Trajectories of Housing Insecurity From Infancy to Adolescence and Adolescent Health Outcomes

We performed a secondary analysis of FFCWB data. As previously described, 4898 participants were enrolled at birth across 20 large, nationally representative US cities with varying local welfare support systems.²⁴  Nonmarital births were oversampled (3:1) to represent births in each city, leading to an oversample of individuals from minoritized racial and ethnic groups with financial disadvantage, to whom nonmarital births disproportionally occur.^24,25  Birthing parents (individuals who gave birth) were interviewed after delivery (baseline) and when their children were 1, 3, 5, 9, and 15 years old. Our institution’s institutional review board deemed this study exempt from human subjects review because these were publicly available, deidentified data.

We created an index measure of housing insecurity using the following indicators based on previous studies: skipping a rent or mortgage payment, doubling up (sharing housing with other families), eviction, homelessness (spending at least 1 night in the past year sleeping in a shelter, car, abandoned building, or another place not meant for residence), or moving more than once during any year since the last timepoint.^{1,2,10,21–23,26}  We created a count of these indicators, from 0 (secure) to 5 (highly insecure), to measure the severity of housing insecurity experienced at each timepoint (ages 1, 3, 5, 9, 15 years).

The primary outcomes at age 15 years were self-reported overall health (SRH) and depressive and anxiety symptoms. SRH was measured with 1 Likert-scaled question: “In general, how is your health?” with 5 answer choices from “poor” (1) to “excellent” (5).²⁷  This question has demonstrated validity across several contexts as a predictor of mortality and overall health.^28–30  We dichotomized SRH by coding “very good” (4) and “excellent” (5) as 1. Dichotomized versions of this measure yield results comparable to its original ordinal form.³¹ 

Depressive symptoms were measured with an adolescent-tailored adaptation of the 5-item Center for Epidemiologic Studies Depression Scale.^32,33  Anxiety symptoms were measured with 6 modified questions from the Brief Symptom Inventory 18, Anxiety Subscale.³⁴  Responses were scored on a 4-point scale and summed into overall scores for each outcome. Depression and anxiety scores ranged from 5 to 20 and 6 to 24, respectively, with higher scores indicating more symptoms.

At baseline, birthing parents reported their age (years), racial and ethnic identity (white, non-Hispanic; Black, non-Hispanic; Hispanic; other), level of education (eg, less than high school, high school/equivalent), household income (Federal Poverty Level [FPL] proximity), nativity (United States born or not), relationship status with the child’s nonbirthing parent (eg, married, cohabitating), household size (number of people in household collected at age 3 years), the child’s biological sex, and first-born status (yes/no).²⁴ 

We included participants with at least 1 housing measure (N = 4714, 96.2% of the main sample) in our analytic sample. Nearly 75% (3476/4898) of participants had housing measurements at 4 or more timepoints. Incomplete case analysis was preferred over a complete case approach to reduce bias from loss to follow-up, which would likely be higher in families experiencing housing insecurity.³⁵  Sensitivity analyses were conducted in a subsample of children with complete data across all 5 timepoints.

GBTM is a statistical methodology that uses longitudinal data (eg, clinical or behavioral measures) to identify clusters of individuals who follow similar developmental, behavioral, or experiential trajectories over time.^36–38  Trajectory models estimate group patterns and may not represent each individual experience exactly. GBTM is useful for modeling incomplete data because it accommodates all available information and provides maximum-likelihood estimations of model parameters.^39,40 

Following previously outlined model-selection procedures, we used GBTM to identify distinct trajectories of housing insecurity from ages 1 to 15 years using our housing insecurity index measure.^36,41  A zero-inflated Poisson model was chosen because the housing insecurity index measure had excess zeroes (70% or more) at every timepoint.⁴¹  The number of trajectory groups was determined using Bayesian information criterion. Several polynomial variations and orders were tested, with an a priori zero-term to represent a “consistently secure” trajectory of housing.³⁶  The final model maximized Bayesian information criterion and entropy, contained group posterior probabilities that exceeded the recommended 0.70 threshold, and demonstrated consistency between observed and model-estimated group membership probabilities.^39,41  Participants were assigned to the trajectory group in which they had the highest probability of membership.

Groupwise comparisons were made using analysis of variance or χ² testing, depending on variable type. Logistic regression was used to model SRH. As demonstrated previously, the distributional nuances (eg, overdispersion, variance patterns) of depressive and anxiety symptom scores were not suitable for linear regression.⁴²  Poisson regression was used to model anxiety symptoms. Negative binomial regression was used to model depression symptom scores because its variance exceeded the mean.⁴³  Baseline sociodemographics significantly associated with the housing groups were considered as covariates.⁴⁴  The child’s biological sex was included a priori because of its relationship with adolescent health.^45,46  Final models were selected in a backward stepwise manner and model assumptions (eg, distribution of outcome, independence of observations) were adequately met.

Tests were 2-tailed and α was set to .05. Statistical analyses were completed using Stata (version 17).⁴⁷  GBTM procedures were completed using the “traj” package.⁴⁸ 

The final group-based trajectory model contained 3 distinct trajectories of housing insecurity experienced from ages 1 to 15 years: no insecurity (“secure”); intermittent-moderate insecurity (“moderately insecure”); and high insecurity in early childhood, trending toward security in adolescence (abbreviated to “highly insecure”) (Fig 1). Most children were classified into the secure (2230/4714, 47.3%) and moderately insecure (2188/4714, 46.4%) groups, whereas 296 (6.3%) children were classified into the highly insecure group. Model summary statistics are in Supplemental Table 4.

Table 1 describes the sociodemographics for the FFCWB sample overall and by housing group. Educational attainment and household income were higher in the secure group and more parents in the secure group were married (34.6%). The highly insecure group had the largest proportions of parents who had not completed high school (51.5%) and who were living below the FPL (46.3%).

None of the children categorized into the secure group experienced any indicators of housing insecurity during the study. Table 2 and Fig 2 show frequency of housing insecurity indicators and prevalence of each individual indicator over time, respectively.

Most children in the moderately insecure group experienced 1 or 0 housing insecurity indicators at each timepoint. More than half in the highly insecure group experienced 2 or more housing insecurity indicators until age 5 years. Housing insecurity was most prevalent at ages 1 and 3 years, respectively, for the moderately and highly insecure groups (Table 2). The most common indicators for both insecure groups were skipping rent and doubling up (Fig 2). These indicators peaked at age 9 years for the moderately insecure group. In the highly insecure group, most indicators began to decrease in prevalence at ages 3 or 5 years. At age 15 years, more than two-thirds (68.2%) of the highly insecure group did not experience any indicators (Table 2).

Approximately 73% (3437/4714) of adolescents had at least 1 outcome measure available. Unadjusted and adjusted comparisons of outcomes at age 15 years between the housing groups can be found in Table 3. The housing groups had significantly different SRH, and depressive and anxiety symptom scores at age 15 years.

More adolescents in the secure group reported “very good” or “excellent” SRH than those in the insecure groups. Adolescents in the moderately and highly insecure groups had a 19% (95% confidence interval [CI], 0.69–0.95) and 33% (95% CI, 0.5–0.91) lower odds, respectively, of reporting “very good” or “excellent” SRH than those in the secure housing group (Table 3).

Adolescents in the highly insecure housing group reported more depressive symptoms on average than their secure and moderately insecure counterparts. Adolescents in the moderately and highly insecure groups reported depressive symptoms at rates of 1.05 (95% CI, 1.03–1.08) and 1.1 (95% CI, 1.08–1.2) times higher, respectively, than adolescents in the secure group (Table 3).

Of the 3 housing groups, adolescents in the secure housing group reported the lowest anxiety symptoms. Individuals in the highly insecure group reported anxiety symptoms at a rate 1.06 times higher than the secure group (95% CI, 1–1.1) (Table 3). Anxiety symptoms reported in the moderately insecure group did not significantly differ from the secure group.

In a sample of US children with socioeconomic disadvantage followed from infancy to adolescence, we identified 3 distinct longitudinal experiences of housing insecurity: secure, moderately insecure, and highly insecure. The rate of housing insecurity (52.7%) in the FFCWB sample, which we selected to examine long-term health effects of specific material hardships, reflects a similar rate reported in another study of low-income households with children.⁴⁹  Baseline educational attainment, marital status, and household income were associated with more secure trajectories. At age 15 years, adolescents in the secure group had better SRH, and lower anxiety and depressive symptoms compared with those who experienced insecure housing. These findings contribute knowledge about patterns of housing insecurity throughout childhood and their associations with adolescent health.

Our study is among the first to identify trajectories of housing insecurity in a sample of children. Although similar to the 4 trajectory models of housing insecurity identified by Kang and Aubry, our model did not contain trajectories of sustained or increasing insecurity, reinforcing evidence that households with children were less likely to experience chronically unstable housing.^21,22  The absence of these “mostly unstable” experiences for FFCWB participants could be due to increased access to safety net programs for households with children. Parents may also describe housing insecurity differently than individuals without children. Future research may employ qualitative methods to understand the lived experiences of families with children who have fluctuating housing insecurity and identify the mechanisms that protect them from more severe experiences of insecurity.

Although our trajectories are not an exact representation of each individual child’s experience, estimating them generated novel information about childhood housing insecurity and allowed us to identify priorities for intervention and future research. In line with life course research, even though children in both insecure groups experienced periods of security, those periods did not diminish the cumulative effects of insecure housing on adolescent health. Because the highest proportions of children in the insecure groups experienced housing insecurity in the first 3 years of life, early childhood may represent a vulnerable period to screen and help families experiencing housing hardships. The reduction of insecurity indicators for the highly insecure group over time, though encouraging, may be partially attributed to loss of follow-up in the FFCWB study, particularly from those experiencing housing insecurity. Children with the highest degree of insecurity may fall through the cracks because of their ever-changing housing situations. Children experiencing fluctuating housing insecurity may also be harder to identify, especially because there are not yet validated screening tools for clinicians to use in practice.⁵⁰  Our results highlight the potential long-term consequences if current public health measures do not identify children experiencing housing insecurity and underscore the need for innovative screening efforts beyond just health systems.

Our work extends current literature showing that deleterious effects of housing insecurity may begin as early as the first year of life. Studies connecting experiences of housing insecurity during various periods of child development to health outcomes later in life have had inconsistent results, which may be due to the child’s age at the time of the analysis and who is reporting the information (eg, child versus parent).^9,13,17–20  We demonstrated that prolonged experiences of housing insecurity spanning the first 15 years of life, regardless of severity, were predictive of poorer SRH and more symptoms of depression in adolescence. Adolescents in the highly insecure group had higher anxiety symptoms, despite the gradual improvement of this trajectory after age 3 years. Therefore, highly insecure housing early in life may have lasting effects regardless of experiences later in childhood, further reinforcing our recommendation for interventions as early as possible. Future studies should examine child psychiatric symptoms longitudinally with housing experiences to clarify the role of housing in mental health across developmental stages.

Though socioeconomic characteristics were significantly different among the housing groups, the differences were not distinct enough to provide any “contextually significant” information about risk factors for housing insecurity. For example, many households in both insecure housing groups had incomes that were well above the FPL, strengthening previous evidence that financial hardship alone is not a reliable indicator of material hardship.⁵¹  Controlling for racial and ethnic identity in our adjusted models showed that housing disparities likely had additional health effects exacerbating the well-documented health disparities experienced by racial and ethnic minority groups. Consequently, we contextualized housing insecurity as a social determinant of health existing independently and comorbidly with other drivers of health disparities. Risk factors for housing insecurity are likely rooted in larger systemic issues (eg, systemic racism, discrimination of female-headed households), and future studies should consider this broader context.^45,52,53 

Though the children in FFCWB were born >20 years ago, the context is the same or worse for families with children today; the national rate of 1-parent households has increased, the cost of living is higher, and individuals’ buying power has not caught up.^54,55  The expiration of pandemic-era federal assistance programs that may have lessened families’ growing financial burden, and the twofold increase in the supplemental child poverty measure from 2021 to 2022 leaves more families in need, fewer resources for providers to offer, and increased urgency for solutions.^56,57 

Our study has several limitations to consider when interpreting the results. Our composite measure of housing insecurity is imperfect because of the dichotomization of each individual indicator; a child who spent 1 night or several months in a place not meant for residence were counted equally. Housing hardships are likely underrepresented because housing insecurity may limit participant ability to participate in long-term research, biasing the FFWCB sample toward participants with secure housing. Moreover, indicators and outcomes could have been underreported because of social desirability bias or mistrust of research entities from historical mistreatment of minoritized racial and ethnic groups. Alternatively, because these data come from individuals from marginalized racial and ethnic groups and with lower incomes who are already disadvantaged, they may overestimate housing insecurity rates as they exist in the general population.

Housing insecurity is a complex, systemic issue with unique implications for children. Examining housing insecurity over years helped detect relationships with adolescent health outcomes not observed in previous cross-sectional analyses. Our findings extend evidence of the cumulative nature of housing insecurity, therefore emphasizing the importance of early intervention for families with children experiencing housing insecurity.

Housing insecurity is preventable and addressable through policy and public health intervention. Future work is needed to validate a universal measure for housing insecurity and implement screening and referral procedures for families with young children to appropriate services. In addition to traditional settings for screening, health systems would benefit from partnering with public health professionals to screen for housing insecurity in community spaces (eg, churches, recreational centers), where they may be able to engage parents of children living in overcrowded or precarious housing. Screening is only half of the battle, and providers need more resources to offer once families experiencing housing insecurity are identified. Policy efforts should prioritize affordable housing accessibility and financial support programs for families with children since skipping rent and doubling up were the most common indicators for the insecure groups. Stakeholders should seek to understand how pandemic-era financial assistance programs succeeded in diminishing child poverty and how they can be adapted into permanent protections for families with young children.

FFCWB

Future of Families and Child Wellbeing Study

FPL

federal poverty level

GBTM

group-based trajectory modeling

SRH

self-reported health