Abstract
Young children experiencing homelessness are at considerable risk for developing physical and cognitive impairments, yet federal and state programs often overlook their needs. Although early intervention programs should serve as family-centered, health-promoting resources for families experiencing homelessness, many do not locate and comprehensively screen eligible children ages ≤3 yr in their communities. Occupational therapy practitioners have a role in advocating for improved access to high-quality, federally mandated programming for this population. They should be aware of the barriers faced by homeless families in accessing equitable early developmental services and of strategies to support individual families and communities experiencing homelessness.
This article highlights the unique developmental needs of young children experiencing homelessness and the challenges faced by this population in accessing equitable early developmental services. The authors outline suggestions for occupational therapy practitioners to advocate for this population at the individual, community, and population levels.
Early childhood experiences and learning opportunities set the stage for later development and occupational opportunities. The urgent need to address early childhood care is supported by research demonstrating that early childhood experiences, positive or negative, can have a lasting impact on children’s life trajectories (Shonkoff, 2016). Despite this knowledge, the public focus on the early childhood needs of some of the most vulnerable children, such as those experiencing homelessness, is considerably lacking. The rate of developmental delay among children experiencing homelessness is double that of their housed peers, yet this population experiences considerable challenges in accessing early developmental services (Clark et al., 2019; Grant et al., 2007). In Massachusetts, for example, an estimated 88% of children experiencing homelessness are underserved by federally funded programs (Lee et al., 2021). Federal and state programs, such as early intervention (EI), are in place to support the developmental needs of young children, but they are not consistently implemented as mandated, leaving children and families experiencing homelessness at a particular disadvantage in regard to receiving high-quality services (Barger et al., 2018; National Center for Homeless Education, 2018).
The purpose of this article is to highlight the unique developmental needs of young children (ages ≤3 yr) experiencing homelessness; describe the challenges faced by this population in accessing early developmental services in one state; and outline suggestions for occupational therapy practitioners to advocate for this population at the individual, community, and population levels.
Children Experiencing Homelessness Are at Considerable Risk for Developing Developmental Impairments
Many young children facing homelessness experience higher rates of developmental delay and social– emotional problems compared with their housed peers, resulting in decreased participation in age-appropriate daily activities. Several biological and social influences can explain this disproportionately high rate of developmental impairment. A growing body of research supports the damaging effects of adverse childhood experiences, defined as traumatic experiences occurring before age 18, on long-term health and developmental outcomes (Chung et al., 2016; Shonkoff, 2016). Traumatic events can trigger stress responses that permanently alter brain development and in turn affect the development of social, emotional, and adaptive functioning (DeCandia & Bassuk, 2012; Shonkoff, 2016; Shonkoff et al., 2012). Children experiencing homelessness are routinely exposed to traumatic events, such as prolonged exposure to unstable physical environments, parental mental health disorders, domestic abuse and conflict, and separation from a primary caregiver (Administration for Children and Families [ACF], 2016).
The effects of these stressors appear to be most damaging in early childhood, the time at which brain plasticity is highest and neural pathways and brain development are most critical (DeCandia & Bassuk, 2012; Shonkoff, 2016). Research suggests that the duration of homelessness and the developmental timing of it may compound developmental risks and lead to poor health outcomes (Sandel et al., 2018). Put more specifically, experiencing homelessness earlier in development appears to increase the risk of negative developmental and health trajectories (Clark et al., 2019; DeCandia et al., 2017; Sandel et al., 2018). Brown et al. (2017) found that children ages 18 to 41 mo had a higher risk of de velopmental delays, behavioral challenges, and poor acquisition of preacademic skills 20 mo after an emergency shelter stay compared with national norms for this age range. Additional factors, such as poverty, domestic violence, parental health literacy, and restraints on physical environments and social supports also affect the development of children experiencing homelessness (Chung et al., 2016; Synovec & Aceituno, 2020).
Children Experiencing Homelessness May Have Restricted Occupational Opportunities
Engagement in age-appropriate, family-centered occupations is critical for young children’s cognitive, emotional, and adaptive functioning (Jasmin et al., 2018; Schultz-Krohn, 2004). Through play, children develop social–emotional skills and acquire language and motor skills that are necessary for participation in a variety of social contexts (DeCandia & Bassuk, 2012). Unfortunately, children experiencing homelessness often lack access to developmentally appropriate toys, healthy caregiver attachments, and enriching environments that allow for engagement in age-expected occupations (Schultz-Krohn, 2004; Townsend & Wilcock, 2004). Parents of young children living in shelters report obstacles to engaging in meaningful family occupational and social routines such as reciprocal play, bath time, and meal preparation, which are critical for early learning and social–emotional functioning (Shultz-Krohn, 2004). Parents often lack autonomy in choosing appropriate health- promoting occupations for themselves and their children because of limitations in resources, time, and knowledge (Schultz-Krohn, 2004; Townsend & Wilcock, 2004). Formation of healthy attachments to caregivers is another primary occupation of early childhood, one that is disrupted by unstable environments and caregivers (DeCandia & Bassuk, 2012). Young children exposed to homelessness experience occupational deprivation that both contributes to and exacerbates developmental delays.
Federal and State Programs Are Not Meeting the Needs of Families Experiencing Homelessness
The problem of developmental impairments among homeless children is compounded by the fact that this population experiences difficulties accessing developmentally appropriate services that could remediate early delays. Although resources and programs vary from state to state, examples of access disparities in one state can highlight the inequities experienced by this population and form the basis of a blueprint for change. For example, in Massachusetts children experiencing homelessness are reported to face significant challenges accessing EI services because of poorly outlined policies and inefficient collaboration among agencies involved in early care (Lee et al., 2021). A specific example is the use of catchment areas, or geographical regions that outline which EI agency will provide services to a family based on that family’s primary residence. The current policies surrounding catchment areas in Massachusetts result in families frequently losing services when they move shelters or temporary residences, forcing families to start over with a new agency, a lengthy and complicated process (Lee et al., 2021). High residential mobility and lack of access to technology influence the capacity of homeless caregivers to communicate with early care providers to coordinate services and establish continuity of care (Perlman, 2013).
Caregivers also report that stigma and a fear of culpability prevent them from seeking out EI services (Lee et al., 2021). They have reported feelings of inadequacy when identifying delays in their children, and they fear involvement of the local department of children and families should EI services be initiated (Lee et al., 2021). Group-based services could minimize the stigma associated with EI, but there is limited funding for this kind of service, and EI programs must rely on individual initiatives by employees to seek out grant funding (DeCandia et al., 2017; Lee et al., 2021).
Although EI and Early Head Start programs have been effective in improving developmental outcomes, enrollment in these programs and their success in detecting and treating developmental delays in children experiencing homelessness is contingent on coordination among schools, service provider agencies, and early childhood programs (National Center for Homeless Education, 2013). Increasing coordination among EI programs and other systems that provide services to homeless families has been identified as an important step in improving access for this population (National Center for Homeless Education, 2013). Part C of the Individuals With Disabilities Education Act of 1990 (Pub. L. 101-476; IDEA) mandates the provision of EI services to children ages ≤3 yr who have developed, or are at risk of developing, impairments. Part of this legislation outlines each state’s obligation to have a comprehensive Child Find System to locate, identify, and evaluate all infants and toddlers from birth to age 3 yr with, or at risk of developing, impairments. Despite these federally mandated requirements, there are considerable gaps in the implementation of Child Find procedures (Barger et al., 2018). The literature suggests that few programs comprehensively screen, evaluate, and provide interventions to eligible children as mandated by Part C of IDEA (Barger et al., 2018).
Shelters, which could act as a first point of entry for children experiencing homelessness to access EI, do not comprehensively screen children for developmental delays (ACF, 2016; Chiu & DiMarco, 2010). One study that surveyed shelter directors across the United States reported that only 19% of children in shelters received developmental assessments (ACF, 2016; Chiu & DiMarco, 2010). Moreover, although the McKinney–Vento Homeless Assistance Act (1987) mandates that local liaisons locate and coordinate educational services for children ages ≥3 yr, there is no such designated role for children ages ≤3 who are eligible for services under Part C of IDEA (National Center for Homeless Education, 2018). Thus, very young children experiencing homelessness may encounter more barriers to appropriate services compared with school-age children. The issue again is that of poor coordination across agencies involved in working with young children and families experiencing homelessness. Although federally funded and state-run EI programs could be the solution to help support positive development in children and families experiencing homelessness, they are simply not meeting these families’ needs.
Opportunities to Advocate for Change
The coronavirus disease 2019 pandemic has brought to light considerable health care inequities faced by marginalized U.S. populations, including children and families experiencing homelessness (Leggiadro, 2020; Sonu et al., 2021). The needs of these children and families are significantly underrepresented in local and state homelessness and early education planning efforts (Perlman, 2013). Awareness of the impact of homelessness on young children among early childhood providers, homeless services providers, and the general public is limited (Perlman, 2013; Sonu et al., 2021). Advocacy initiatives to reduce health care disparities have largely focused on the adult population (Perlman, 2013); however, examples of innovative policies and initiatives throughout the country that address the needs of children experiencing homelessness can provide a blueprint for future advocacy. In Massachusetts, for example, legislation is currently in committee that would mandate developmental screenings for all children entering a shelter (H. 200, 2021). Additional legislation was introduced that would create a new director-level disability-access position in the Massachusetts Department of Early Education and Care; this person would be responsible for improving language access and providing subsidies for early education and care. These requirements could significantly improve access to, and coordination of services for, children experiencing homelessness (H. 605, 2021).
The institutional and structural barriers faced by children and families experiencing homelessness are complex and multifaceted. Occupational therapy practitioners are capable of advocating for this population through actions that influence individual, community, or population-level outcomes. In the sections that follow, we offer a few examples of how occupational therapy practitioners can support this underserved population.
Individual Clients and Families
Help Families Establish Routines in Shelters or Temporary Residences
Occupational therapy practitioners understand the importance of structure and routine to both the development of skills and meaningful engagement in family relationships, and they can support families in shelters by helping them establish routines around play, mealtimes, and grooming.
Educate Families on Low-Cost Games and Activities to Support Their Children’s Development
Occupational therapy practitioners can use existing family or shelter materials to demonstrate how to play a variety of games, support language acquisition, and increase children’s independence in daily activities.
Connect Families With Resources
Occupational therapy practitioners can use individual advocacy skills to ensure that families have the skills and tools to follow through with referrals, and they can connect families with local programs and resources.
Communities Experiencing Homelessness
Advocate for Trauma-Informed Training for Early Intervention Staff
Clinicians need special training in trauma-informed care to best meet the needs of this population (ACF, 2016; Lee et al., 2021). Occupational therapy practitioners working with families experiencing homelessness need this training and are encouraged to advocate for trauma-informed training in their practice settings.
Develop or Support the Development of Group-Based Services in Shelters
Occupational therapy practitioners working in EI should advocate for the provision of shelter-based groups, which may include working with administrators to locate grant funding for services.
Research and Connect With Other Programs in Your Area That Could Support Clients
Occupational therapy practitioners can identify and facilitate collaboration opportunities between EI programs and other community-based organizations, such as Early Head Start centers; Special Supplemental Nutrition Programs for Women, Infants, and Children (WIC); university-sponsored free therapy clinics; and homelessness advocacy groups. These collaborations may also extend to the creation of state association special interest groups or fieldwork opportunities.
Advocate for Increased Interagency Coordination
Local organizations that serve families experiencing homelessness, such as advocacy groups, shelters, Head Start programs, and EI programs, should take steps to improve coordination with each other. Occupational therapy practitioners can suggest infrastructure changes or create communities of practice to increase this coordination.
Homeless Population
Connect With Legislators
Occupational therapy practitioners should connect directly with their legislators to advocate for existing or new legislation that would improve the EI or early education landscape in their state. Occupational therapy practitioners can learn about pending legislation through state or federal resources or by connecting directly with advocacy groups who are working with people experiencing homelessness.
Use Social Media as an Advocacy Tool
Social media has been identified as an important tool for health promotion because it is a means of engaging with audiences, and thus it should be considered when advocacy initiatives are being developed (Neiger et al., 2012). Occupational therapy practitioners are encouraged to use social media to highlight inequities experienced by the homeless population, share the work of advocacy groups that are pursuing meaningful solutions, and outline calls to action for fellow practitioners.
Conclusion
AOTA’s (2017) Vision 2025 defines leaders as those who are “influential in changing policies, environments and complex systems” (p. 1). There is a need for increased public and political awareness of, and action to eradicate, the barriers faced by homeless families in accessing equitable, high-quality early developmental services. Early childhood programming and resources vary from state to state, and across the country children experiencing homelessness are at risk of developing lifelong impairments in health and quality of life (Clark et al., 2019; Grant et al., 2007). Occupational therapy practitioners are skilled at identifying how personal and environmental factors affect a person’s ability to carry out daily activities, including important childhood occupations (e.g., play and learning). Occupational therapy practitioners working in EI, in community-based practice settings, and with families experiencing homelessness should be aware of the challenges this population faces when trying to access federal or state programming that supports childhood developmental needs. We encourage occupational therapy practitioners to use the advocacy actions we have outlined in this article to ensure equitable access to health-promoting and preventive EI services for this population.