conflicts, share, and foster their creativity. They should not have to worry about where they will sleep, if they will have food to eat, or how to manage the stress they see in their parents. But nearly every patient I see who has experienced homelessness or unstable housing is burdened by significant mental health repercussions.
The mental health impacts on these children can show up in different ways: depression and thoughts of suicide, anxiety, hyperactivity, hypervigilance, insomnia, panic attacks, and anger or aggression, to name just a few. If their parents struggle with mental health disorders, which are often the result of their housing struggles and stressors, this can shape the mental health outcomes in the children. For example, parental anxiety can rub off on children; similarly, if a parent feels constant stress, this can strain how they relate to their child, so that effective and nurturing parenting becomes a challenge.
Discussions about homelessness often focus on mental health as a cause for the loss of housing. Studies, however, have shown repeatedly that housing unaffordability is the main driver of homelessness. In fact, the stress of homelessness often causes mental health to deteriorate. While 3 percent of children in the United States have depression and 7 percent have anxiety, half of children who have experienced homelessness have depression and anxiety, and one in three children who are homeless have experienced a major mental disorder by the time they are 8. High school students experiencing homelessness attempt suicide at three to six times the rate of students in stable housing.
While there is a paucity of data on the long-term affects of childhood homelessness on later health and housing stability as adults, we know that significant childhood trauma can have an impact on the health of adults. Childhood trauma has been linked to higher rates of chronic diseases, including heart disease, cancer, and diabetes. A recent study provides evidence that experiencing homelessness as a child leads to more difficulty maintaining stable housing as an adult. Even years after they were homeless, many of my patients continue to experience deep anxiety and depression, struggle to develop healthy relationships with their peers and parents, and suffer from multiple chronic health problems.
When I ask Ari and Ryan’s family what they need to get back into their own stable home, their answer is simple. All they need is a home that their mom can afford on her income. Many housing programs for people who are homeless have focused on providing support for mental health or substance abuse issues. But most families who are homeless simply need an affordable place to live. In fact, a study looking at different forms of housing support found that long-term housing subsidies had the best outcome for stabilizing housing and preventing returns to homelessness for families. Housing vouchers such as those offered by the Housing Choice Voucher (previously referred to as Section 8) program can be all that is needed to help many families get back on their feet.
The Biden administration’s Build Back Better plan, currently stalled in the Senate, includes $150 billion for affordable housing. A share of this funding would help to expand the Housing Choice Voucher program to provide an additional 300,000 households with vouchers. While expanding Housing Choice Vouchers is an essential step, it would aid only a portion of the almost 3 million US children, like Ari and Ryan, who lack stable housing. Currently, only one in four voucher-eligible households receive rental assistance. The National Low Income Housing Coalition estimates that 6.8 million affordable housing units are needed to house all the families labeled extremely low-income in this country.
Ari and Ryan’s family was fortunate. After many years of trying to save enough to afford their own place, they were able to get a housing subsidy. Unfortunately, housing shortages in their area forced them to settle for a new place that was nearly two hours from their previous community. Even so, their mom was grateful to finally have a home for her sons. Most other children in Ari and Ryan’s position aren’t so lucky. Until affordable housing, such as that provided by vouchers, is widely available to every family that needs it, far too many children will continue to experience an anxiety that no child should have to face.