Protecting Children From Unhealthy Homes and Housing Instability

Protecting Children From Unhealthy Homes and Housing Instability

Highlights

• Several federal programs, including HUD’s Office of Lead Hazard Control and Healthy Homes, work to protect children from home health hazards such as lead or asthma triggers. Poor-quality housing disproportionately affects low-income and minority children.
• The Omaha Healthy Kids Alliance and the Healthy Homes Coalition of West Michigan are two local nonprofits that use various strategies to address home health concerns, including one-on-one home assessments; training for parents; and coordination with other programs, systems, and initiatives.
• Housing instability can lead to a range of negative outcomes for children, especially when instability leads to homelessness. The U.S. Interagency Council on Homelessness (USICH) has identified youth experiencing homelessness as a priority population and set a goal of ending youth homelessness by 2020.
• The Hollywood Homeless Youth Partnership and the Houston Coalition for the Homeless are two local organizations implementing strategies from USICH’s “Framework to End Youth Homelessness” by collecting better data about youth experiencing homelessness and building the capacity of youth-serving agencies.

Children who do not live in safe, quality housing — whether because of the presence of health hazards such as lead or asthma triggers; housing instability, including homelessness; or other reasons — experience high rates of physical, mental, and emotional problems.1 Poor-quality housing disproportionately affects low-income and minority children (see “Housing’s and Neighborhoods’ Role in Shaping Children’s Future,” p. 1), and certain populations such as lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) youth and youth aging out of foster care are at increased risk of experiencing homelessness.2 Improving the health and well-being of children, especially those in the most vulnerable groups, depends in part on protecting them from unhealthy homes and housing instability. This article reviews some of the federal programs that address home health and homelessness and profiles several local organizations that coordinate collaborative efforts to assess and remediate home health hazards and address the needs of youth experiencing homelessness.

Unhealthy Homes

Evidence shows that poor-quality housing negatively affects children’s physical and emotional health.3 Childhood asthma has been associated with poor air quality and exposure to mold and allergens from dust mites, cockroaches, and rodents. Lead paint exposure has been linked to cognitive impairments including reduced impulse control.4 The presence of fire hazards, carbon monoxide, radon, secondhand smoke, poor lighting, cluttered floors, and unsecured firearms in the home along with inadequate adult supervision of young children in tubs and pools heighten the risk of disease or injury.5 These largely preventable home health hazards impose high health and economic costs on children, their families, and society at large, with a number of studies citing annual health costs in the billions of dollars for each of several specific home health threats.6 Studies have found that various interventions can effectively improve children’s health and reap cost savings.7

Regular hand washing and removing shoes before entering a home can help protect children from exposure to lead through contaminated soil. Photo courtesy: Centers for Disease Control and Prevention Public Health Image Library/ Cade Martin, photographer In response to these hazards and the harm they inflict on children and families, HUD’s Office of Lead Hazard Control and Healthy Homes enforces lead and lead-based paint regulations, supports research and outreach, develops guidelines and standards for healthy homes, and administers grant programs to support local organizations that promote healthy homes.8 In 1999, the Office of Lead Hazard Control initiated its Healthy Homes Initiative, which built on its existing Lead Hazard Control program to promote holistic home health assessments and interventions.9 Although funding for lead hazard control efforts remains the core of the office’s grant programs, applicants can also request supplemental Healthy Homes funding to address other health hazards.10 In addition, in recent years, HUD’s Healthy Homes Demonstration Grant and Healthy Homes Production Grant programs provided funding to nonprofits and other organizations for direct remediation and outreach, and its Lead and Healthy Homes Technical Studies programs currently fund research on home health hazards and interventions, such as a University of Texas at Austin study of the merits of using heating, ventilation, and air conditioning (HVAC) filters to evaluate the relationship between the concentration of asthma triggers in filter dust and asthma severity for asthmatic children in low-income rural households.11 A 2007 evaluation of Healthy Homes Initiative grant programs found that many grantees had successfully identified and remediated health threats and had demonstrated a positive health impact for various interventions.12 For example, the Cuyahoga County Department of Development combined weatherization and health interventions designed to control mold and moisture. Teaming with researchers from Case Western Reserve University and other partners to study mold and moisture remediation in homes of children with asthma, the department found reduced asthma symptoms and associated hospitalizations, especially when the interventions included home repairs such as the removal of water-damaged materials, leak repairs, and HVAC improvements.13 More recently, a Healthy Homes Technical Studies grant supported research finding that children who have a parent with asthma, live without air conditioning, or were exposed to high levels of dampness-associated molds at age 1 (but not at age 7) were at the highest risk of having asthma at age 7.14

Several additional federal initiatives seek to make home environments healthier. The U.S. Centers for Disease Control and Prevention’s (CDC’s) Healthy Homes and Lead Poisoning Prevention program, for example, supports efforts to tackle a range of home health dangers such as mold and cockroach dander, and the U.S. Environmental Protection Agency (EPA) works to contain threats posed by lead, radon, and other hazardous materials that affect home and neighborhood environments.15 HUD also partners with the U.S. Department of Agriculture (USDA) to support the Healthy Homes Partnership, an effort coordinated by Auburn University that provides home health information through a network of state coordinators. The initiative encourages residents to reduce health hazards in their homes.16 HUD and USDA also support the Northeastern Integrated Pest Management (IPM) Center at Cornell University to provide multifamily housing providers with technical assistance and training in IPM.17 HUD’s Office of Fair Housing and Equal Opportunity has worked with the Office of Lead Hazard Control and Healthy Homes to issue notices on the link between the presence of lead-based paint and familial status discrimination. HUD and its partners have charged many legal cases to protect families from discrimination related to lead hazard control regulations — for example, when landlords refuse to rent to families with children so that they do not have to complete required lead abatement. Finally, recognizing that home health issues cut across traditional silos, the Federal Healthy Homes Work Group convenes the expertise of representatives of HUD, the U.S. Department of Health and Human Services’ CDC and National Institute of Environmental Health Sciences, EPA, USDA, the U.S. Department of Energy, U.S. Department of Labor, and the National Institute of Standards and Technology to establish and promote healthy homes guidelines and support home health education, training, and research. In 2013, the interagency group drafted Advancing Healthy Housing: A Strategy for Action, published under the auspices of the President’s Task Force on Environmental Health Risks and Safety Risks to Children, to guide these efforts.18 In June 2013, Jon L. Gant, then-director of the Office of Lead Hazard Control and Healthy Homes, pointed to the development of the National Healthy Housing Standard by the National Center for Healthy Housing (NCHH) and the American Public Health Association as a vital early step in implementing the federal strategy.19

The evolution of federal policy regarding home health hazards — galvanizing first around lead control and remediation and later expanding to a more holistic “healthy homes” approach that encompasses a range of home environmental health threats — follows a wider pattern also adopted by national organizations such as NCHH and many local nonprofits.20 Two local healthy homes organizations that began with lead poisoning prevention campaigns and have since broadened their missions to include additional environmental threats that affect children’s well-being are the Omaha Healthy Kids Alliance (OHKA) and the Healthy Homes Coalition of West Michigan (HHC).

Omaha Healthy Kids Alliance

In Omaha, Nebraska, community mobilization for lead hazard control initially centered on the threat associated with an American Smelting and Refining Company lead refining plant sited on a 23-acre stretch of downtown. For more than a century, beginning in the 1870s, the refinery spread lead pollution over the surrounding area, contaminating the soil over an area of approximately 27 square miles containing thousands of residences. Aaron Ferer & Sons Company, and later Gould Electronics Inc., operators of a lead battery recycling plant, exacerbated the problem.21 In response to the Douglas County Health Department’s finding of elevated blood lead levels among the city’s children, the Omaha City Council invited EPA to investigate. EPA sampled the soil on local properties and, with the U.S. Army Corps of Engineers, began replacing residential soil in 1999.22 In 2004, EPA designated the area a Superfund site for large-scale cleanup and remediation.23 To facilitate community dialogue and coordinate collaboration among organizations responding to lead hazards, concerned stakeholders formed the Omaha Lead Site Community Advisory Group (CAG). The following year, CAG, in collaboration with then-mayor Mike Fahey, announced the formation of OHKA with initial funding provided by Union Pacific Railroad.24

The Omaha Healthy Kids Alliance partners with volunteers to paint and clean yards and basements. Photo courtesy: Omaha Healthy Kids Alliance EPA’s designation of Omaha as a Superfund site and its residential soil remediation activities played critical roles both in sensitizing the community to the dangers associated with lead and in the founding of OHKA, but it had unintended consequences that complicate OHKA’s current work. Although EPA cleanup remediates lead in residential yards — a significant threat to children’s health — it does nothing to address the primary lead threat, which has been and continues to be inside the home. The Douglas County Health Department estimates that exposure to lead-based paint accounts for 90 percent of Omaha’s incidences of lead poisoning.25 OHKA chief executive officer Kara Eastman notes that some families assume that once their yard has been replaced, they no longer have to worry about lead, even though they may still have lead hazards inside their home.26

OHKA’s Healthy Homes program assesses homes for lead as well as mold, radon, and other hazards.27 In 2012, OHKA augmented this program with a $750,000 award from the Kresge Foundation’s Advancing Safe and Healthy Homes Initiative to fund a full-time outreach worker, a city healthy homes inspector who works with code inspectors, and the assessment and remediation of health threats in 120 low-income homes.28 The grant enables OHKA to make approximately $1,500 worth of repairs to each home, such as replacing moldy drywall, stabilizing lead paint, and addressing asthma triggers.29 The grant funding to support a city code official has come just as the city is adopting new software that will allow other code enforcers to automatically refer cases to the healthy homes inspector when they see a health-related hazard. The opportunity, as Eastman sees it, is for reframing code enforcement: “[Y]ou’re not just there to give a ticket to somebody but rather to help a child or help somebody’s health.” Although this process is still in its early stages, it shows promise as a more systematic approach to health-related code enforcement that merits further evaluation.30

Outreach, education, and training are important components of OHKA’s efforts to protect children from home health hazards. In May 2014, OHKA hosted the first of a planned annual event, the Healthy Homes Summit, to promote community awareness of home health issues.31 In addition to its presence at the summit and other community events, OHKA produces public service announcements and developed a book geared toward children, The Lead Detectives, for outreach.32 OHKA seeks partners who are already engaged with children or their homes. Since 2011, OHKA’s participation in the One Touch program, which includes an information management system developed by the private consulting firm Tohn Environmental Strategies, has facilitated collaboration with other housing service providers including Habitat for Humanity, Rebuilding Together, the Omaha Housing Authority, the City of Omaha Planning Department, and the Omaha Public Power District. The One Touch system streamlines data gathering and referrals among the participating organizations. For example, someone doing a weatherization assessment could also take note of healthy homes issues and easily refer the client to OHKA. Eastman says of the program, “We’re finding increased collaboration, that we’re able to better serve the families, and that fewer of us have to leave a home with unmet needs, because we have other resources to put into the home.”33 When OHKA sent a risk assessor to the home of an Omaha grandfather and found flaking and peeling lead-based paint, the organization was able to not only address the lead threat but also refer him to the nonprofit partner Rebuilding Together, which addressed additional health hazards by repairing his roof, gutters, ceiling, and plumbing.34

Healthy Homes Coalition of West Michigan

Appropriate precautions must be taken when working with lead-based paint. Here a worker uses a sander attached to a high-efficiency particulate air-filtered vacuum. Photo courtesy: Centers for Disease Control and Prevention Public Health Image Library Founded in 2006, the Healthy Homes Coalition of West Michigan (HHC) grew out of the Get the Lead Out! campaign, which began in Grand Rapids in 2001 after a high number of children, many of them low-income and minority, were found to have elevated levels of lead in their blood.35 Harnessing the power of a community galvanized against one environmental health threat, community members began asking what could be done to address other home health hazards.36 HHC executive director Paul Haan remembers one voice in particular: that of a woman named Adriana, whose home had been made lead safe for her adopted child and visiting grandchildren and who urged him to think more broadly about the environmental threats affecting children in Grand Rapids. HHC took the lessons learned from the lead safety campaign and began applying them to other home health concerns — initially, radon and carbon monoxide.37 HHC has since expanded its mission to combat additional health threats such as fire hazards and asthma triggers.38

Healthy Homes for Healthy Kids, HHC’s primary program, conducts one-on-one home assessments to identify and address home health hazards for low- to moderate-income households (those earning less than 80 percent of the area median income) with children aged 5 and under who live in homes built before 1978.39 HHC staff members provide each family with an assessment report and a plan and connect the family with appropriate remediation services, such as lead control or pest management.40 When needed, HHC also installs smoke alarms and carbon monoxide detectors, which are free for qualifying households through funding from the Federal Emergency Management Agency.41 Families in need connect with HHC through informal referrals from other community organizations and participants, including the local Head Start program, Cherry Street Health Services, and Home Repair Services.42 This referral system is how Grand Rapids parent Londi Santos Porres was able to obtain urgently needed services through HHC. Cherry Street Health Services referred Porres to HHC after detecting an elevated level of lead in her daughter’s blood. HHC assessed Porres’ home for lead and other health threats, connected her with the Get the Lead Out! program, installed smoke and carbon monoxide alarms, and lowered the maximum water temperature on her hot water heater to reduce the risk of scalding.43

The Healthy Homes Coalition of West Michigan partners with families to combat home health threats such as water leaks and high levels of lead dust. However, when landlords are uncooperative, the best option may be to move to a healthier environment (as did the Deavers family, pictured here). Photo courtesy: Healthy Homes Coalition of West MichiganHHC is exploring ways to partner with additional programs, systems, and initiatives to reach more households, particularly before problems develop. Among the potential new partnerships are those with health care providers (with the possibility of tapping into Medicare and Medicaid reimbursement for housing services with a health impact), early childhood education programs, and early childhood home visitation programs. Collaborating with programs and systems that already interface with children — in some cases in their homes — will allow HHC to more efficiently identify and target high-need households.44 One example of a fruitful community collaboration is HHC’s work with Bethany Christian Services to obtain required radon tests and smoke and carbon monoxide detectors for refugee women seeking licenses to start in-home child care businesses. The partnership affords HHC the opportunity to intervene in potential at-risk environments where children might spend considerable time and promote healthy homes awareness among childcare workers.45

Working with community health workers, early childhood educators and childcare providers, nurses, and others who have regular contact with children is one important way in which HHC increases awareness about common home health hazards and strategies to combat them.46 HHC provides healthy homes training for parents and professionals and is a member of the National Healthy Homes Training Network, an NHCC project jointly funded by CDC, EPA, and HUD.47 HHC distributes a newsletter, attends community events, and partners with local media to raise public awareness of home health issues.48 HHC disseminates the latest relevant research on its website, such as information about an evaluation of a Seattle-area intervention that combines home repairs with in-home education to control childhood asthma.49 HHC draws from the body of established healthy homes research to ensure that its programs are evidence based.50 For example, HHC’s use of home assessments to guide its multifaceted, tailored asthma interventions is based on a body of clinical evidence of their effectiveness. A review of evidence by NCHH, which HHC uses as a guide whenever possible, classifies this and other interventions as demonstrating “sufficient evidence” of success.51 The organization also advocates for relevant policies at the federal, state, and local levels. For example, HHC staff have testified before the state legislature regarding funding for lead hazard control.52

Challenges

OHKA and HHC face common challenges, such as limited and unstable funding as well as landlords who are unwilling to comply with the law or participate in remediation programs. However, the two organizations also face challenges specific to their local contexts, such as OHKA’s struggle to convince residents that EPA-required soil replacement does not remove all lead threats from their home environment.53 Both organizations have received service from AmeriCorps members in the past but have since lost that support, which has significantly limited HHC’s ability to offer hands-on remediation services.54

The greatest challenge that organizations like OHKA and HHC face when remediating unhealthy homes, however, is the sheer scope of the problem; the Federal Healthy Homes Work Group notes that millions of homes in the United States have moderate to severe physical issues.55 “We can’t programmatically work our way out of this problem,” Haan says. “We can go door by door, and that’s good, because people need that help, but while we are doing that work we ought to be looking for the broader, more systemic solutions,” such as more proactive code enforcement for rental housing and other efforts to ensure that affordable housing is quality affordable housing. Haan argues that creating healthy homes must be considered a public health issue, not just a matter of individual responsibility.56 Both the home-by-home interventions and the education and advocacy work of local organizations such as OHKA and HHC are critical steps in the pursuit of healthier homes for children.

Housing Instability and Youth Homelessness

Just as the presence of various health hazards within the home puts children at risk, evidence links housing instability with a range of negative outcomes for children. Because the children who become homeless are part of a larger set who experience housing instability and poor-quality housing, they exhibit many of the problems associated with children living in unhealthy homes such as asthma and lead poisoning, among others.57 A 2013 point-in-time (PIT) national estimate found nearly 200,000 homeless children and youth, including 61,000 between the ages of 18 and 24.58 Other estimates, employing broader definitions of homelessness that include doubling up or couch surfing and covering a longer period, find that each year as many as 1.7 million youth under 18 experience homelessness for at least one night, and approximately 550,000 youth and young adults up to age 24 experience homelessness for more than a week.59 In addition to economic circumstances and a lack of affordable housing, family conflict and trauma are common causes of youth homelessness, and certain subpopulations are overrepresented among homeless youth, such as those who are pregnant or parenting, LGBTQ, or exiting the juvenile justice or foster care systems.60 Youth experiencing homelessness exhibit high levels of physical, emotional, and mental health problems, are prone to engaging in risky behaviors, and are vulnerable to various dangers.61

In response to the problem of youth homelessness, the U.S. Interagency Council on Homelessness (USICH) has developed a “Framework to End Youth Homelessness,” identified youth experiencing homelessness as a priority population, and set a goal of ending youth homelessness by 2020. The framework, an outgrowth of USICH’s 2010 federal strategic plan to end homelessness, Opening Doors, and its 2012 amendment, is led by USICH and the Administration on Children, Youth, and Families at the U.S. Department of Health and Human Services. The framework outlines a two-part strategy to address youth homelessness: get better data and strengthen capacity at the federal, state, and local levels. Fuller, more accurate data are necessary to understand the scale and nature of youth homelessness — including the overrepresentation of LGBTQ youth among the homeless population — to advocate for resources and foster collaboration, and “to inform smarter, more targeted strategies to tackle tough problems.”62 To improve data on youth homelessness, USICH developed new youth-specific strategies for PIT counts through its Youth Count! interagency initiative, and the organization is working to better coordinate federal data systems. Obtaining more accurate data will allow agencies, researchers, and service providers to monitor changes and measure progress.

To build capacity, the USICH framework outlines a three-phase plan. The first phase, which is already underway, involves disseminating a preliminary evidence-based youth intervention model to service providers; this model outlines client- and system-level strategies designed to improve the four core outcomes of stable housing, education or employment, permanent relationships, and socioemotional well-being. The model also emphasizes planning interventions based on risk and protective factors that will be tailored to serve vulnerable subpopulations (LGBTQ youth, pregnant and parenting youth, youth exiting foster care, youth involved with the juvenile justice system, and victims of sexual exploitation). During the second phase, USICH will evaluate and revise the preliminary intervention model. Finally, in the plan’s third phase, USICH will build capacity at federal, state, and local levels, scaling up effective interventions and discarding ineffective ones based on the lessons learned from the second phase (although evaluation will be ongoing).

Houston Coalition for the Homeless: Getting Better Data

Food insecurity is among the many vulnerabilities faced by youth experiencing homelessness. One local organization implementing the USICH’s data strategy is the Coalition for the Homeless of Houston/Harris County. The Coalition — a private, nonprofit organization founded in 1982 — is the lead agency in the area’s continuum of care (CoC), the group of service providers that provide a full range of housing and supportive services for people experiencing homelessness. The Coalition manages a Homeless Management Information System, which tracks where youth are accessing homeless response services and examines the characteristics of homeless youth, and leads the CoC’s annual PIT count. In 2013, the Coalition participated in Youth Count! to obtain a more accurate estimate of youth in the PIT count, and its community was one of the nine sites evaluated in an Urban Institute study of the initiative.63

Youth experiencing homelessness are notoriously difficult to count.64 The differing definitions of homelessness among federal and community agencies and organizations, the difficulty of locating youth in a wide range of housing situations such as couch surfing or doubling up, the ethical and legal questions involved in engaging with minors, and the reluctance of youth to self-identify as homeless complicate efforts to obtain an accurate estimate. Among the challenges specific to Houston, according to Gary Grier, a Coalition project manager, are the city’s lack of youth shelters and large geographic area. Youth Count! addresses some of these challenges by fostering collaboration among the involved federal and local parties including academics and grassroots volunteers. Youth Count! also employs youth-specific methods such as identifying “homeless hotspots” where otherwise hidden youth might gather, using nontraditional tools such as social media, employing respondent-driven sampling — using information from respondents to identify additional youth — and deploying specialized outreach teams composed of veteran service providers and current or former homeless youth.65

For the 2013 PIT and its added youth component, the Coalition partnered with the University of Texas at Houston’s School of Public Health, which developed a 17-question, youth-specific survey. To encourage participation, respondents received a $5 fast food gift card. The Coalition worked with an LGBTQ-focused service center to better reach LGBTQ youth and targeted other hard-to-count youth such as those doubling up or couch surfing. Coalition staff trained a team of volunteers from the school of public health, local homeless and youth organizations, and an area youth shelter for 18- to 21-year-olds, Covenant House Texas, to carry out the survey.66 Altogether, more than 30 state and local agencies participated in the planning and execution of the count. Past and present residents of Covenant House helped special outreach teams identify and survey areas that they knew to be common destinations for unaccompanied homeless youth. Alongside these efforts, schools with high numbers of at-risk students conducted a more limited survey.67

The findings from the 2013 count support the general statistics regarding high-risk groups. Among the youth surveyed, 2 out of every 5 had aged out of foster care, 1 in 5 identified as gay or bisexual, 17 percent of females were pregnant, 1 in 3 had been in the correctional system during the past year, and 11 of 160 identified as transgender. Three-quarters of those surveyed had not worked in the previous week.68 Along with the data gathered, some lessons learned from the pilot include the need for peer participation in planning and administering surveys, youth-centric language, respondent-driven sampling, and a data collection period that is longer than the standard 6 hours for PIT counts.69 The Coalition also hopes to improve the school-based survey, which was of limited value because of restrictions on the information surveyors were allowed to collect.70

Grier says that the improved count will help the Coalition and youth homeless service providers to better understand the nature of the problem they face. He adds that data that go beyond the scope of the PIT and CoC needs assessments — such as information about other kinds of housing instability among youth as well as the needs and wants of respondents — will help stakeholders develop systems that youth will want to access.71 Finally, says Grier, more accurate data are essential for establishing a baseline from which to measure progress and evaluate the efficacy of intervention models.72

Hollywood Homeless Youth Partnership: Building Capacity

The Hollywood Homeless Youth Partnership (HHYP), a strategic partnership of youth-serving agencies in Los Angeles, is deeply engaged with USICH’s capacity-building strategy. HHYP was founded in 1992 to formalize the longstanding collaboration of its member organizations. Six local agencies are currently members of HHYP: the Division of Adolescent and Young Adult Medicine at Children’s Hospital Los Angeles, Covenant House California, Los Angeles LGBT Center, Los Angeles Youth Network, My Friend’s Place, and Step Up on Second. HHYP does not provide services directly to youth experiencing homelessness; rather, it enhances the service capacity of its members by fostering peer-to-peer collaboration, sharing best practices, providing training and professional development, and increasing leverage for advocacy and fundraising, among other benefits.73 As Heather Carmichael, executive director of My Friend’s Place, puts it, HHYP “amplifies the amount of work that we could do as one organization; it really gives us a deeper well to work from.”74

The member agencies share a commitment to trauma-informed care, a longtime value that was more formally articulated in the mid-2000s with support from the National Child Traumatic Stress Network. A trauma-informed approach recognizes the prevalence of trauma among youth experiencing homelessness and adjusts understandings of behaviors, expectations, and interventions accordingly.75 The trauma-informed approach is consistent with the USICH framework’s focus on risk factors, of which trauma is one.76 HHYP also adopted the Attachment, Self-Regulation, and Competency framework, which Boston researchers developed to guide interventions with children who have experienced physical or emotional trauma.77 The common approach fosters professional trust among the agencies. As Carmichael says, when someone calls from a member organization, “we know that they’re using trauma-informed practices, [and] we understand their models, which really helps our clinical social workers do better matching of housing programs where a young person might thrive and [achieve] better outcomes.”78

HHYP is currently forming a strategic plan that, among other goals, will align its program priorities — service impact, training and capacity building, research and evaluation, and policy and advocacy — with the four core youth outcomes in the USICH framework. HHYP has formally adopted the framework outcomes with some modifications; for example, broadening the outcome for socioemotional well-being to include physical well-being to better reflect the range of traumas that homeless youth may experience.79 Carmichael notes that “the [USICH] outcomes are not defined in a very operational way yet,” adding that USICH may need to develop intermediate benchmarks and measures in addition to core outcomes to incorporate the process-oriented work done by many providers serving homeless youth.80 HYPP’s critical engagement with the USICH outcomes and preliminary intervention model promises to advance the national dialogue about youth experiencing homelessness and assist USICH’s efforts to refine the model.81

In various ways, HHYP is already participating in metropolitan, regional, and national outreach and discussion. HHYP’s emphasis on and experience with trauma-informed care makes the organization particularly well-suited to inform the national discussion about intervention models and service delivery. HHYP has developed policy briefs and, with funding from the National Child Traumatic Stress Network, a series of 11 online training modules on various topics related to direct service for youth, all framed by a trauma-informed approach. On a regional level, HHYP and King County’s Homeless Youth and Young Adult Initiative co-led a west coast convening of service providers. Such forums encourage the productive exchange of ideas — allowing HHYP, for example, to share its expertise on trauma while learning from groups with strengths in other areas, such as education.82 Locally, HHYP has started the Los Angeles Coalition to End Youth Homelessness, through which HHYP can promote trauma-informed care, and the coalition as a whole is pushing the Los Angeles CoC to include a youth survey in the next PIT count. The collaboration at each of these levels ultimately serves to increase the service quality and capacity of HHYP member agencies.83

The Coalition for the Homeless of Houston/Harris County is working to improve methods for counting youth in annual point-in-time counts. Photo courtesy: Coalition for the Homeless of Houston/Harris County Unique Needs of Youth Experiencing Homelessness

Arlene Schneir, associate director of the Division of Adolescent and Young Adult Medicine at Children’s Hospital Los Angeles and a member of the HHYP executive team, notes that youth experiencing homelessness “look different, act different, [and] are visible in the community differently.”84 Youth have different needs from adults and may need different outcomes. Likewise, assessments of vulnerability, definitions of homelessness, and interventions for youth may need to be tailored for youth. The USICH framework accounts for the need for youth-specific interventions, and HUD’s move to require CoCs to estimate youth as a distinct category in PIT counts recognizes the unique needs and circumstances of youth in order to better incorporate them into the general count of people experiencing homelessness. These efforts will be further advanced as more organizations adopt the youth-specific methodologies developed through Youth Count!

Collaboration Is Key

Anything that stands in the way of access to safe, quality housing threatens children’s health and well-being. Housing instability, up to and including homelessness, and unhealthy homes deny children the home environments that best equip them for positive life outcomes. Both federal programs and local initiatives are directed toward reducing barriers to safe, stable, healthy housing for all, but significant challenges remain. The local organizations profiled above work with limited and unstable funding; interface with various federal, state, and local programs and agencies with differing rules, definitions, and requirements; and face problems daunting in their scope and complexity.

The United States Interagency Council on Homelessness has set a goal to end youth homelessness by 2020. Photo courtesy: U.S. Department of Housing and Urban Development Flickr photostream Collaboration, both at the federal and local levels, is a critical tool for organizations seeking to make the most of limited resources. “Collaboration with the wider community is key to our success,” says HHC’s Haan. “It just doesn’t make any sense not to be collaborative.”85 Federal initiatives such as USICH and the Federal Healthy Homes Work Group recognize the need to break down traditional silos and work in concert, and these promising starts can filter down throughout the respective agencies to better align definitions, restrictions, and regulations. The differing definitions of homelessness that HUD and the U.S. Department of Education use, for example, result in dramatically different estimates of youth homelessness; these differences can damage the credibility of an organization like the Houston Coalition that cites a HUD-defined statistic when the media or another organization might cite a conflicting statistic that relies on the U.S. Department of Education’s definition.86 Ann Oliva, HUD’s Deputy Assistant Secretary for Special Needs, explains that this issue is difficult in part because of varying forms of homelessness and need for services: “Ending homelessness among youth is a priority for HUD and its federal partners. The greatest challenge that we face is that the number of homeless youth and their needs are not well understood. For HUD it is important to understand how many youth need housing assistance and would likely be on the streets without it, and we try to learn that through annual point-in-time counts in every community. This is challenging in part because youth often avoid traditional homeless services, choosing instead to stay with friends or remain hidden out of fear of being returned to abusive situations. Other federal agencies have to assess the need for their services, such as education and employment, which is usually involves using a broader definition of homelessness. Homeless youth also have unique developmental needs that need to be taken into account. To end youth homelessness, CoCs should partner with schools, the child welfare system, and Runaway and Homeless Youth providers to implement a youth-informed system of care that includes developmentally appropriate services and housing programs for youth.”

At the local level, collaboration among service providers, academics, and governments can enhance the capacity of providers. Partnership with the University of Texas at Houston has aided the Houston Coalition for the Homeless’ youth counts, and OHKA’s funding of a healthy homes code inspector and participation in the One Touch program promise a more systematic approach to advancing healthy homes in Omaha compared with relying on resident requests and limited referrals. Strategic partnerships such as these leverage expertise, resources, and contacts to broaden these organizations’ impact, advancing children’s health and well-being by more effectively promoting healthy homes and housing stability.

Related Information:

Healthy Homes Go Green

1. Jung Min Park, Angela R. Fertig, and Paul Allison. 2011. “Physical and Mental Health, Cognitive Development, and Health Care Use by Housing Status of Low-Income Young Children in 20 American Cities: A Prospective Cohort Study,” American Journal of Public Health 101:S1, S255; Rebekah Levine Coley, Tama Leventhal, Alice Doyle Lynch, and Melissa Kull. 2013. “Relations Between Housing Characteristics and the Well-Being of Low-Income Children and Adolescents,” Developmental Psychology 49:9, 1785–7.
2. Yumiko Aratani. 2009. “Homeless Children and Youth: Causes and Consequences,” National Center for Children in Poverty, 4, 6.
3. Coley, Leventhal, Lynch, and Kull, 1785–7.
4. Tama Leventhal and Sandra Newman. 2010. “Housing and Child Development,” Children and Youth Services 32:9, 1168–9.
5. U.S. Department of Health and Human Services. 2009. “The Surgeon General’s Call to Action to Promote Healthy Homes,” U.S. Department of Health and Human Services, 1–2.
6. Healthy Homes Work Group. 2013. Advancing Healthy Homes: A Strategy for Action, 8.
7. Ibid., 9.
8. “Office of Lead Hazard Control and Healthy Homes and (OLHCHH),” U.S. Department of Housing and Urban Development website (portal.hud.gov/hudportal/HUD?src=/program_offices/healthy_homes). Accessed 15 July 2014.
9. “The Healthy Homes Program,” U.S. Department of Housing and Urban Development website (portal.hud.gov/hudportal/HUD?src=/program_offices/healthy_homes/hhi). Accessed 15 July 2014.
10. U.S. Department of Housing and Urban Development. 2011. “Notice of Funding Availability for HUD’s Fiscal Year (FY) 2012 Lead-Based Paint Hazard Control Grant Program and Lead Hazard Reduction Demonstration Program,” 2–3.
11. U.S. Department of Housing and Urban Development. 2014. “The Healthy Homes Demonstration Grant Program;” U.S. Department of Housing and Urban Development. 2011. “Notice of Funding Availability for HUD’s Fiscal Year (FY) 2012 Healthy Homes Technical Studies Program,” 1; U.S. Department of Housing and Urban Development. 2013. “FY 2013 Healthy Homes Technical Studies Grant Abstracts,” Office of Healthy Homes and Lead Hazard Control.
12. Healthy Housing Solutions. 2007. “An Evaluation of HUD’s Healthy Homes Initiative: Current Findings and Outcomes,” U.S. Department of Housing and Urban Development, Office of Healthy Homes and Lead Hazard Control, 92.
13. Ibid., 59; Carolyn M. Kercsmar, Dorr G. Dearborn, Mark Schluchter, Lintong Xue, H. Lester Kirchner, John Sobolewski, Stuart J. Greenberg, Stephen J. Vesper, and Terry Allan. 2006. “Reduction in Asthma Morbidity in Children as a Result of Home Remediation Aimed at Moisture Sources,” Environmental Health Perspectives 114:10, 1574–5.
14. Tiina Reponen, Stephen Vesper, Linda Levin, Elisabet Johansson, Patrick Ryan, Jeffery Burkle, Sergey A. Grinshpun, Shu Zheng, David I. Bernstein, James Lockey, Manuel Villareal, Gurjit K. Khurana Hershey, and Grace LeMasters. 2011. “High Environmental Relative Moldiness Index during Infancy as a Predictor of Asthma at 7 Years of Age,” Annals of Allergy, Asthma & Immunology 107:2, 126.
15. “CDC’s Healthy Homes and Lead Poisoning Prevention,” Centers for Disease Control and Prevention website (www.cdc.gov/nceh/lead/about/program.htm). Accessed 15 July 2014; “Healthy Homes,” Centers for Disease Control and Prevention website (www.cdc.gov/nceh/lead/healthyhomes.htm). Accessed 15 July 2014; “Radiation Protection: Radon,” U.S. Environmental Protection Agency website (www.epa.gov/radiation/radionuclides/radon.html#epadoing). Accessed 15 July 2014; “Lead: Renovation, Repair and Painting Program,” U.S. Environmental Protection Agency website (www2.epa.gov/lead/renovation-repair-and-painting-program). Accessed 15 July 2014.
16. “Housing and Community Living: Healthy Homes Initiative,” U.S. Department of Agriculture website (www.csrees.usda.gov/nea/family/in_focus/housing_if_healthyhomes.html). Accessed 25 June 2014.
17. “About Us,” Northeastern IPM Center website (www.stoppests.org/about-us/). Accessed 8 September 2014. 
18. Healthy Homes Work Group, 11.
19. “National Center for Healthy Housing and APHA Publish National Healthy Homes Standard to Maintain Safe and Healthy Homes,” 10 June 2013 press release. Accessed 7 August 2014.
20. National Center for Healthy Housing. “Timeline;” Interview with Kara Eastman, July 2014; Interview with Paul Haan, June 2014.
21. U.S. Environmental Protection Agency. 2010. “Omaha Lead;” U.S. Environmental Protection Agency. 2009. “Final Record of Decision: Decision Summary, Omaha Lead Site Operable Unit Number 2, Omaha Nebraska,” 4–6.
22. “Final Record of Decision,” 4–6.
23. “History,” Omaha Healthy Kids Alliance website (www.omahahealthykids.org/about/history/). Accessed 24 June 2014.
24. Community Advisory Group for the Omaha Lead Site. 2005. “Minutes for Meeting Held Wednesday, September 28, 2005.”
25. “Get the Lead Out,” Omaha Healthy Kids Alliance website (www.omahahealthykids.org/programs/get-the-lead-out/). Accessed 24 June 2014.
26. Interview with Kara Eastman, July 2014.
27. “Get the Lead Out.”
28. “Kresge Grant,” Omaha Healthy Kids Alliance website (www.omahahealthykids.org/our-impact/kresge-grant/). Accessed 24 June 2014; Omaha Healthy Kids Alliance. 2014. “Improving Health Through Housing: Results from the Field.”
29. Interview with Kara Eastman, July 2014.
30. Ibid.
31. “2014 Summit,” Omaha Healthy Kids Alliance website (www.omahahealthykids.org/events/2014-summit/). Accessed 23 June 2014.
32. “Lead Detectives,” Omaha Healthy Kids Alliance website (www.omahahealthykids.org/programs/lead-detectives/). Accessed 15 July 2014.
33. Interview with Kara Eastman, July 2014.
34. Alex McKeone. n.d. “From the Field: A Story of the Work of Omaha Healthy Kids Alliance and Our Partners,” Omaha Healthy Kids Alliance. Accessed 25 July 2014.
35. “About: Our History,” Healthy Homes Coalition of West Michigan website (www.healthyhomescoalition.org/history). Accessed 17 June 2014.
36. Interview with Paul Haan, June 2014.
37. Ibid.
38. “About: Our History.”
39. “Strategies: Home Visits,” Healthy Homes Coalition of West Michigan website (www.healthyhomescoalition.org/home-visits). Accessed 15 July 2014.
40. Healthy Homes Coalition of West Michigan. 2013. “Featured Program: Healthy Homes for Healthy Kids,” Advisor (Spring), 2; Interview with Paul Haan, June 2014.
41. Healthy Homes Coalition of West Michigan. 2013. “FEMA Renews Support for Fire Safety,” Advisor (Summer), 4.
42. Interview with Paul Haan, June 2014.
43. Healthy Homes Coalition of West Michigan. 2013. “Solving the Lead Problem: Londi’s Story,” Advisor (Spring), 1. 
44. “News: Three Pathways,” Healthy Homes Coalition of West Michigan website (www.healthyhomescoalition.org/news-feed/post/31/ThreePathways). Accessed 17 June 2014.
45. Healthy Homes Coalition of West Michigan. 2013. “Collaborating with Community,” Advisor (Summer), 1. 
46. Interview with Paul Haan, June 2014.
47. “Training: Healthy Homes Training Center,” National Center for Healthy Housing website (www.nchh.org/Training/National-Healthy-Homes-Training-Center.aspx). Accessed 17 June 2014; Interview with Paul Haan, June 2014.
48. “Strategies: Education & Outreach,” Healthy Homes Coalition of West Michigan website (www.healthyhomescoalition.org/education). Accessed 17 June 2014.
49. “News: Combining In-Home Education with Housing Interventions Improves Childhood Asthma Control,” Healthy Homes Coalition of West Michigan website (www.healthyhomescoalition.org/news-feed/post/28/CombiningInHomeEducationwithHousingInterventionsImprovesChildhoodAsthmaControl). Accessed 17 June 2014. The study referenced is Jill Breysse, Sherry Dixon, Joel Gregory, Miriam Philby, David E. Jacobs, and James Krieger. 2014. “Effect of Weatherization Combined With Community Health Worker In-Home Education on Asthma Control.” American Journal of Public Health 104:1, e57-e64.
50. Interview with Paul Haan, June 2014.
51. Email communication with Paul Haan, 23 July 2014; National Center for Healthy Housing. 2009. “Housing Interventions and Health: A Review of the Evidence,” 10, 16.
52. “News: Healthy Homes Goes to Lansing,” Healthy Homes Coalition of West Michigan website (www.healthyhomescoalition.org/news-feed/post/29/HealthyHomesGoestoLansing). Accessed 17 June 2014.
53. Interview with Kara Eastman, July 2014; Interview with Paul Haan, June 2014.
54. Ibid.
55. Healthy Homes Work Group, 4.
56. Interview with Paul Haan, June 2014.
57. Park, Fertig, and Allison, S255.
58. Meghan Henry, Alvaro Cortes, and Sean Morris. 2013. “The 2013 Annual Homeless Assessment Report (AHAR) to Congress: Part 1, Point-in-Time Estimates of Homelessness,” U.S. Department of Housing and Urban Development, Office of Community Planning and Development, 46.
59. National Alliance to End Homelessness. “An Emerging Framework for Ending Unaccompanied Youth Homelessness,” 1, 5.
60. U.S. Interagency Council on Homelessness. 2013. “Framework to End Youth Homelessness: A Resource Text for Dialogue and Action,” 11.
61. Park, Fertig, Allison, S255; Aratani, 6–7.
62. U.S. Interagency Council on Homelessness, 5.
63. Michael Pergamit, Mary Cunningham, Martha Burt, Pamela Lee, Brent Howell, and Kassie Bertumen. 2013. “Youth Count! Process Study,” Urban Institute.
64. Ibid., 5.
65. Email communication with Gary Grier, 8 July 2014.
66. Pergamit, et al., 13–4.
67. Ibid.; Email communication with Gary Grier, 8 July 2014.
68. Catherine L. Troisi and Gary M. Grier. 2013. “Homeless in Houston: It’s Cold Out There,” Coalition for the Homeless of Houston/Harris County.
69. Email communication with Gary Grier, 8 July 2014.
70. Troisi and Grier. 2013.
71. Email communication with Gary Grier, 8 July 2014; Email communication with Gary Grier, 14 July 2014.
72. Email communication with Gary Grier, 8 July 2014.
73. Interview with Arlene Schneir, July 2014.
74. Interview with Heather Carmichael, July 2014.
75. Hollywood Homeless Youth Partnership. 2009. “10 Reasons for Integrating Trauma-Informed Approaches in Programs for Runaway and Homeless Youth;” Interview with Arlene Schneir, July 2014.
76. U.S. Interagency Council on Homelessness, 14.
77. Kristine Jentoft Kinniburgh, Margaret Blaustein, Joseph Spinazzola, and Bessel A. van der Kolk. 2005. “Attachment, Self-Regulation, and Competency: A Comprehensive Intervention Framework for Children with Complex Trauma,” Psychiatric Annals 35:5, 424–30.
78. Interview with Heather Carmichael, July 2014.
79. Hollywood Homeless Youth Partnership. 2013. “Strategic Plan,” 6, internal document.
80. Interview with Heather Carmichael, July 2014.
81. U.S. Interagency Council on Homelessness, 3.
82. Interview with Arlene Schneir, July 2014.
83. Ibid.
84. Ibid.
85. Interview with Paul Haan, June 2014.
86. Interview with Marilyn Brown, July 2014.