Abstract
Unhoused children and adolescents have high rates of adverse childhood experiences (ACEs). The objective of this study was to characterize a large cohort of unhoused children and investigate rates of psychiatric diagnoses, medical diagnoses, and utilization of emergency department (ED) resources depending on the presence of additional documented ACEs. A retrospective cohort of all unhoused children who presented to the ED of a large Midwestern health system from January 2014 to July 2019 were included. Unhoused status was determined by address field or ICD-10 code for homelessness (Z59.0). Demographics and ED visits were extracted from the electronic health record. Past medical history, ACEs, chief complaint (CC), length of stay (LOS), imaging, and labs were extracted by chart review. T-tests, chi square tests, and Fisher’s exact tests were completed for each sub-analysis. Unhoused children with at least one additional ACE had higher odds of the following psychiatric disorders: depression (OR = 5.2, 95% CI = 3.4- 7.9), anxiety (OR = 3.4, 95% CI = 32.1–5.5), behavioral disorder (OR = 7.2, 95% CI = 35.1- 10.4), psychoses (OR = 6.0, 1.9–18.4), bipolar disorder (OR = 19.8, 95% CI = 34.6–84.9), suicidal ideation (OR = 8.0, 95% CI = 34.8–13.4), post-traumatic stress disorder (OR = 10.1, 95% CI = 35.4–18.6), and attention deficit hyperactive disorder (OR = 4.1, 3.0–5.7). Patients with additional documented ACEs were also more likely to have a prior psychiatric admission (p < 0.001). Unhoused children and adolescents with exposure to additional documented ACEs are more likely to have some serious psychiatric and medical diagnoses compared to other unhoused children.
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References
Ambelas, A. (1979). Psychologically stressful events in the precipitation of manic episodes. The British Journal of Psychiatry: The Journal of Mental Science, 135(1), 15–21. https://doi.org/10.1192/BJP.135.1.15
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., Dube, S. R., & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–186. https://doi.org/10.1007/s00406-005-0624-4
Ayano, G., Ayano, G., Shumet, S., Tesfaw, G., & Tsegay, L. (2020a). A systematic review and meta-analysis of the prevalence of bipolar disorder among homeless people. BMC Public Health, 20(1), 1–10. https://doi.org/10.1186/S12889-020-08819-X/FIGURES/3
Ayano, G., Solomon, M., Tsegay, L., Yohannes, K., & Abraha, M. (2020b). A Systematic Review and Meta-Analysis of the Prevalence of Post-Traumatic Stress Disorder among Homeless People. The Psychiatric Quarterly, 91(4), 949–963. https://doi.org/10.1007/S11126-020-09746-1
Ayano, G., Tesfaw, G., & Shumet, S. (2019). The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry, 19(1). https://doi.org/10.1186/S12888-019-2361-7
Barnes, A. J., Gilbertson, J., & Chatterjee, D. (2018). Emotional health among youth experiencing family homelessness. Pediatrics, 141(4). https://doi.org/10.1542/peds.2017-1767
Barnes, A. J., Gower, A. L., Sajady, M., & Lingras, K. A. (2021). Health and adverse childhood experiences among homeless youth. BMC Pediatrics, 21(1). https://doi.org/10.1186/S12887-021-02620-4
Bender, K., Ferguson, K., Thompson, S., Komlo, C., & Pollio, D. (2010). Factors associated with trauma and posttraumatic stress disorder among homeless youth in three U.S. cities: The importance of transience. Journal of Traumatic Stress, 23(1), 161–168. https://doi.org/10.1002/JTS.20501
Briggs, M. A. (2013). Providing care for children and adolescents facing homelessness and housing insecurity. Pediatrics, 131(6), 1206–1210. https://doi.org/10.1542/PEDS.2013-0645
Cates, C. B., Weisleder, A., & Mendelsohn, A. L. (2016). Mitigating the Effects of Family Poverty on Early Child Development through Parenting Interventions in Primary Care. Academic Pediatrics, 16(3 Suppl), S112–S120. https://doi.org/10.1016/J.ACAP.2015.12.015
De Rosa, C. J., Montgomery, S. B., Kipke, M. D., Iverson, E., Ma, J. L., & Unger, J. B. (1999). Service utilization among homeless and runaway youth in Los Angeles, California: Rates and reasons. Journal of Adolescent Health, 24(3), 190–200. https://doi.org/10.1016/S1054-139X(98)00081-0
Desai, R. A., Liu-Mares, W., Dausey, D. J., & Rosenheck, R. A. (2003). Suicidal ideation and suicide attempts in a sample of homeless people with mental illness. The Journal of Nervous and Mental Disease, 191(6), 365–371. https://doi.org/10.1097/01.NMD.0000071584.88965.E1
Eynan, R., Langley, J., Tolomiczenko, G., Rhodes, A. E., Links, P., Wasylenki, D., & Goering, P. (2002). The association between homelessness and suicidal ideation and behaviors: Results of a cross-sectional survey. Suicide & Life-Threatening Behavior, 32(4), 418–427. https://doi.org/10.1521/SULI.32.4.418.22341
Fazel, S., Khosla, V., Doll, H., & Geddes, J. (2008). The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLoS Medicine, 5(12), 1670–1681. https://doi.org/10.1371/JOURNAL.PMED.0050225
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8
Gentil, L., Grenier, G., & Fleury, M. J. (2021). Determinants of suicidal ideation and suicide attempt among former and currently homeless individuals. Social Psychiatry and Psychiatric Epidemiology, 56(5), 747–757. https://doi.org/10.1007/S00127-020-01952-3
Gewirtz, A. H., DeGarmo, D. S., Lee, S., Morrell, N., & August, G. (2015). Two-year outcomes of the Early Risers prevention trial with formerly homeless families residing in supportive housing. Journal of Family Psychology: JFP: Journal of the Division of Family Psychology of the American Psychological Association (Division 43), 29(2), 242–252. https://doi.org/10.1037/FAM0000066
Gewirtz O’Brien, J. R., Edinburgh, L. D., Barnes, A. J., & McRee, A. L. (2020). Mental health outcomes among homeless, runaway, and stably housed youth. Pediatrics, 145(4). https://doi.org/10.1542/peds.2019-2674
Ginzler, J. A., Garrett, S. B., Baer, J. S., & Peterson, P. L. (2007). Measurement of negative consequences of substance use in street youth: An expanded use of the Rutgers Alcohol Problem Index. Addictive Behaviors, 32(7), 1519–1525. https://doi.org/10.1016/J.ADDBEH.2006.11.004
Heerde, J. A., Scholes-Balog, K. E., & Hemphill, S. A. (2015). Associations between youth homelessness, sexual offenses, sexual victimization, and sexual risk behaviors: A systematic literature review. Archives of Sexual Behavior, 44(1), 181–212. https://doi.org/10.1007/S10508-014-0375-2
HHS., & CMS. (2019). Utilization of Z Codes for Social Determinants of Health among Medicare Fee-for-Service Beneficiaries, 2019 Background. www.ccwdata.org
Hodgson, K. J., Shelton, K. H., Van Den Bree, M. B. M., & Los, F. J. (2013). Psychopathology in young people experiencing homelessness: a systematic review. American Journal of Public Health, 103(6). https://doi.org/10.2105/AJPH.2013.301318
Holtrop, K., Chaviano, C. L., Scott, J. C., & Smith, S. M. N. (2015). Identifying relevant components to include in a parenting intervention for homeless families in transitional housing: Using parent input to inform adaptation efforts. The American Journal of Orthopsychiatry, 85(6), 600–611. https://doi.org/10.1037/ORT0000111
Iwundu, C. N., Chen, T. A., Edereka-Great, K., Businelle, M. S., Kendzor, D. E., & Reitzel, L. R. (2020). Mental Illness and Youth-Onset Homelessness: A Retrospective Study among Adults Experiencing Homelessness. International Journal of Environmental Research and Public Health, 17(22), 1–13. https://doi.org/10.3390/IJERPH17228295
Jordans, M., Rathod, S., Fekadu, A., Medhin, G., Kigozi, F., Kohrt, B., Luitel, N., Petersen, I., Shidhaye, R., Ssebunnya, J., Patel, V., & Lund, C. (2018). Suicidal ideation and behaviour among community and health care seeking populations in five low- and middle-income countries: A cross-sectional study. Epidemiology and Psychiatric Sciences, 27(4), 393–402. https://doi.org/10.1017/S2045796017000038
Kamieniecki, G. W. (2001). Prevalence of psychological distress and psychiatric disorders among homeless youth in Australia: A comparative review. The Australian and New Zealand Journal of Psychiatry, 35(3), 352–358. https://doi.org/10.1046/J.1440-1614.2001.00910.X
Kertesz, S. G., Larson, M. J., Horton, N. J., Winter, M., Saitz, R., & Samet, J. H. (2005). Homeless chronicity and health-related quality of life trajectories among adults with addictions. Medical Care, 43(6), 574–585. https://doi.org/10.1097/01.MLR.0000163652.91463.B4
Kim, K., & Garcia, I. (2019). Why Do Homeless Families Exit and Return the Homeless Shelter? Factors Affecting the Risk of Family Homelessness in Salt Lake County (Utah, United States) as a Case Study. International Journal of Environmental Research and Public Health, 16(22). https://doi.org/10.3390/IJERPH16224328
Koball, A. M., Rasmussen, C., Olson-Dorff, D., Klevan, J., Ramirez, L., & Domoff, S. E. (2019). The relationship between adverse childhood experiences, healthcare utilization, cost of care and medical comorbidities. Child Abuse & Neglect, 90, 120–126. https://doi.org/10.1016/j.chiabu.2019.01.021
Kozloff, N., Stergiopoulos, V., Adair, C. E., Cheung, A. H., Misir, V., Townley, G., Bourque, J., Krausz, M., & Goering, P. (2016). The Unique Needs of Homeless Youths With Mental Illness: Baseline Findings From a Housing First Trial. Psychiatric Services (Washington, D.C.), 67(10), 1083–1090. https://doi.org/10.1176/APPI.PS.201500461
Lee, H., Kim, Y., & Terry, J. (2020). Adverse childhood experiences (ACEs) on mental disorders in young adulthood: Latent classes and community violence exposure. Preventive Medicine, 134, 106039. https://doi.org/10.1016/J.YPMED.2020.106039
Liu, M., Luong, L., Lachaud, J., Edalati, H., Reeves, A., & Hwang, S. W. (2021). Adverse childhood experiences and related outcomes among adults experiencing homelessness: A systematic review and meta-analysis. The Lancet Public Health, 6(11), e836–e847. https://doi.org/10.1016/S2468-2667(21)00189-4
McManus, H. H., & Thompson, S. J. (2008). Trauma Among Unaccompanied Homeless Youth: The Integration of Street Culture into a Model of Intervention. Journal of Aggression, Maltreatment & Trauma, 16(1), 92. https://doi.org/10.1080/10926770801920818
Moss, H. B., Ge, S., Trager, E., Saavedra, M., Yau, M., Ijeaku, I., & Deas, D. (2020). Risk for Substance Use Disorders in young adulthood: Associations with developmental experiences of homelessness, foster care, and adverse childhood experiences. Comprehensive Psychiatry, 100. https://doi.org/10.1016/J.COMPPSYCH.2020.152175
Narendorf, S. C., Cross, M. B., Santa Maria, D., Swank, P. R., & Bordnick, P. S. (2017). Relations between mental health diagnoses, mental health treatment, and substance use in homeless youth. Drug and Alcohol Dependence, 175, 1–8. https://doi.org/10.1016/J.DRUGALCDEP.2017.01.028
Post, R. M. (1992). Transduction of psychosocial stress into the neurobiology of recurrent affective disorder. The American Journal of Psychiatry, 149(8), 999–1010. https://doi.org/10.1176/AJP.149.8.999
Prigerson, H. G., Desai, R. A., Liu-Mares, W., & Rosenheck, R. A. (2003). Suicidal ideation and suicide attempts in homeless mentally ill persons: Age-specific risks of substance abuse. Social Psychiatry and Psychiatric Epidemiology, 38(4), 213–219. https://doi.org/10.1007/S00127-003-0621-8
Radcliff, E., Crouch, E., Strompolis, M., & Srivastav, A. (2019). Homelessness in Childhood and Adverse Childhood Experiences (ACEs). Maternal and Child Health Journal, 23(6), 811–820. https://doi.org/10.1007/s10995-018-02698-w
Ross, M. K., Romero, T., & Szilagyi, P. G. (2021). Adverse Childhood Experiences and Association With Pediatric Asthma Severity in the 2016–2017 National Survey of Children’s Health. Academic Pediatrics, 21(6), 1025–1030. https://doi.org/10.1016/j.acap.2021.04.021
Sakai-Bizmark, R., Mena, L. A., Estevez, D., Webber, E. J., Marr, E. H., Bedel, L. E. M., & Yee, J. K. (2020). Health care utilization of homeless minors with diabetes in New York state from 2009 to 2014. Diabetes Care, 43(9), 2082–2089. https://doi.org/10.2337/dc19-2219
Sakai-Bizmark, R., Chang, R. K. R., Mena, L. A., Webber, E. J., Marr, E. H., & Kwong, K. Y. (2019). Asthma hospitalizations among homeless children in New York state. Pediatrics, 144(2). https://doi.org/10.1542/peds.2018-2769
Sandel, M., Sheward, R., De Cuba, S. E., Coleman, S., Heeren, T., Black, M. M., Casey, P. H., Chilton, M., Cook, J., Cutts, D. B., Rose-Jacobs, R., & Frank, D. A. (2018). Timing and Duration of Pre- and Postnatal Homelessness and the Health of Young Children. Pediatrics, 142(4). https://doi.org/10.1542/PEDS.2017-4254
Semborski, S., Redline, B., Madden, D., Granger, T., & Henwood, B. (2021). Housing interventions for emerging adults experiencing homelessness: A scoping review. Children and Youth Services Review, 127. https://doi.org/10.1016/J.CHILDYOUTH.2021.106081
Sheller, S. L., Hudson, K. M., Bloch, J. R., Biddle, B., Krauthamer Ewing, E. S., & Slaughter-Acey, J. C. (2018). Family Care Curriculum: A Parenting Support Program for Families Experiencing Homelessness. Maternal and Child Health Journal, 22(9), 1247–1254. https://doi.org/10.1007/S10995-018-2561-7
Sleegers, J., Spijker, J., Van Limbeek, J., & Van Engeland, H. (1998). Mental health problems among homeless adolescents. Acta Psychiatrica Scandinavica, 97(4), 253–259. https://doi.org/10.1111/J.1600-0447.1998.TB09996.X
Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., & Navalta, C. P. (2002). Developmental neurobiology of childhood stress and trauma. Psychiatric Clinics, 25(2), 397–426. https://doi.org/10.1016/S0193-953X(01)00003-X
Wenzel, S. L., Rhoades, H., Harris, T., Winetrobe, H., Rice, E., & Henwood, B. (2017). Risk behavior and access to HIV/AIDS prevention services in a community sample of homeless persons entering permanent supportive housing. AIDS Care, 29(5), 570. https://doi.org/10.1080/09540121.2016.1234690
Wing, R., Gjelsvik, A., Nocera, M., & McQuaid, E. L. (2015). Association between adverse childhood experiences in the home and pediatric asthma. Annals of Allergy, Asthma & Immunology: Official Publication of the American College of Allergy, Asthma, & Immunology, 114(5), 379–384. https://doi.org/10.1016/J.ANAI.2015.02.019
Xiang, J., Kaminga, A. C., Wu, X. Y., Lai, Z., Yang, J., Lian, Y., Wang, X., Wen, S. W., Liu, A., & Dai, W. (2021). Lifetime prevalence of suicidal attempt among homeless individuals in North America: A meta-analysis. Journal of Affective Disorders, 287, 341–349. https://doi.org/10.1016/J.JAD.2021.03.052
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EJP and JCL recent affiliations include Case Western Reserve University School of Medicine, Cleveland, OH, USA. JW recent affilitions include the Department of Psychiatry & Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA. Both of which overlapped with work on this project but are no longer these authors' primary affiliations.
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Pan, E.J., Liu, J.C., Zha, A.C. et al. Adverse Childhood Experiences (ACEs) in Unhoused Children Increase Odds of Psychiatric Illness, Physical Illness, and Psychiatric Admission. Journ Child Adol Trauma (2024). https://doi.org/10.1007/s40653-023-00608-z
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DOI: https://doi.org/10.1007/s40653-023-00608-z