You can see them in local gas stations pumping gas for spare change; or in malls, playing pinball machines for hours, their faces reflected in blinking lights; or on the street, panhandling for loose change for something to eat. They are "functionally" homeless children -- they may have an address but do not have a home -- that is, a safe place to grow and thrive.
In addition to the truly homeless children who live in families that cannot provide for them, there are now thousands of others across the nation who, through neglect or other circumstances, should be classified as homeless.
In the District, shelters for the homeless house in excess of 1,000 children every month from displaced families. But these are only a fraction of the truly displaced children. "Homeless" children can be found not only among the poor but the middle class as well. The evidence is their presence at all hours in suburban shopping malls, game rooms or on street corners.
Our knowledge of the numbers and health status of street children and functionally homeless children is limited. But all indications are that the homeless child is at severe health risks, compared with other children. Since 1985, the number of homeless families in the city has tripled, with children constituting nearly 67 percent of the District's shelter population.
Last year, the House Select Committee on Hunger reported that there are more homeless families with children than homeless single adults.
Dr. James Egan, chairman of psychiatry at Children's Hospital, says that the growing numbers of middle-class street children follow "the same road" taken by the child who is homeless because of poverty: "drug and alcohol use, early sexual experiences, teenage pregnancy, declining scholastic achievement and self-destructive behaviors, to name a few."
In the health setting, we encounter such children at the extremes of the clinical spectrum. At one end, the at-risk child is often brought by parents or other "care takers" into the emergency room, clinic or private office, for trivial, if not nonexistent, physical conditions -- often at inappropriate times. The parents or care takers use a visit to the doctor to compensate for their otherwise neglect. Sometimes, the parents or care takers require alcohol or drugs to handle their guilt, and they show up intoxicated.
These children, who may or may not have overt signs of abuse or neglect, often go unreported to child protection authorities. Many health professionals, physicians, nurses and others do not have the clinical expertise to pick up the neglect. However, many if not most health professionals base their reporting of marginal neglect on their judgment of what legal authorities will "do" or "not do." Many of the most committed professionals are not sanguine that timely significant help can be obtained by reporting such cases to the authorities.
At the other extreme, the street child comes to the health setting as a critical patient: seriously physically or sexually abused, an accident victim, a crime scene casualty or with serious medical conditions that have been neglected. Even though they may be seriously injured or ill, some children "slip through the cracks" and go unreported. But in even those cases that are reported, the child is faced with a legal system too slow, cumbersome or inadequate to respond to his or her needs.
Our record as a nation in helping children in general, much less the homeless, is becoming shameful. In our country, children lead all the age groups in the growing ranks of the poverty stricken, constituting 28 percent. To a staggering degree, children are being subjected to abandonment, neglect and abuse. In the District, for example, the numbers of children in substantiated abuse and neglect cases was 2,090, a rise of 27 percent since 1981.
Nationally, there has been a slowing of the decline of infant mortality, with infant mortality in selected minority groups actually showing increases. High rates of teenage pregnancy, accidental and intentional injury and drug, tobacco and alcohol abuse are found in our youth population. In addition, we will likely leave many of our children with the legacy of AIDS.
When we chronicle the problems of our children one by one, we are overwhelmed by them. No "silver bullet" cure exists for any of these afflictions. Either out of frustration or a lack of understanding, we wish these children more of a good whipping or a stiff jail sentence, both of which they no doubt have had more than their quota. All children simply need a safe place to live and enough people to look after them.
In the past, the priests of Boys Town were folk heroes whose mission was to salvage orphans and delinquents. Boys and girls clubs, recreation centers and the "Y"s were places of both fun and sanctuary for those children. Many of these institutions are still with us. But they are losing the battle.
In the health arena, programs are needed to address both the physical and mental health of homeless children. Their health needs require careful assessment. There need to be specialized health programs that emphasize parent support and education, community outreach, tracking and follow-up care of homeless children. These programs should have strong linkages to secondary and tertiary specialty health services.
We must massively invest in our children. As a society that is growing older, we cannot afford to squander a single ounce of the talent, creativity, energy and strength of our youth. We, as a society and as individuals, should provide adequate money, resources and time to assure shelter, nutrition, clothing, education, recreation and health care for our children. We must go one step further and adopt a goal of assuring that all children have a right to a home with people to care for them. We are far short of that goal now.
Andrew McBride, MD, MPH, is vice president for child advocacy at Children's Hospital. Second Opinion is a forum for points of view on health policy issues.