When the diagnosis is homelessness, what is the cure?

Childhood lasts a lifetime and for more than 3,700 children in Ireland today so too will the impact of homelessness on their health and wellbeing.

A small child presented to a specialist outpatient clinic in Dublin suffering from ringworm infestation, iron-deficiency anaemia and severe dental decay that required 10 of her teeth to be extracted.

Her diagnosis? Homelessness. Her prognosis? Without intervention, a lifetime blighted by preventable illness.

According to Focus Ireland, since the end of the Covid-19 pandemic, the number of homeless children in Ireland has risen by 60 per cent. The latest figures from the Department of Housing, Local Government and Heritage show that in June 2023 there were 3,765 children experiencing homelessness in Ireland.

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As well as the devastating psychological impact of homelessness, these children are also suffering physical ill health as a direct result of their social circumstances. These include conditions such as faltering growth, developmental delay, anaemia, severe dental decay and rickets. All of these conditions are preventable.

Homelessness is an adverse childhood experience. Research has shown that cumulative adverse events in childhood have a direct impact on life expectancy and physical health outcomes into adulthood.

Dr Aoibhinn Walsh is a consultant paediatrician with a special interest in inclusion health with Children’s Health Ireland (CHI). She is the only paediatrician in Ireland employed to focus on inclusion health and has a temporarily funded team to care for some of the most vulnerable children in Ireland.

Inclusion health is a method of healthcare delivery that seeks to overcome the many barriers faced by people accessing equitable care. All of Walsh’s small patients and their parents are experiencing significant social adversity.

Walsh runs the Lynn Clinic at CHI, a community outreach clinic for children at risk of social exclusion, based in Dublin’s north inner city. The clinic runs once a fortnight, however, Walsh says a recent increase in referrals means she is hoping to increase this to once a week. She also sees follow-up cases in Children’s Health Ireland at Temple Street.

The clinic is funded on a temporary basis by the HSE and is staffed by Walsh, two clinical nurse specialists, a non-consultant hospital doctor (NCHD), two administration staff and a project manager. Walsh also pays huge credit to the many NGOs and charities that work with children and families in the area which she says have provided invaluable additional support.

She also acknowledges that a lot of her colleagues around the country are caring for homeless children or those facing social exclusion every day. However, they are doing this as part of their already very busy general practice.

Walsh and her team treat children under the age of 16. Coupled with children presenting with general medical issues, they also see children with more serious conditions such as epilepsy and complex heart disease. Another group are children from the marginalised migrant population who may have undergone complex surgeries abroad and haven’t been appropriately managed or followed up.

According to Walsh, while the children she cares for may already have an underlying medical diagnosis, they are also suffering from medical problems directly related to their social circumstances.

“Examples of that would be severe implications for growth in nutrition. We see a lot of faltering growth with children who are well below the height and weight of their peers,” she says.

Sadly, a lot of the nutritional difficulties faced by children are directly associated with being homeless and not having access to the things a lot of us take for granted such as a family kitchen and space to play.

“They don’t have ready access to a well-equipped kitchen, or they might have to book an appointment time, but their caregiver, usually the mother, might have six other children to try to manage. And then when you’re looking at younger children... preschool age there can be fussy eating... I love messy play... you offer children foods and feed them finger food and you help them become more sensory and familiar with it. But if you can imagine you’re in a hotel room with a carpet and no highchair. How are you supposed to encourage an improved appetite in your child if you don’t have the basic facilities to be able to do what’s needed?

“So we see a lot of faltering growth. And, as a consequence of that, we are seeing iron-deficiency anaemia and vitamin D deficiency, and we’re seeing some cases of rickets. These have direct lifelong implications for growth, cognition and development if they’re not treated,” Walsh says.

She says her clinic was also seeing young children with “very severe dental decay” but, thanks to a partnership with HSE dentistry, children under 12 are now being seen as part of the holistic care package offered at the Lynn Clinic.

“I look at the pressure some of these families have in homelessness and they’re trying to feed their children, they’re trying to advocate for housing, they have a lot of other stressors, and what I might see as a priority as a medical doctor may not be their immediate priority for their family. So we try to help signpost them to things like dental checks or we will make appointments for them if it is not a serious dental problem… we will link with their local dentist for them to try help them to engage with those services.”

As any parent or caregiver knows, sleep is an essential building block for young children’s physical and mental health. According to Johns Hopkins All Children’s Hospital in the US, “Studies have shown that kids who regularly get an adequate amount of sleep have improved attention, behaviour, learning, memory, and overall mental and physical health. Not getting enough sleep can lead to high blood pressure, obesity and even depression.”

For children with neurodiversity, sleep is even more important and Walsh says she has seen children with escalations of challenging behaviours or self-injurious behaviour because they are sleeping in a confined space that cannot meet their sensory needs. Their siblings’ sleep is also affected as they are all sleeping in the same room.

“When I look at these children, they’re never just a family in isolation. They’re part of their accommodation infrastructure, which can include many such children who have all these difficulties. We have small children, we have preschool children who are being fed at night, either prolonged breastfeeding or taking bottles throughout the night. And it’s not from a nutritional perspective, it’s because it’s the only way their parents can get them to sleep. But when their teeth aren’t being brushed then they’re getting severe dental decay, and a lot of them, if they’re drinking cow’s milk or their mother is anaemic, they’re then getting anaemia because of this.

“We were seeing babies co-sleeping with parents in overcrowded rooms because there’s no space for a cot and that’s a real risk for sudden infant death syndrome.”

Walsh says they are also seeing malnutrition in the form of obesity due to unhealthy foods being served at homeless accommodation and families not being allowed to prepare their own food.

Coupled with a poor diet, Walsh says children in homeless accommodation are often housed in hotels near busy roads with little or no green space to play and exercise. This means the children are forced to spend a lot more time watching television or playing on screens than is recommended.

“And again that’s about small children who can’t get to sleep and if you have three other children in the room who need to sleep, you are going to give them the phone and I can’t say I wouldn’t do any differently if it keeps everybody quiet,” she says.

The population of homeless children being cared for by Walsh and her team is wide and varied; each child has their own specific needs depending on their situation.

She says about 30 per cent of the children are from the Roma community; 20-25 per cent are refugee or international protection applicants; and the other 50 per cent are Irish citizen children who have been born into homelessness or found themselves homeless due to a myriad of different reasons.

Walsh adds that she sees a lot of intergenerational homelessness where the children’s parents and grandparents before them have also been homeless themselves or spent time in foster care or prison. “It’s a real cycle of deprivation,” she says.

Another consequence of homelessness is that the majority of the children referred to Walsh don’t have their own GP and therefore do not have access to the usual standard of primary healthcare a lot of us take for granted. The lack of a dedicated GP also has implications for their follow-on care.

Walsh says that, for example, a child who is homeless may be registered with a GP in north Dublin and living in a B&B in the city centre with no private transport or even access to bus fare.

The lack of a GP also means that homeless children are more likely to present to the emergency department with common childhood illnesses. This was borne out by a 2021 research study which reviewed the number of homeless children attending a paediatric emergency department in Dublin from January 1st, 2017 to December 31st, 2020.

The review found that compared with their non-housed peers, homeless children were younger, less likely to be fully vaccinated and have registered GPs. The study also found that homeless children had increased reliance on emergency services for their primary healthcare needs.

A further barrier to care for these families is the transient nature of homelessness, a referral letter for a hospital paediatric appointment in 12 or six months will never be delivered to a child whose family has been forced to move within the homeless service to another hotel or B&B.

Moving house and starting at a new school is a hugely stressful time for any child. Walsh has seen homeless children who have attended seven different primary schools in their short lives. She has also cared for families whose children were enrolled in their local schools before losing their homes. These children were happy in their school and doing well despite their social adversity, so rather than disrupt their children’s lives even more, parents, she says, were spending up to three hours on public transport to bring their children to school from the hotel or B&B they were forced to move to within the homeless service. Walsh and her team work to help families overcome the many barriers they experience in accessing healthcare such as confirming their language and preferred method of communication. It may seem basic but the reality is that WhatsApp is free when there is free wifi available and, therefore, much more accessible.

“We didn’t get responses from texting. People didn’t have credit on their phones. So we use WhatsApp which they can get free when wifi is available. And we will use the translator to convey appointment details not only in English, but in their spoken language, to again be able to inform them of upcoming appointments that they need to attend,” she says.

Walsh acknowledges that she finds the complex medical cases “relatively easy” to treat because she knows the tests to order and the medication to prescribe.

However, she says it is the “really basic” issues like nutrition, growth, play, development and exercise that she will never get right while these children remain without a home.