Mental disorders in offspring of parents who have been homeless
Authors: Wayne Hall
Journal: The Lancet Public Health (2017)

Homelessness is a pressing public health and humanitarian problem, which has probably worsened in many developed countries in the wake of austerity policies implemented after the global financial crisis of 2007–08.1Fazel S Geddes JR Kushel M The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations.Lancet. 2014; 384: 1529-1540Summary Full Text Full Text PDF PubMed Scopus (778) Google Scholar The residents of many large cities have sadly become accustomed to seeing homeless people sleeping in doorways or begging for change in their streets. Homeless people can also be parents and, as Sandra Feodor Nilsson and colleagues2Nilsson SF Laursen TM Hjorthøj C Thorup A Nordentoft M Risk of psychiatric disorders in offspring of parents with a history of homelessness during childhood and adolescence in Denmark: a nationwide, register-based, cohort study.Lancet Public Health. 2017; 2: e541-e550Scopus (15) Google Scholar report in The Lancet Public Health, a parental history of homelessness is a risk factor for poor mental health in children. The authors used record linkage to follow up a nationwide, prospective cohort of 1 072 882 children aged 0–16 years in Denmark from Jan 1, 1999, to Dec 31, 2015. A register of individuals in contact with homeless services provided data on parental history of homelessness, and data on mental disorders in parents and their offspring was obtained from a psychiatric case register covering the population of Denmark. These study features substantially improved on smaller and less well controlled studies than the present study, which have reported higher rates of mental disorders in the children of parents with a history of homelessness than in those whose parents had not been homeless.3Bassuk EL Richard MK Tsertsvadze A The prevalence of mental illness in homeless children: a systematic review and meta-analysis.J Am Acad Child Adolesc Psychiatry. 2015; 54: 86-96.e2Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar Nilsson and colleagues found that children born to a parent with a history of homelessness were more likely to receive a psychiatric diagnosis (IRR 2·5 [95% CI 2·3–2·7] for homeless mother, 2·3 [2·2–2·5] for homeless father, and 2·8 [2·4–3·2] for two homeless parents) than children of parents without such a history (after adjusting for year and the child's age, sex, and country of origin). The risk was reduced after adjusting for a parental history of mental illness or substance use disorders and parental age at birth, but remained significant. Children who had two homeless parents were at greater risk of developing attachment disorders (IRR 32·5 [24·6–42·9]) and substance use disorders (3·7 [1·5–9·0]) than those whose parents had not been homeless. The cumulative risk of a child developing a mental disorder by the age of 15 years was 35·9% (95% CI 27·1–44·8) if their mother had a history of homelessness and a psychiatric diagnosis. The risk was 10·2% (10·1–10·3) for children whose mothers had no such history. There are many reasons why parental homelessness would increase the risk of mental disorders in offspring. Homelessness makes parenting difficult and it is usually accompanied by social adversity and poverty.4Braveman P Heck K Egerter S Rinki C Marchi K Curtis M Economic hardship in childhood: a neglected issue in ACE studies?.Matern Child Health J. 2017; (published online Oct 3.)DOI:10.1007/s10995-017-2368-yPubMed Google Scholar Unstable housing interferes with children's schooling and prevents them from developing friendships and social relationships with peers. There could also be genetic risks of developing mental disorders that increase the risk of parental homelessness and their offspring's risk of developing these disorders. Like all studies that link large administrative datasets, Nilsson and colleagues' study is restricted in its ability to control for important confounders that are not assessed in these datasets. These factors include the availability of alternative family support, undiagnosed mental disorders in parents, and the parents' and children's pre-existing risks of developing these disorders. These cofounders limit the authors' ability to make inferences about the specific ways in which homelessness contributes to the development of mental disorders in children. Nonetheless, the study findings clearly show that the children of homeless parents are at increased risk of developing attachment and substance use disorders. These mental disorders are likely to further diminish the life chances of these children by reducing their educational attainments and subsequent employment opportunities. These disorders also reduce their chances of developing healthy and satisfying relationships in adulthood.5Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1543) Google Scholar Denmark has a well developed social welfare system; the predicament of children with homeless parents is likely to be much worse in countries that have radically cut social welfare and health services in times of austerity. Nilsson and colleagues' findings strengthen the case for improving health services and social support for homeless adults and their children. It is less clear, in the absence of good quality research,6Fitzpatrick-Lewis D Ganann R Krishnaratne S Ciliska D Kouyoumdjian F Hwang SW Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review.BMC Public Health. 2011; 11: 638Crossref PubMed Scopus (159) Google Scholar, 7Bassuk EL DeCandia CJ Tsertsvadze A Richard MK The effectiveness of housing interventions and housing and service interventions on ending family homelessness: a systematic review.Am J Orthopsychiatry. 2014; 84: 457-474Crossref PubMed Scopus (54) Google Scholar which interventions will most effectively reduce homelessness and its attendant social disadvantages. Finding better ways to address parental homelessness should be a research priority for services that seek to improve the mental health of homeless people and their children. I declare no competing interests. Homeless people—their health and their children's health400 000 in Europe. 550 000 in the USA. About 3000 in Paris, Barcelona, or London. Those are the estimates of the number of people homeless nightly. Although methodological and definition differences challenge estimations of the number of people who are homeless and comparisons between countries, still those numbers speak for themselves. What they might not reveal, however, are the visages, the lives and stories behind those estimates. Full-Text PDF Open AccessRisk of psychiatric disorders in offspring of parents with a history of homelessness during childhood and adolescence in Denmark: a nationwide, register-based, cohort studyParental homelessness was associated with an increased risk of psychiatric disorders in offspring during childhood and adolescence. These findings have important implications for public health and policy because they suggest a need for improvement in the support of socially marginalised families to help prevent psychiatric illness in offspring. Full-Text PDF Open Access