OBJECTIVE: Previous studies of homeless children have described more health problems and service use than in housed children, but failed to control for potential confounding factors that may differ between these children. This observational study examines the relationship of homelessness and other determinants to health status and service use patterns in 627 homeless and low-income housed children. METHODS: Case-control study of 293 homeless and 334 low-income housed children aged 3 months to 17 years and their mothers conducted in Worcester, Massachusetts. Information was collected about mothers' housing history, income, education, emotional distress, and victimization history. Standardized instruments were administered to assess children's health. Health service use questions were adapted from national surveys. Main outcome measures included health status, acute illness morbidity, emergency department and outpatient medical visits. Multivariable regression analyses were used to examine the association of family and environmental determinants, including homelessness, with health status and service use outcomes. RESULTS: Mothers of homeless children were more likely to report their children as being in fair or poor health compared with their housed counterparts. Homeless children were reported to experience a higher number of acute illness symptoms, including fever, ear infection, diarrhea, and asthma. Emergency department and outpatient medical visits were higher among the homeless group. After controlling for potential explanatory factors, homeless children remained more likely to experience fair or poor health status (adjusted odds ratio [OR] = 2.83; 95% confidence interval [CI], 1.16, 4.87), and a higher frequency of outpatient (OR = 1.71; 95% CI, 1.18, 2.48) and emergency department visits (OR = 1.21; 95% CI, 0.83, 1.74). Mothers' emotional distress was independently associated with acute illness symptoms and frequent use of outpatient and emergency department settings. CONCLUSIONS: Homelessness is an independent predictor of poor health status and high service use among children. The present findings highlight the importance of preventive interventions and efforts to increase access to primary care among homeless children.

OBJECTIVE: Hunger, with its adverse consequences for children, continues to be an important national problem. Previous studies that document the deleterious effects of hunger among children cannot distinguish child from family hunger and do not take into account some critical environmental, maternal, and child variables that may influence child outcomes. This study examines the independent contribution of child hunger on children's physical and mental health and academic functioning, when controlling for a range of environmental, maternal, and child factors that have also been associated with poor outcomes among children. METHODS: With the use of standardized tools, comprehensive demographic, psychosocial, and health data were collected in Worcester, Massachusetts, from homeless and low-income housed mothers and their children (180 preschool-aged children and 228 school-aged children). Mothers and children were part of a larger unmatched case-control study of homelessness among female-headed households. Hunger was measured by a set of 7 dichotomous items, each asking the mother whether she has or her children have experienced a particular aspect of hunger during the past year--1 concerns food insecurity for the entire family, 2 concern adult hunger, and 4 involve child hunger. The items, taken from the Childhood Hunger Identification Project measure, are summed to classify the family and divided into 3 categories: no hunger, adult or moderate child hunger, or severe child hunger (indicating multiple signs of child hunger). Outcome measures included children's chronic health condition count using questions adapted from the National Health Interview Survey, Child Health Supplement, and internalizing behavior problems and anxiety/depression, measured by the Child Behavior Checklist. Additional covariates included demographic variables (ie, age, gender, ethnicity, housing status, number of moves, family size, income), low birth weight, child life events (ie, care and protection order, out of home placement, abuse, severe life events count), developmental problems (ie, developmental delay, learning disability, emotional problems), and mother's distress and psychiatric illness. Multivariate regression analyses examined the effect of child hunger on physical and mental health outcomes. RESULTS: The average family size for both preschoolers and school-aged children was 3; about one third of both groups were white and 40% Puerto Rican. The average income of families was approximately $11 000. Among the school-aged children, on average 10 years old, 50% experienced moderate child hunger and 16% severe child hunger. Compared with those with no hunger, school-aged children with severe hunger were more likely to be homeless (56% vs 29%), have low birth weights (23% vs 6%), and have more stressful life events (9 vs 6) when compared with those with no hunger. School-aged children with severe hunger scores had parent-reported anxiety scores that were more than double the scores for children with no hunger and significantly higher chronic illness counts (3.4 vs 1.8) and internalizing behavior problems when compared with children with no hunger. There was no relationship between hunger and academic achievement. Among preschool-aged children, who averaged 4 years of age, 51% experienced moderate child hunger and 8% severe child hunger. For preschoolers, compared with children with no hunger, severe hunger was associated with homelessness (75% vs 48%), more traumatic life events (8.5 vs 6), low birth weight (23% vs 6%), and higher levels of chronic illness and internalizing behavior problems. Mothers of both preschoolers and school-aged children who reported severe hunger were more likely to have a lifetime diagnosis of posttraumatic stress disorder. For school-aged children, severe hunger was a significant predictor of chronic illness after controlling for housing status, mother's distress, low birth weight, and child live events. For preschoolers, moderate hunger was a significant predictor of health conditions while controlling for potenns while controlling for potential explanatory factors. For both preschoolers and school-aged children, severe child hunger was associated with higher levels of internalizing behavior problems. After controlling for housing status, mother's distress, and stressful life events, severe child hunger was also associated with higher reported anxiety/depression among school-aged children. CONCLUSION: This study goes beyond previous research and highlights the independent relationship between severe child hunger and adverse physical health and mental health outcomes among low-income children. Study findings underscore the importance of clinical recognition of child hunger and its outcomes, allowing for preventive interventions and efforts to increase access to food-related resources for families.