How Does Homelessness Affect Parenting Behaviour? A Systematic Critical Review and Thematic Synthesis of Qualitative Research

The recovery experiences of homeless service users with substance use disorder: A systematic review and qualitative meta-synthesis

BACKGROUND

The relationship between homelessness and substance use disorder (SUD) is layered and complex. Adults pursuing recovery while dealing with homelessness and SUD face many challenges. Little research has inspected qualitative first-person accounts of recovery in the context of homelessness and SUD, and few studies have employed conceptualisations of recovery beyond abstinence. In this systematic review study, we examine the qualitative literature on the recovery experiences of adult homeless service users with SUD.

METHODS

2,042 records were identified via database and secondary searching strategy. After title and abstract and full text screening, 15 eligible studies remained. Critical Appraisal Skills Programme quality appraisal criteria was used to assess potential bias in the studies. Meta-ethnography was employed to synthesise extracted data.

RESULTS

Four themes were generated from the extracted data: Two sides of the Service Coin; Navigating Relationships; Recovery Practices and Personal Attributes; and Housing as Foundational for Recovery.

CONCLUSION

Unconditional housing, a broad array of supports, opportunities to contribute to society, and family reunification supports all facilitate the development of recovery for adults with SUD experiencing homelessness. Implications for policy are discussed.

Building resilience in families experiencing homelessness through integration of health, parenting and child development programs

Children who experience homelessness are vulnerable to mental health problems, developmental delays and lower academic achievement. Research suggests that parental health literacy, sensitive parenting behaviour and child self-regulation are modifiable mechanisms that might enhance children's resilience to adversities associated with homelessness, yet empirical evidence on implementing such interventions in shelter settings is limited. Through a coordinated academic-community partnership, this study aimed to examine the (1) feasibility of conducting an integrated health approach in shelter settings and (2) the effectiveness of separate interventions on child and parent outcomes. Results are discussed in terms of best practices in shelter settings and building resilience in families experiencing homelessness with young children.

Infant fearful distress, parent intrusiveness, and adversity in families experiencing homelessness

Infants experiencing homelessness face risk for developing mental health problems in the future. Parents residing in shelters experience adverse events at elevated rates compared to non-homeless individuals, which can impact their infants during a time of rapid development depending on how the parent copes. For some, trauma linked to these events may manifest in an intrusive parenting style that interferes with the child's developing capacity for self-regulation. We utilized a sample of 60 parent-infant dyads recruited while residing in emergency homeless shelters to evaluate associations among parents' history of adversity, intrusive parenting behaviors, and infants' fearful distress. Observed parent intrusiveness during a free play interaction was significantly associated with infant fearfulness observed in a separate behavioral task during which infants viewed a series of masks. Furthermore, there was a moderating effect for parent history of adversity such that the association between parent intrusiveness and infant fearful distress was stronger among parents with more past experiences of adversity.

Profiles and Predictors of Neurodevelopmental Functioning among Young Children Experiencing Family Homelessness

In the context of family homelessness, children experience acute adversities related to loss of housing and residential mobility compounded with more chronic, poverty-related adversities and stressors. Among children in families experiencing homelessness, variability in experiences and outcomes warrant person-centered approaches to better delineate patterns of risk and resilience. Using latent profile analysis as a person-centered approach, we identified five distinct profiles of neurodevelopmental functioning within a sample of 231 children (ages 3-5 years old) staying in emergency homeless shelters with their families. Latent profiles were informed by indicators from parent-reported items for ten different domains of neurodevelopmental functioning. We examined whether demographic and ecological factors including age, ethnicity, adverse childhood experiences, parent mental health, and overreactive parenting would predict profile membership. Overall, half of the children in the sample demonstrated a profile of resilient functioning across developmental domains. Profiles of maladaptive functioning differed in areas of strength and challenge, with a small percentage of children showing poor functioning across all domains. Children whose parents had more mental health problems or overreactive parenting were significantly more likely to show profiles of poor functioning than to show resilient functioning. Implications for future research, practice, and policy are discussed.

Lifestyle Patterns of Children Experiencing Homelessness: Family Socio-Ecological Correlates and Links with Physical and Mental Health

Diet, screen time, physical activity, and sleep combine into lifestyle patterns with synergistic effects on health. This study aimed to identify lifestyle patterns in children without housing and assess their associations with physical and mental health and family socio-ecological factors. In the 2013 ENFAMS cross-sectional survey (children aged 6-12 experiencing homelessness, Greater Paris area, n = 235), parents reported socio-ecological factors, children's behaviours, and mental health (the latter was also child-reported). Nurses measured children's haemoglobin concentrations and body mass index. Principal component analysis was used to derive sex-specific lifestyle patterns. Hierarchical linear regressions and "outcome-wide" analyses assessed, respectively, these patterns' relations to health and family socio-ecological factors. A rather healthy lifestyle pattern-similarly characterized by diverse diet and high sleep time-was identified, with slight differences by sex. Scores for this pattern were higher for children in food-secure or higher-income households, whose parents were proficient in French, who slept longer, or who received more social support compared to their counterparts, with some nuances by sex. Higher scores for this pattern were associated with higher prosocial behaviour scores (girls) and lower anxiety and hyperactivity-inattention symptoms scores (boys), but not with physical health. For this underserved and understudied population, the results highlight the importance of family socio-ecological factors in shaping the lifestyles and mental health of children.

Perceptions of support in shelter environments for caregivers and young children experiencing family homelessness

BACKGROUND

Young children who stay with their families in homeless shelters face chronic challenges related to extreme poverty and acute risks from stressful events surrounding the loss of housing and move to shelter. These adversities increase the likelihood of a range of poor developmental outcomes. Consistent with the risk and resilience perspective, however, many children who experience family homelessness succeed, functioning as well or better than their non-homeless peers. As such, efforts to support resilience should consider how best to enhance protective factors, such as supportive environments within shelter settings.

METHODS

With data from 60 caregivers of children ages birth to 5 years recruited from family shelters, we assessed caregivers' perceptions of community support as well as child and family well-being in terms of recent adverse experiences, parenting stress, access to social support, and child social-emotional functioning.

RESULTS

Many caregivers experiencing family homelessness perceived negative aspects of the shelters where they were staying with their children. Furthermore, children whose caregivers had more negative perceptions of the shelter environment displayed worse social-emotional functioning, even when accounting for differences in parenting stress, recent family adversity, and other sources of social support.

CONCLUSIONS

Because young children rely on their caregivers as primary resources for nurturance and support, we encourage family homelessness service providers to work in partnership with caregivers to create more inclusive and empowering practices within the shelter context. Doing so is likely to improve children's developmental outcomes and the overall well-being of the families.

Social Workers’ Choice Making in Supporting Nature Activities by Parents and Children in Shelters

Visiting a natural environment such as a garden or park helps people to recover from stressful circumstances. Women’s shelters and homeless shelters have started to integrate nature in their work, especially for families who seek temporary refuge, with the aim to support parents’ functioning and resilience. For professionals who want to facilitate engagement with nature among their clients, it may be helpful to learn how other professionals choose nature activities for the support of parents. The current study was aimed to uncover how social workers choose a nature activity for the support of parents, resulting in a model that can be used as a reflective tool among shelter professionals. The model is based on an analysis of actions of professionals, captured in case descriptions written by shelter professionals about parenting supportive nature activities that they facilitated for families under their care. The model shows that social workers promoted a back-and-forth between children’s exploration away from the parent and being with the parent. In facilitating these interactions, social workers used nature as an environment with stress reducing and strengthening capacities for parents and as an environment with supportive qualities for children’s play. A dimensional framework was extracted that described how professionals may choose activities.

What about the babies? A critical review of infants' and toddlers' absence in homelessness scholarship

Rates of family homelessness continue to reach unprecedented levels. As many as two million young children experience family homelessness each year, with an estimated one in 10 younger than one year old. Yet, despite their high prevalence, a dearth of studies have specifically investigated infants' and toddlers' experiences of homelessness. Overall, the available literature suggests homeless infants and toddlers experience increased risk to physical health, development, and well-being at an individual- and family-level. This presents a severely limited understanding of homeless infants' and toddlers' experiences, with substantial gaps remaining. This review documents the scant existing literature on infant and toddler development within the context of homelessness at both the individual and family-system levels, and proposes next steps for research, practice, and policy.

"From Analog to Digital": The Feasibility, Acceptability, and Preliminary Outcomes of a Positive Parenting Program for Street-Connected Mothers in Kenya

BACKGROUND

Children of street-connected women in Kenya are at risk of child maltreatment. There have been increasing calls for positive parenting programs for parents experiencing homelessness, however never has one been implemented with this population. We therefore adapted the evidence-based Parenting for Lifelong Health for Young Children program using participatory methods, and piloted the adapted program with street-connected mothers in Kenya.

OBJECTIVES

To (a) determine if the adapted program was feasible and acceptable with street-connected mothers, and (b) assess indicative effects on child maltreatment, positive parenting, and parental stress.

PARTICIPANTS AND SETTING

Two groups of 15 mothers (ages 19+, and 20- ) participated between June-July 2018 in Eldoret, Kenya. Participants were eligible if they (a) were the mother of at least one child and (b) self-identified as street-connected.

METHODS

Feasibility was measured via enrollment, attendance, drop-out rates, and engagement in take-away activities. Focus groups explored program acceptability and program outcomes. Self-report surveys assessed pre-post changes in child maltreatment, parental stress, parental sense of inefficacy, and positive parenting practices.

RESULTS

70% of participants attended ≥3/4 of sessions, 10% dropped out, and >50% of take-away activities were completed. Participants reported high acceptability and requested its continuation for themselves and other parents. There was an increase in supporting good behaviour (t(21)=8.15, p < .000) and setting limits (t(18) = 10.03, p < .000); a reduction in physical abuse (t(23) = -2.15, p = .042) and parental stress (t(22) = -7.08, p < .000); results for parental inefficacy were not statistically significant (t(22) = 0.15, p = .882).

CONCLUSIONS

The adapted program is feasible and acceptable to street-connected mothers, and may reduce child maltreatment and parental stress, and increase positive parenting. Further research should test program effectiveness.

Housing insecurity and adolescent well-being: Relationships with child welfare and criminal justice involvement

BACKGROUND

Housing insecurity is endemic among low-income, marginalized families throughout the United States. Unstably housed families face increased likelihood of coming into contact with various social systems that upend family routines and norms, but the roles of these contacts in linking housing insecurity with long-term adolescent outcomes are unknown.

OBJECTIVE

The present study tested whether family contacts with the criminal justice and child welfare systems mediated links between housing insecurity and adverse adolescent outcomes.

PARTICIPANTS AND SETTING

Data came from at-risk families with children born 1998-2000 in 20 large American cities followed over 15 years (N = 2,892).

METHODS

Structural equation modeling estimated a measurement model using confirmatory factor analysis and a structural model testing direct and indirect pathways from housing insecurity to adolescent depression and delinquency via contact with the criminal justice and child welfare systems.

RESULTS

Housing insecurity was associated with increased contact with both the criminal justice and child welfare systems. Housing insecurity at age 5 was directly associated with adolescent depression at age 15 (β = 0.09, p < 0.05) and indirectly associated with adolescent delinquency via mothers' criminal justice (β = 0.04, p < 0.05) and child welfare (β = 0.07, p < 0.05) contacts.

CONCLUSIONS

Families with high needs may face stigma or seek assistance that increases surveillance of families and thus likelihood for sanctioning by the criminal justice and child welfare systems. Providers and systems working with low-income, insecurely housed families must consider stigma faced by clients to avoid further marginalizing underserved populations.

NIH Toolbox executive function measures with developmental extensions: Reliability and validity with preschoolers in emergency housing

Research has shown that executive function (EF) skills are associated with resilience in preschoolers experiencing risk and adversity, but these studies have typically relied on large batteries of tasks to measure children's EF skills. There is a need for brief, reliable EF assessments that can be used in the field with diverse young children. The current study assessed the validity and test-retest reliability of two tablet-based EF tasks from the NIH Toolbox: The Dimensional Change Card Sort (DCCS) and the Flanker Inhibitory Control and Attention Test, each with a developmental extension (Dext) that is triggered when a child struggles with the standardized versions. Dext versions include easier levels intended to improve task accessibility for younger and disadvantaged children. Eighty-six preschoolers residing in emergency housing participated in two study sessions about one week apart, completing tablet-based DCCS-Dext and Flanker-Dext tasks, along with a table-top EF task (Peg-Tapping) and measures of vocabulary and numeracy. The majority of participants triggered the Dext portion of the DCCS and almost half triggered the Dext portion of the Flanker, underscoring the need for extensions of the Toolbox EF tasks to lower the floor of these measures. The Dext EF measures were positively associated with Peg-Tapping, after controlling for age and vocabulary, indicating construct validity. They were also correlated with math achievement, suggesting criterion validity. DCCS-Dext and Flanker-Dext showed moderate test-retest reliability after one week. Together, these findings demonstrate the value of developmental extensions for assessing EF skills among children experiencing risk and adversity.

Experiencing Nature to Satisfy Basic Psychological Needs in Parenting: A Quasi-Experiment in Family Shelters

Finding fulfillment of basic psychological needs may be difficult for parents living in shelters after becoming homeless or after escaping violence. This study tested if experiencing nature was associated with the basic psychological needs of parents in shelters. Need satisfaction and need frustration were measured among parents in shelters (N = 160), with one measurement in the standard indoor context of the shelter and one measurement while experiencing nature. Experiencing nature was associated with enhanced need satisfaction (d = 0.28) and reduced need frustration (d = −0.24). The effect was especially pronounced for parents with young children. Our findings suggest that the physical environment matters for parents’ basic psychological need fulfillment as they interact with their children in the context of sheltering. This finding opens a potential avenue for supporting parental functioning and resilience in the face of risk if these effects were to be replicated across settings using controlled experimental designs. At the very least, the findings may be discussed with practitioners and parents in the context of making shelter life and work more conducive to mental health and family functioning.

Understanding Mechanisms Driving Family Homeless Shelter Use and Child Mental Health

Homeless shelters throughout the U.S. are overcrowded and under-resourced. Families with children face substantial barriers to timely, successful shelter exit, and prolonged shelter stays threaten child mental health. This community-based system dynamics study explored barriers to timely, successful shelter exit and feedback mechanisms driving length of stay and child mental health risk. Group model building - a participatory systems science tool - and key informant interviews were conducted with clients (N = 37) and staff (N = 6) in three family homeless shelters in a Midwestern region. Qualitative content analysis with emergent coding identified key themes feedback loops. Findings indicated overcrowding delayed successful shelter exit; longer stays exacerbated crowding and stress in a vicious cycle. Furthermore, longer stays exacerbated child risk for mental disorder both directly and indirectly via crowding and caregiver stress. Capacity constraints limited families served, while contributing to ongoing unmet need. Future research should investigate the roles of these dynamic feedback relationships in the persistent vulnerability of homeless families. Service design should prioritize interventions that alleviate crowding and subsequent threats to mental health such as private or scattered-site shelter accommodations, affordable child care, and homelessness prevention to facilitate successful shelter exit and mitigate child mental health risk.

'Every day is hard, being outside, but you have to do it for your child': Mixed-methods formative evaluation of a peer-led parenting intervention for homeless families

We conducted a mixed-methods, formative evaluation of a peer-led parenting intervention for homeless families. Participants were parents living in temporary accommodation with self-identified difficulties related to parenting an index child aged 2-11 years. An evidence-based programme ('Empowering Parents, Empowering Communities') was adapted for delivery with the target population in London, UK. We assessed feasibility in terms of session attendance rate, intervention completion rate and potential for impact on a range of parent-reported outcomes measures. Acceptability and appropriateness were examined by a user satisfaction measure and qualitative interviews. The intervention was delivered across three group cohorts (N = 15). Thirteen parents completed the programme (including one parent who required two attempts). We found improvements in child behavioural difficulties, parenting knowledge and practices, while parental well-being and social support were unchanged. Participants were highly satisfied overall, with indications that the peer-led model mitigated negative expectancies of services and normalized experiences of parenting in challenging conditions. Parental self-care and 'the good enough parent' were strongly endorsed topics, although some content (e.g. timeout) was deemed impractical. These promising findings warrant further testing under controlled conditions.

Cumulative Adversity Profiles Among Youth Experiencing Housing and Parental Care Instability

This study applies cumulative adversity and stress proliferation theories to examine risk and protective resource profiles of youth with three different levels of housing and parental care instability. Data derive from a state representative sample (n=27,087) of school-based adolescent students. ANCOVA analyses identified significant differences in sociodemographic and psychosocial functioning variables for youth with 0, 1, or 2 forms of housing and parental care instability, with more deleterious functioning being observed among youth with greater levels of instability. Those experiencing either or both housing and parental care instability are more represented by males, sexual minorities, and youth of color; psychosocial risk and protective factors demonstrated consistent differences between instability groups. Dimensions of cumulative adversity operate with social marginalities (e.g., race, sexual minority status) relative to instability, with higher frequency of victimization, lower grades, diminished self-regulation capabilities and school engagement, weakened psychological health, and strained family and peer relationships. The paper discusses theorized mechanisms through which cumulative adversity conveys effects as well as implications for social work prevention and resilience-fostering strategies in schools and other youth-serving settings.

Assistive Technology for the Upper Extremities After Stroke: Systematic Review of Users' Needs

BACKGROUND

Technical innovations have the potential to compensate for loss of upper-limb motor functions after stroke. However, majority of the designs do not completely meet the needs and preferences of the end users. User-centered design methods have shown that the attention to user perspectives during development of assistive technology leads to devices that better suit the needs of the users.

OBJECTIVE

To get more insight into the factors that can bring the design of assistive technology to higher levels of satisfaction and acceptance, studies about user perspectives on assistive technology for the upper limb after stroke are systematically reviewed.

METHODS

A database search was conducted in PubMed, EMBASE, CINAHL, PsycINFO, and Scopus from inception to August 2017, supplemented with a search of reference lists. Methodological quality of the included studies was appraised. User perspectives of stroke survivors, carers, and health care professionals were extracted. A total of 35 descriptive themes were identified, from which 5 overarching themes were derived.

RESULTS

In total, 9 studies with information gathered from focus groups, questionnaires, and interviews were included. Barriers and enablers influencing the adoption of assistive technology for the upper limb after stroke emerged within 5 overarching but highly interdependent themes: (1) promoting hand and arm performance; (2) attitude toward technology; (3) decision process; (4) usability; and (5) practical applicability.

CONCLUSIONS

Expected use of an assistive technology is facilitated when it has a clear therapeutic base (expected benefit in enhancing function), its users (patients and health care professionals) have a positive attitude toward technology, sufficient information about the assistive technology is available, and usability and practical applicability have been addressed successfully in its design. The interdependency of the identified themes implies that all aspects influencing user perspectives of assistive technology need to be considered when developing assistive technology to enhance its chance of acceptance. The importance of each factor may vary depending on personal factors and the use context, either at home as an assistive aid or for rehabilitation at a clinic.