Feasibility of Shelter-Based Mental Health Screening for Homeless Children

Abstract

Homeless children are known to be at risk for mental health and behavioral disorders due to housing instability and family and environmental risk factors, such as domestic violence. However, homeless children seldom receive screening for mental health and behavioral disorders with validated instruments. Moreover, few examples exist of programs that integrate outreach, screening, referral to appropriate diagnostic and therapeutic services, and care coordination. We describe early results of the Medical Home for Homeless Children Project, whose nurse care coordinators work with homeless families to conduct standardized nursing assessments that include evidence-based screening for child mental health and behavioral disorders with referral and case management for mental and behavioral health services. Screening identified a group of children with mental health issues that warranted referral, and many of those referrals were successfully completed.

Family homelessness is a problem in the United States. Sheltered homeless families represented about one-third (535,447) of the 1.5 million homeless people in the U.S. in 2009, and children comprised nearly 60% (321,268) of these individuals.¹ In the last decade, the percentage of adults and children who were homeless in Duval County, Florida, increased by 19.9%.² In Florida, children comprise 16.1% of all sheltered homeless individuals.³ Homeless children have higher rates of mental and behavioral health problems than housed children, and homeless children are especially at risk for conditions such as anxiety and depression.^4,5 Indeed, one study indicated that the majority (78%) of school-age homeless children had a behavior problem, academic delay, or depression.⁵ These higher rates of mental health problems among homeless children may be the result of adverse childhood experiences associated with homelessness.⁶ Access to mental health services is often limited due to the families' unstable living arrangements and system barriers,⁷ and this situation commonly leads to a failure to address mental health needs in homeless children.⁸

The high-risk status of homeless children creates a critical need for screening, referral, and coordination of mental health services; however, there is little reported research on whether these programs are feasible and practical.⁹ Strategies such as mental health outreach and screening among homeless children may represent one way to identify child mental health problems early in the life course and represent an opportunity for preventing mental health symptoms from worsening in childhood and persisting into adulthood.¹⁰ When screening is combined with referral and care coordination within a medical home model, the overall strategies may address the system- and family-level barriers and facilitate appropriate treatment in this difficult-to-reach group. However, research on this type of coordinated approach to mental health services for homeless children is scant. To provide more insight into this issue, this study focused on the research question, “What mental health screening and referral rates might be achieved by a nurse-led medical home for homeless children?”

PURPOSE

This pilot study assessed the feasibility of a nurse-run mental and behavioral health screening, referral, and coordination program, called the Medical Home for Homeless Children Project (MHHCP), in screening children who reside in nine homeless shelters in Jacksonville, Florida. The focus of the study was on the practicality of service delivery given resource constraints and the challenges of working with a target population whose living arrangements are transitional.⁹ These shelters are community-based organizations, and some of them are run by faith-based agencies. They serve approximately 476 children per year. MHHCP nurses aim to conduct outreach and screening for physical health, development, and mental health conditions; coordinate referrals to physical health, mental health, and social services; track screening results and referrals; and follow up with this large number of children to ensure that they access and continue in appropriate care.

METHODS

This study employed a retrospective analysis of data collected by the MHHCP staff that included demographic, screening, referral, and follow-up data from children entering the program from December 2011 to November 2012, the study year. For the purposes of this study, we defined homeless as any child or family who presented at one of the nine homeless shelters in Jacksonville. Staff at all homeless shelters referred children to nurse care coordinators (NCCs) if the children were expected to stay at the shelter for at least three days. Children who were expected to be in shelters for shorter durations (<3 days) were not referred. NCCs went to the shelter for three visits to introduce MHHCP services and conduct a comprehensive nursing health assessment and mental health screening. For mental health screening, they used the Ages and Stages Questionnaire: Social Emotional (ASQ:SE) for children aged 0–5 years¹¹ and the Strengths and Difficulties Questionnaire (SDQ) for children aged 6–17 years.¹²

The ASQ:SE and the SDQ are widely used child mental health screening tools that are validated for use with populations affected by poverty, low education, low income, and other factors common to homeless populations.^13,14 Standardized cutoff scores were used to identify passing and failing scores on the ASQ:SE by age interval. SDQ scores >17 were coded as a failing score for all ages. Parents/guardians completed the screening instruments (with NCC assistance where appropriate) on a voluntary basis. The NCC discussed the screening results with the parents/guardians and referred children who had a failing score (i.e., scored above standard assessment cutoffs), or whose parents expressed concerns about their children's mental health, to mental/behavioral and developmental health services in the community. The NCC followed up with both the family and the provider to ensure the referral was completed.

The NCCs collected and tracked the following information: demographic data on the child (e.g., age, race, and gender), the agency to whom the child was referred, appointment date, screening instrument score, and the date the referral was completed. Mental health referrals were coded as kept, not kept, or in progress as of the end of January 31, 2013. If children were already receiving mental health care at the time of the nursing assessment, a referral was deemed unnecessary.

OUTCOMES

Of the total estimated annual population of 476 homeless children, 326 (68%) had initial contact with MHHCP during the study period. A total of 118 (36%) of these 326 children completed screenings (Table 1). More than half of the children who completed screening (53%) were ≤5 years of age, 53% of the children were male, and 56% were African American. The 118 screened children had 73 caregivers, of whom 70 (96%) were female, 17 (23%) were aged 18–24 years, 30 (41%) were aged 25–34 years, and 26 (36%) were aged ≥35 years. Of the parents/guardians, 40 (55%) were African American, 26 (36%) were white, 63 (86%) were unmarried, and 39 (54%) had less than a 12th grade education (data not shown).

Table 1.

Screening status of children <18 years of age served by the Medical Home for Homeless Children Project (n=326): Jacksonville, Florida, December 2011–November 2012

^aUnscreened children are children who did not receive ASQ:SE or SDQ screening.

^bScreened children are children who received ASQ:SE screening or SDQ screening.

^cEligible children are children who were in the homeless shelter long enough (≥3 days) to have contact with a Medical Home for Homeless Children Project nurse care coordinator.

ASQ:SE = Ages and Stages Questionnaire: Social Emotional

SDQ = Strengths and Difficulties Questionnaire

Slightly less than one-quarter (n=12) of the younger children had an ASQ:SE failing score (above the cutoff), prompting a mental health referral. One-third (n=22) of the older children had a failing SDQ score (above the cutoff, mean score = 11.5), also prompting a referral (Table 2). An additional 16 children were considered to be at risk due to the identification of factors in the clinical interview (e.g., the caregiver saying that the child was overactive, fighting with siblings, withdrawn, or holding in his/her feelings) despite having passing ASQ:SE or SDQ scores (below the cutoff). These 16 children were also referred.

Table 2.

Mental health assessment results of children <18 years of age served by the Medical Home for Homeless Children Project: Jacksonville, Florida, December 2011–November 2012

^aThe ASQ:SE measures social and emotional functioning in children aged ≤5 years. To determine if a child scored below or above the ASQ:SE cutoff, the following scores (listed in parentheses by age range) were used: 6 months of age (45), 12 months of age (48), 18 and 24 months of age (50), 30 months of age (57), 36 months of age (59), and 48 and 60 months of age (70). Taken from: Squires J, Bricker D, Heo K, Twombly E. Identification of social-emotional problems in young children using a parent-completed screening measure. Early Childhood Res Q 2001;16:405-19.

^bThe SDQ measures mental health functioning in children aged 6–17 years. The SDQ cutoff score was 17. Taken from: Goodman R, Ford T, Simmons H, Gatward R, Meltzer H. Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatry 2000;177:534-9.

ASQ:SE = Ages and Stages Questionnaire: Social Emotional

SDQ = Strengths and Difficulties Questionnaire

In total, of the 118 children screened, 50 were referred for mental health services on the basis of their ASQ:SE and SDQ screening results or their clinical interview. Of these 50 children, as of January 31, 2013, 25 (50%) had completed their initial appointment for a mental health referral, five (10%) had referrals in progress, and 17 (34%) either had no record of a completed referral or the referral was in progress.

LESSONS LEARNED

Mental health screening of children in homeless shelters provides an important opportunity to identify children at high risk for mental health disorders. This project demonstrated that providing mental health screening through shelter-based care coordination to increase access to mental health services for these children was feasible in terms of practicality.⁹ Linking the mental health screening to care coordination can result in increased access to mental health services for these children.

While MHHCP aims for 100% screening of all children in shelters, in this study, NCCs completed mental health screening on only about one-third of the total number of children who were in homeless shelters for at least three days during the study year. Multiple reasons account for this low rate. First, many of the children who enter shelters are there for very short periods of time (i.e., less than a week), making it difficult to screen them. Children who reside in an MHHCP-accessible shelter for longer periods of time are screened more consistently. Another factor was the overall severity of circumstances that families encounter, including the child's mental health. Unless the child currently has substantially disruptive behavior or difficulties in school, mental health may be a lower priority for the parent/guardian than other urgent health issues, such as asthma exacerbations, infections, or getting required services (e.g., physicals and immunizations) to get the child back into school. In addition, the large proportion of parents/guardians with less than a high school education suggests that health literacy may be a factor in consenting to the screening process. In particular, mental health literacy may be an issue in screening participation, as parents/guardians may not recognize certain kinds of disorders and may hold different perspectives than NCCs concerning the need for treatment; as a result, these factors may impede their compliance.¹⁵ Also, some parents/guardians who had previous experience with the child protective services system may have been hesitant to share any family mental health issues with the NCC for fear of it resulting in new child abuse reports and child removal.

The screened children differed from unscreened children in important ways. A greater proportion of older children than younger children were screened, likely because families with younger children had shorter stays and higher rates of turnover in the shelters. The high rate (33%) of older homeless children having SDQ scores above the cutoff is much greater than the prevalence of failed SDQ scores that has been reported for the general population (7%).¹⁶ This higher rate may be due to the accumulated risks of negative life experiences, including homelessness, that result in higher rates of mental health disorders in children. Also, mental health symptoms may become more manifest in later years. The 23% of younger homeless children aged 0–5 years who scored above the ASQ:SE cutoff was comparable with rates found in the general population (29% at 36 months of age).¹³ The reasons for lack of referral completion may be similar to the barriers to screening itself: rapid turnover and the families having other, more pressing priorities, such as food and shelter.

CONCLUSION

Although MHHCP's objective is 100% referral completion, the 50% completion rate for an initial appointment to mental health services represents a substantial proportion of high-risk children who received mental health services who otherwise would likely not have received them. Briggs et al.¹³ found that universal social-emotional screenings are far from optimal even for well-child visits in committed pediatric practices. A large portion of the screenings accomplished with this project can be attributed to nursing outreach, relationship building, and care coordination through the episode of care. A critical determinant for the success of referrals post-screening is the general capacity in the community for children's mental health services and the system's outreach efforts. One aspect of adequate capacity that the MHHCP nurses have found to be critical is the availability of targeted case management by mental health service providers that complements the outreach and care coordination offered on the front end by the nurses. MHHCP nurses indicated that targeted case management both reduces barriers to access to therapeutic behavioral on-site services and assists their efforts at maintaining families in services over time.

The MHHCP did demonstrate that shelter-based screening and referral of homeless children by nurses is both needed and feasible, particularly for children with longer stays in shelters. While there may be missed opportunities for screening in shelters due to families' brief stays, more research is needed to clarify if children with shorter stays in homeless shelters are also at higher risk for mental health disorders. More research is particularly warranted to determine how best to increase the rates of both screening and completed referrals to mental health services for children in homeless shelters.