Supporting the Health and Wellness of Children Experiencing Homelessness in the Time of COVID-19

Supporting the Health and Wellness of Children Experiencing Homelessness in the Time of COVID-19

Steve Shuman: Now we're getting ready to begin. Let me introduce two people who have so much experience and expertise on today's topic, Dr. Jacki Hart and Katie Volk. Katie and Jacki, you want to take it away.

Jacki Hart: Thank you, Steve. Good morning, good afternoon, good evening from wherever you're zooming in from. We do have a tremendous amount of material as Steve mentioned, so we're going to try to get through this as quickly as possible. My name is Dr. Jacki Hart. I am trained as an internist. Most of my clinical work has been in lifestyle medicine and prevention. I connected with the folks at C4 Innovations a few years ago with the intention of applying lifestyle medical principles to the most vulnerable populations amongst us where health disparities are the greatest, so that's the advantage that I speak from. Katie?

Katie Volk: Hi, everyone. My name is Katie Volk, and at C4 Innovations. I am a child development specialist by training and have been doing homelessness and mental health work for many – many years now. I'm delighted to be. Here early childhood is where my heart is at, so it's a pleasure to spend time with you all this afternoon. Today, what we're going to do is walk through a little bit about housing instability and COVID-19. We'll talk about the impact of what that looks like, and we'll also talk about neuroplasticity. And then, we'll get into how Head Start programs can help, but hopefully have a little bit of time for Q&A and resources. Naturally, with over 500 of you here, we don't have time to do individual introductions. But we are going to bring up a poll. We'll have a few polls throughout. We're going to bring up poll number one here. If you could bring that up. This is how we will get to know you all a little bit. It looks like this is not poll number one, at least not what I'm seeing. But hopefully, you're seeing poll number one, which asks about how many years you've been in the field of early education. You can interpret that however you like. I see lots of people answering here.

It's like watching the ticker tape all the numbers are going up. It looks like we have at least half of you so far have been in the field for quite some time – so more than 11 years. I stopped it at that point when we were writing this. And then it looks like everybody else has a variety of experience. There's still a few more people answering here. All right. We would love to get to know you all in more detail, but we'll, for now, leave it at that. It sounds like about half of you have been in the field for a while and the rest of you have somewhere between 0 and 10 years. My guess is that some of what we talk about you'll be familiar with. And we'll talk about how that's changed during COVID-19 as well. Let's get right into it then.

Pre pandemic, one in 30 children experienced homelessness in the United States each year. And that number goes birth through 18. So when we're talking about children, we're talking about birth through 18 – one in 30. We know that, typically, families who are homeless are headed by women who have young children. But the pandemic has shifted those numbers in ways that we're actually still learning about, and I'm going to transfer it to Jacki to talk about this a little bit.

Jacki: Katie is correct that the data is still emerging, and what I tend to say is that in many ways, we have just delayed the process as opposed to eliminating it through things like the CARES Act and the American Rescue Plan, eviction moratoria – and renter's relief has been extended now through the end of September. So the true impact on homelessness and housing instability really won't manifest, I'm guessing, until the first quarter of 2022. I say that because the court systems are very much backed up, so even after those things expire at the end of September, it will be months before we actually see the true impact. One thing that I meant to say early on is that we talk about housing instability more than we talk about homelessness, per se. We think of it as a continuum with homelessness on one end of the spectrum. Many of the studies that we'll share with you the research has been done specifically on families experiencing homelessness. But the stresses and the strains and both the causes and the outcomes are applicable to families who are experiencing housing instability anywhere along that spectrum.

You can go ahead, Katie. Katie mentioned in the beginning that the vast majority of these families are women. Thankfully, through Head Start, you use the definition from the Department of Education – the McKinney-Vento definition – which, when you're talking about families, it's key to distinguish that from the number that we usually hear from the Housing and Urban Development Department because the counts that we get from HUD are not as accurate as the counts that we get through the Department of Education.

When you think about the numbers and include families with children under 6, it's roughly two and a half million children who have experienced homelessness. A couple other points that are key on this slide, the concept of housing instability is actually quite difficult to define. One of the ways in sort of our work and in research that we assess that experience is by measuring how often children and families move. And that term is called residential mobility. What we know very broadly about residential mobility is that if kids move three or more times in their lifetime anywhere from 0 to 18, they're at increased risk for health issues, and mental health issues, and developmental delays and educational problems.

When you think about families experiencing housing instability, that average, those families move about two times per year. Sort of think about how that compounds over their lifetime. A lot more needs to be understood about that term specifically, but that's one of the ways that we measure unstable housing. Doubling up – hopefully many of you have heard of that term. It essentially means when you have two or more people living in a bedroom, or two or more families living in a housing space that's not intended for that number of people. I'll talk in a little bit about housing related costs in the context of cost burden. But do you want to go on there, Katie?

Katie: As Jacki mentioned, we use the McKinney-Vento definition of homelessness here, which is what that one in 30 number at the beginning of the webcast refers to. And it basically boils down to this – just by way of quick refresher – can the student or the child go to the same place every night? Fixed, regular, adequate – same place, every night, in a safe and sufficient space. As you can see it has to do with stability. If you're ever trying to figure out is this family experiencing housing instability, this is a good way to just answer these three questions for yourself.

And families are homeless for a whole host of reasons. First, there's an imbalance between income and housing. You all, I'm sure, are familiar with this: Minimum wage is not enough to cover the cost of fair market rent in any jurisdiction in the United States, and there's a shortage in affordable housing in the United States. These two dynamics have been with us for many – many – many years, decades in fact. The other cause of homelessness, particularly for families, is domestic violence. We'll talk a little bit about that in a minute. And there's a whole bunch of dynamics at play there. And what goes on then during the pandemic is that COVID-19 has exacerbated all of these dynamics in ways, like I said, that we're still not sure of. The courts are still adjudicating evictions. There's been moratoriums on things. In terms of domestic violence – which can look like a lot of different things, not just physical violence – we're still not sure, as a field, what the impacts of this have been. We do know that it is harder for people who are in violent situations to leave because of the pandemic. It's made people more isolated rather than more connected. We included this wheel of power and control here as a resource for you all. I know that many of you may be familiar with it because it's something to sort of just be really familiar with as you're thinking about what homelessness, housing instability, and domestic violence looks like for the families that you're working with.

In the homelessness research, about 2/3 of caregivers – and this is all research that's been done with women – about 2/3 of women who experience homelessness have experienced domestic violence, which is two to three times the rate of all women. And so, it's a big factor. Jacki, do you want to talk a little bit about what this looks like in terms of the pandemic?

Jacki: Sure. While this isn't specific data or data that's specific to families experiencing housing instability, it's relevant because as Katie just pointed out, the sort of pathway to homelessness for women is often through domestic violence. Overall, domestic violence has increased anywhere from 21% to 35% over the course of the pandemic. A few interesting things. One is that early on, reporting of domestic violence had dropped, and as I'm sure many of you can imagine, that was because people were in places and spaces where it wasn't actually safe for them to report what was going on at home. There are multiple contributing factors to why domestic violence has increased during this stressful time for everyone. Economic and psychological stresses, greater exposure to unsafe relationships, reduced community support through school, and work, and church and other settings. Diminished ability to seek help, as I mentioned, poor coping strategies. One thing that is interesting is that alcohol sales have increased during the time of COVID – 36%. People who use violence and drink, they’re sort of more likely to use violence. The other things specific to COVID is that those who are experiencing violence have often been fed misinformation about, “It's unsafe to go to your doctor. It's unsafe to go to clinics. It's unsafe to go to hospitals,” none of which is actually true.

Another sort of interesting statistic that I like – that sort of telling about this – is that even though in the early parts of the pandemic phone calls were down, Google searches for domestic violence and abuse were way up – up by 75%. That sort of tells you that people were finding ways to search on their phones or other devices to gather information. You can move on to the … Don't go to the next slide. OK.

What does this all mean or what is this all sort of related to? I had mentioned earlier that my background is in lifestyle medicine. And what I would say is that my work sort of interfaces between how we impact things for individuals, communities, families, and how we think about this on a public health scale. Social determinants of health, as defined by the World Health Organization, are conditions in which people are born, grow, live, work, and age that affect health and the rates of illness within populations. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. This diagram that I have there is actually from Healthy People 2020 because I happen to like that better than the one that they've now redone for Healthy People 2030. But the data that I'm sharing are the goals and objectives for Healthy People 2030.

Every decade, the Department of Health and Human Services sets out specific goals and objectives that we try to aspire to reach. A few that I selected – there's many – many – but a few that I've selected that are specifically related to housing … Objective is to lower the cost burden for families to 25.5% of families experiencing a high-cost burden. What a cost burden is – is essentially when you're using 30% or more of your income to pay for housing related costs. Some of the data pre pandemic was that roughly 40% of families were experiencing that level of cost burden sort of across the board. Now, that number is much closer to 50% across the board. And when you break that down by race or ethnicity, the disparities are dramatic. I'm just going to share those numbers with you. Currently, 54.9% of Black renters experience 30% or more cost burden. 53.5% of Latinx renters, 45.7% of Asian renters, 42.6% of white renters, and 50% of Native American Indian or Alaskan native renters are experiencing the cost burden of that level greater than 30%. I don't have the current pandemic numbers in terms of severe cost burden. Severe cost burden is defined as spending more than 50% of your income on housing related costs. And housing related costs include the housing itself, utilities, repairs, et cetera. It is a telling shift in the pandemic. There's a lot that I can talk about here. I do just want to point out that one of the objectives that they have set is to improve mental health services for adults experiencing homelessness. They haven't attached a specific number or specific goal, but just the fact that they're sort of talking about this on a national public health level is really key, and you'll see why as we continue talking.

We're going to move now into this concept that quality matters. Again, we talk about homelessness or housing instability on a spectrum. But when people are living in unstable locations that are confounded by crowding and environmental issues that increase their health risks, quality does matter. You can keep going Katie. I sort of alluded to a couple of things here. One is that housing costs refers to not just rent itself but all of the other associated costs. That demand and that strain has also been heightened during the pandemic because having kids and students at home, it makes it very difficult to learn if you don't have adequate internet access, if you're worried about your electricity being shut down, et cetera, et cetera. It's also been a time when landlords have sort of used the excuse of COVID to not do repairs and not do the things necessary to make a living circumstance more tenable. We talked a little bit about overcrowding, and I mentioned the terminology of doubling up. The very obvious risk during the pandemic is the increased risk of infection and overcrowded circumstances. It also puts a significant stress and strain on relationships, as we talked about specifically with domestic violence, but more broadly than that. And one point I'd like to make here is the emphasis on poor sleep. When we talk about – later in the conversation when we talk about brain function and development – sleep is critical. And it's sort of one of those things – I wouldn't call it hidden – but it's one of those things you don't necessarily automatically think about. But in those circumstances, that is one of the most difficult pieces, for children to get adequate sleep in those situations.

Katie: We also want to talk about family well-being, because as you all know, as early childhood educators and people who work in the field of early education, family well-being is incredibly important as is early education and care. And that means kids who … And these are some statistics for you here. But when we think about quality, I think about child to teacher ratios. We think about developmentally appropriate practice that is culturally sensitive and attuned to the backgrounds of families. We think about family-centered care, which I know is something many of you may be familiar with. And we know that all of the domains of well-being are interrelated. The quality of my child's sleep is related to the quality of what our home environment looks like, which might also be related to what it looks like behaviorally during the day. It might relate to what nap schedules look like, so it's all really interrelated here. Over many – many years, Ann Masten and her colleagues and many others in the homelessness and resilience field have looked at what the literature says around protective factors. How can we make sure that kids are resilient in the face of stress? And what they've noticed is that there is a protective factor of executive functioning – so problem solving, reading cues and relationships, planning, reasoning, all the things that good early childhood education is trying to promote – helps to promote resilience. And that's one of the things that has really remained true across 20 years of resilience research.

We want to talk to you – and I'm just doing a time check here, Jacki – we're going to talk for about 10 seconds about impacts and neuroplasticity here. And, let me turn it over to – well, let me talk a little bit more and then I'll turn it over to Jacki. The experience of mothers – and that's where all the research has been done – is that many who have experienced homelessness or most who have experienced homelessness have a lifetime history of traumatic stress across multiple areas and across their lifetime. And that impacts their mental health, but Jacki is going to talk about for a minute here.

Jacki: When Katie was just talking, it reminded me of sort of another overarching objective of ours. One of the ones I've already mentioned, which is that homelessness is really on a spectrum of housing instability. But another is that this is an intergenerational issue and an intergenerational problem, which means that solutions ultimately are systemic. Solutions ultimately need to be addressed on a broader public health level. But in terms of the impact between a parent and a child, one circumstance that has the greatest negative impact really is maternal depression.

Again, we talk about moms because 80% of the parents in this category are moms. In the general public, mothers who experience depression – it's roughly 12%. When you look at moms living in poverty or ethnic and racial minorities, that number doubles. When you talk about low-income moms with young children, like the population that you all work with and also young parents, then that number increases even further. And for those who experience homelessness again, because that's the group that's been studied but I would argue that you could substitute housing instability here, that number grows to between 45% and 85%.

And when you think about this, when someone is experiencing depression, it makes it very difficult to look for housing, maintain housing, look for jobs, maintain that job, and to be an effective caretaker. There's this sort of narrative or misconception in the medical and psychiatric world where people say it's normal for people experiencing these difficult challenges to feel sad or feel anxious. Well, A - it's not normal, and B - there's a difference between feeling sad and having clinical depression, so there needs to be a much greater effort with this population to screen for, recognize, identify, and then treat maternal depression.

I think there's another poll. Katie, maybe you could bring that up now just relative to what you all are seeing in terms of COVID and in the places where you work.

Katie: And while you all are filling out that poll, I'll just say because I know I saw a question. When we're talking about doubled up families, we're not talking about like, “I grew up living with my grandfather.” We're not talking about that kind of doubled up. We're talking about living in a space not meant for the number of people living there, and doubled up due to economic necessity. The National Center on Homeless Education – and that link is at the end of this webcast – has some really good resources on identifying families that are doubled up that fit the McKinney-Vento definition. But that's really what we're talking about. I just wanted to clarify. We're not talking about multi-generational homes or people who choose to live together. It's really more like, “Can my kids and I crash on your couch for a month because we got evicted?” It's more that kind of homelessness or housing instability, if you will.

Jacki: Kate, that seems to be slowing down. If you want to pull up the results. OK. It looks like many of you are already seeing the impact from the pandemic on housing instability. The other thing that I was going to say when Katie was just mentioning about doubling up, the issue –  another sort of issue around doubling up in the way that Katie just described it is it puts children at significant risk of exposures to certain circumstances. It increases the risk of domestic violence, it increases the risk of exposure to violence, it increases the risk of trafficking. It's unsafe for all sorts of reasons. But one thing that I just wanted to talk about here again, we don't have a lot of data yet about COVID specifically for this population. What we know very broadly and very generally is that there are significant disparities in who has contracted COVID, who has been hospitalized for COVID, who has died from COVID. But there's sort of this belief out there that kids are not impacted by the virus itself. Not entirely true. Just like we see disparities in who is impacted by the virus as adults, we also see those disparities for children as well. The other thing that is unique about COVID relative to children is that they may not have acute symptoms, but some of them do go on to develop long-term symptoms. “Long COVID” – I'm not sure who's heard of that terminology or not, but essentially, if people have symptoms four to five weeks post contraction of the virus. You will see that at times with kids. And the reason that I point that out is because in the settings where you work, if you see kids who have reduced energy or enthusiasm, or they just seem more lethargic, trying to push them to do additional activity actually exacerbates the symptoms – does the opposite of what you anticipate or want or hope. On a positive note, if they are not kids with COVID, especially young kids under 6, they are not efficient transmitters, so the likelihood of contracting the virus from children in your work setting is pretty minimal. You want to go on Katie?

Katie: Yeah, and Jacki I think we’re going to, just in the interest of time, should speed up a little bit.

Jacki: OK. Do you want me to skip this one then?

Katie: Yes.

Jacki: Yeah, let's skip this. OK. We've talked about what residential mobility is. As you can imagine, that decreases health care access. It results in poorer physical and oral health, in large part because people don't have a consistent medical or dental home. Long term, it puts kids at greater risk for high blood pressure, heart disease, diabetes, and weight related issues. I do want to just touch briefly on the concept of vaccine hesitancy. One of my roles right now is that I work for an organization called the Vaccine Immunotherapy Center at Mass General Hospital. I spend a fair amount of time working on systems to get vaccines to difficult to reach populations, like people experiencing homelessness and undocumented immigrants. But what's interesting is that we're really at a transition phase from supply to demand. And I raise it here with all of you in part because the best way to convince people who are a bit hesitant or reluctant to get a vaccine is for them to talk to trusted sources. I imagine in your settings that many parents may ask you about it, especially as vaccines become increasingly available to children. This week, Pfizer is available to kids between 12 and 15, and they're predicting that by September the vaccine will be available to kids as young as 2 years old. Any reservations and questions that people have, they may actually bring them to you. The best approaches are be patient, be kind, hear questions out. There there's a lot of historical reasons why minorities, in particular, African-Americans are nervous about taking the vaccine. There's a small percentage of people – some say as high as 20%, others predict that it's roughly 12% –who will never take the vaccine. But then there are a lot of people who are in this kind of reluctant hesitant – what I heard somebody call “deliberators” – they're still thinking. That's sort of why I raised that in this context.

Katie: The bottom line here is that housing is health care. When you have a stable safe place to call home that's consistent and well maintained, it provides you with a degree of health that there is really no substitute for. There are many examples of what inadequate or substandard housing look like. Many times families don't want to talk about this piece of it because there's a lot of stigma and shame that comes with it. It's just something to be aware of, and my guess is that many of you have seen pieces of this over the course of your careers.

We want to switch a little bit to talking about what the impact of all of this is on children's well-being, and then get to some strategies for what you do and how you respond. When you think about stress for kids, and this comes from the Center for the Developing Child at Harvard, it comes from their model. You can think about positive, tolerable, and toxic levels of stress. Positive levels of stress is like my son, when he was young, used to go and stand on the pitcher's mound, and it looked totally stressful to me, but for him that was positive. Sometimes there's stress that's good for kids. They build their confidence. The same is true for young kids. Tolerable stress is when you have an adult around to buffer the impacts of that stress.

If you think of family transitions, if you think a lot about what the social distancing and quarantine measures have look like, if there is a caregiver around to buffer that stress – explain it in a developmentally appropriate way, help kids through that – it becomes a buffer. When the stress levels reach the level of toxic, which means there are cumulative effects and caregivers are unable to buffer that. And by caregivers, I mean not just mom but anybody who is caring for the child. Over time, it can disrupt brain architecture and lead to some of the outcomes around health and mental health that we've been talking about. Like I said, the Center for the Developing Child has phenomenal resources and little videos to explain much of this, if that's something you're interested in learning more about, but it's just a helpful model to think about what some of these adverse childhood experiences, some of which are up on the screen, may look like. Jacki, do you want to talk a little bit about the neuroscience piece and then I can get to the strategies?

Jacki: Sure. Essentially, what happens when people are experiencing toxic stress – and I love Katie's examples because it sort of contextualizes the differences in the kind of dose of stress –but it essentially puts you in that fight or flight response at almost all times or essentially all times as opposed to what most of us feel, which is sort of blows up and down of those experiences. When you're constantly in that fight or flight posture, you're secreting hormones, like cortisol, which elevate inflammation throughout your body and your brain. Other things that are elevated at the same time are neurotransmitters, like adrenaline – that sort of a common one that people hear about. The inflammatory markers like cytokines and interleukins and something called the “tumor necrosis factor” – they can actually change the brain structure and architecture. The system in your brain that's most impacted, it is called the limbic system, which is responsible for memories and emotions. Experiences translate into memories, the memories are significantly intertwined with the emotional centers.

The positive side … You can move on, Katie. On to the next slide – and actually to the next slide. The positive thing is that even if you've had a cumulative level of negative experiences and adverse experiences, that can be, if not reversed at least mitigated. We used to believe decades ago that the brain was sort of a stagnant – brain development was stagnant. You reached a certain point and that was it, but really since the 1960s, we've understood that the brain can generate new cells, and it can generate new pathways. It can actually rewire. It all sort of takes place in that limbic part of the brain where emotions and memories intersect. And so, it gives us hope.

And one of the pieces that's most critical is the relationship between the mom and the child. You can go to the next slide, Katie. This is just another visual about this concept of brain plasticity or adaptability, the two different types that neurologists refer to are functional and structural. “Functional” being if you've had a traumatic brain injury or a stroke, then another part of the brain literally takes over the function. Structural plasticity is what we are talking about, and where you all come in very significant ways because you introduce a new and different experiences so the brain can be rewired, and kids can develop resilience and adaptability.

Katie: Let's go ahead and talk about some strategies that you can use to support families, because the bottom line is that people can and do recover – that goes for adults as much as it goes for kids, our brains are all plastic. Children are resilient, but it happens with support –support that puts families in charge, that comes from a trauma informed and person-centered point of view that puts relationships and safety at the center of much of what we're talking about. Because as we've talked about, homelessness disrupts a whole bunch of things, and so does housing instability.

But Head Start has a real role to stabilize many of these things. Family routines become stabilized; certainly, that academic and social learning piece. For parents, it gives them a respite from parenting. Anybody who's been at home over the last year quarantined with children and trying to work at the same time knows that a respite from parenting can sometimes be helpful, especially when you're trying to have other basic needs met. It also helps meeting some of the children's basic needs around health and well-being, and food, and security. A couple of strategies for you all to consider, and we use when we're talking about this, we're using an ecological model. Recall your child development days of Bronfenbrenner where you've got the child in the middle and there are concentric circles around the child really supporting the whole environment that that child is in.

Some of these things are well within our control. Some of them are far out of our control. We're going to talk about all of them. That's something I know to acknowledge and to keep in mind. One is to have developmentally appropriate trauma-informed classroom. Thinking about what a child's developmental age is versus their chronological age. I'm going to give you an example in a minute of what that may look like. Doing everything you can to promote safety, not just physically safety, but kind of emotional – I think of it as emotional, psychological, spiritual safety. Being really consistent with children; paying attention and knowing the signs of both the externalizing behaviors and the internalizing behaviors because children don't often come to us and say, “Hey, I'm feeling really stressed out.” That's not what young kids are going to do, but you're going to see it come out through how they're behaving, whether that's a lot of stomachaches, or kind of restlessness, or fatigue or the more externalizing behaviors we see, which are knocking things over and picking fights and being more aggressive and all those kind of things.

I find this a helpful checklist to go through when working with kids in these kinds of settings. Think about what does this child need to thrive at this stage of their life and in this domain of development. What is scaring them? Where is their fear coming from, and what is comforting to them? And then, from a developmental point, what skills are they trying to master? I want to give two examples – I'm just doing a little time check here – I want to give two examples of kids that I worked with who were very – very different but in this young age group. One of them –we'll call him Brian – was just about 4-years-old. He was living in the shelter, very quiet and had some kind of developmental stuff that was, like his fine motor skills weren't quite where the other 4-year-olds were, and you could tell he struggled with that. His expressive communication skills were a struggle, so he couldn't really express what was going on.

Rather than outwardly get frustrated, he was just very quiet and would sit in the group and often just look really confused about what was going on in the group. It felt more like he was kind of a shy toddler than a 4-year-old. And what we attribute it to is that stress, whether it's traumatic or just significant stress, often makes kids regress. It didn't surprise me that Brian looked more like a toddler than a 4-year-old. I will say – and I tell this story whether I'm in front of Head Start providers or not, just so you all know – his mother, one of her main priorities was to enroll him in Head Start because she thought he needed a really good environment to be in. And that happened, and I was there once a week or twice a week running a program with the kids. He became more confident; his personality started to emerge; he seemed to be able to follow what was going on with the other kids. I think he had some safety in that routine. I think the Head Start teachers were working with him on these various developmental skills, and we saw this whole transformation of this little boy because whoever was working with him looked at these kinds of questions.

The other example I'll give of how you consider stage and domain is of a little girl who I'll call Carrie. She was a little older, she was almost 5 and 1/2. I always refer to her as my little hummingbird. She, I swear, must have burned like 10,000 calories a day. She was constantly like flitting all around, like going from place to place – smart as a whip. She could speak English, Creole with her mother, French – because it was French Creole that her mother spoke. She had a little bit of French and was trying to convince the other parents in the shelter to teach her Spanish at 5 – very impressive. What she had a hard time doing – so, my little Brian, I had on the one hand was kind of shy and looked younger – what she was really trying to do is she was constantly in a state of hyper arousal. It was often masked by the fact that she was a really friendly, outgoing, really smart young girl. But when we would try to get her to slow down, and we were doing a lot of mindfulness activities with the kids, she would insist that her heart wasn't beating. When we tried to put her hand – have her put a hand on her heart, she struggled with breathing. Because this was a little girl who was operating at a really high, chronically aroused – hyper aroused state. What did she need to thrive? She needed some coping skills to be able to calm herself down. Eventually, I did convince her that her heart was actually beating, and we used a lot of like mindfulness and body techniques to help her with that. She was scared, I think, so that was what was accounting for her hyper arousal. Her mother was incredibly comforting to her, so she was the only kid in the sessions that we were running that we had … Actually, her mom would come and just sort of sit off to the side because it would help her calm a little bit. And she was trying to master some level of control over her environment, which is a really common thing for any 5-year-old, particularly a 5-year-old who had been through the traumas and instability that she had been through. Just some questions you can ask yourself as you're thinking about this. Thinking about family-centered care, which is I know something Head Start does really – really well. But prioritizing the parents as decision makers for their children's care, involving them in the process.

There was actually a survey done of families who were housing – who were living in shelters, and they identified service needs. And I've listed them here for you all as your reference, but that last one was “services to help support their children's health and well-being.” And, to me, this is where Head Start really – really can come in and make a huge difference. These are the features of family-centered care. Spending time with the family; listening carefully and actively; having the parent as a partner in their child's care – which seems really like something kind of obvious but often doesn't happen or gets chipped away at in very subtle kind of stigmatizing sort of ways; being sensitive to family values and customs; providing specific information that the parent requests and needs. You all have a lot of information at your disposal. And so, using that wisely. And using that relational framework that is really at the center of much of what you do, because when you're working with families, you are supporting a two-generation approach. You are working both with the caregivers and with the children, and actually, even more than two generations, if you are working with little Brian. The family was – they were working with Brian, but Brian also had an infant sister. And if he had an older brother, then you'd be working with the entire family, whether you realized it or not and even if your work was direct. Because we know that parents suffer stress. That is like child development 101. And you all … I would actually say it's not just parents, it's caregivers. And if a child is spending six or seven or eight hours in your care, in your classroom, in your setting, you are also a stress buffer to them.

While we're here thinking about caregiver stress, another strategy that is really key – and I'm going to ask Kate to pull up the last poll here – because another strategy that is really key, and I don't want to have missed, is that our own health care and well-being absolutely matters in this process. You can't spread what you don't have. Really focusing on taking care of ourselves, being mindful ourselves in whatever way that makes sense to us. Whether it's being physically active, or staying hydrated, or sleeping it off, or somehow figuring out a way to nurture personal relationships and stay connected. Through all of those strategies and more – this is not an exhaustive list – helps us be better caregivers and better colleagues for the children in our care and is really a key part of how we should approach the work.

I can see many of you answering there. Unfortunately, with a group this big, we couldn't put “other,” so hopefully, these are some of the strategies that hopefully you have used here. I'm going to keep going because I want to make sure we get to the last piece here. Kate, you can go ahead and end that poll. It looks like the results are slowing down here. Because I do also want to take a minute to acknowledge that we are working, like we showed Bronfenbrenner model of the child situated ecologically. Jackie has talked a lot about the social determinants of health.

There are a lot of systemic injustices at play here, and we acknowledge that. We know that many of us in the room cannot, in our classrooms or in our programs, address all of these every day at the level to which they may need to be addressed. But we all have a role to play in thinking about inequity, in thinking about racism, in thinking about how policy, historical policy flaws in the affordable housing arena and in other places have contributed to some of these inequities, thinking about what the current policy flaws are. We want to at least acknowledge that and say wherever you are, wherever your sphere of influence is, do your best to make sure that you're always thinking with that systemic lens as well in wherever you are able to address that. And that may be in small ways, or it may be in big ways depending on what particular hats you're wearing. I'm going to go ahead and turn it back over to Jacki to close us out here. And I can see there are questions and other things popping up here. I'll take a look at that and see if we can answer a few of those at least, but take it away Jacki.

Jacki: Well, we actually went over this earlier, but I do just want to reinforce what Katie just mentioned. And many of the solutions here are on the public health and systemic level. And the pandemic has been awful for all of us and has put a tremendous stress on the population that we're talking about. But what I'm heartened by is that people are taking this opportunity to really look at that broader scale level because what each of us does on a day to day basis is critical in terms of the impact on children directly and in terms of the impact on the families. But in terms of the long-term changes we can make, there are a lot of big thinkers and policy makers that are thinking about those broader scale issues. And if we get nothing else out of this sort of terrible time period that has heightened all of the inequities – the racial inequities that predated the pandemic, and the economic inequities and the health disparities – if nothing else, it sort of awakened the country to how much we need to change. Thank you all for your patience and for being here. Thank you, Steve and Kate and Barbara and Olivia for your behind the scenes help and planning and logistics, and our colleague Bethany who has been instrumental in putting all of this together.

Steve: Thank you Jackie, thank you Katie. We have time for one or two questions. And if we don't get to your questions, please send them to health@ecetta.info. Olivia and Barbara will type that address right into the chat for you to see. The handout is in the chat. The handout has links to everything – a copy of the slides, the evaluation, and all the resources that Jackie and Katie mentioned today and are also in the slides. Katie, I wonder, is there a rate of homelessness and domestic violence for rural communities? When I looked, it looked like that was hard to identify.

Katie: Yeah, it's a hard question. And I saw that pop up in the Q&A box. Housing and homelessness and residential instability varies so much from jurisdiction to jurisdiction anyway. In rural areas, it's a lot harder to identify families because of the nature of the geography, quite frankly. What I would say is, if you're interested in the data for your particular area, you can look to your local homeless coalition. Most cities and states have coalitions for the homeless. You can also look to the National Center for Homeless Education. That website is going to be at the end of your slide deck here today, and get some of those numbers because it does look a little bit different.

Steve: Thank you. Yeah, go ahead Jacki.

Jacki: I was just going to add that through the Bassuk Center, we also have an organization called the National Center to End Family Homelessness. We do a fair amount of research through the health subcommittee, and we make a real concerted effort to try to gather data and information about families and children experiencing homelessness in rural locations because it does look very – very different from urban areas.

Steve: Thank you. And an interesting question – we've done a lot this year around substance use. The question is, does the data indicate that substance use causes homelessness or does homelessness lead to substance use?

Katie: It varies between individual homeless, so single adults who are homeless and families that are homeless. The rates of substance use among families that are homeless are actually fairly low, although I don't have current data at the tips of my fingers. I'm not sure. It's a good question, which comes first, the chicken or the egg, so to speak? I think generally speaking, the rates of substance use are lower than people think that they are. I'll say that.

Jacki: Yeah. That's exactly right. It's lower for families than you would imagine in adults, and that's who are experiencing homelessness. But in the research, it's often measured as an association. So not necessarily evaluated as a cause and effect, but that there is – what the rate of association is.

Steve: Thank you. So association more than cause. Thank you. Thank you, Jacki. Katie, can you take me to the next slide so we can close things out. I really appreciate all the great comments and questions people have typed into the chat. Here is the evaluation link. Barbara has added it to the chat. Here it is again. It will also appear when this webinar closes down. It is also in the resource handout. The resource handout has a link to the evaluation, a link to the slides, a link to all of the resources. It even has a link to the certificate. But the best way to get this certificate is to complete the evaluation. When you hit “Submit,” a new URL will open, and you'll be able to download your certificate and keep it wherever you like.

Next slide, please. We want to let you know that you can always reach us at health@ecetta.info. Our website is part of the ECLKC, and if you go to all of our health resources, there are additional homelessness resources across the ECLKC, and many of them are linked in the resource handout. And on the next slides – there we are. We have all kinds of modules and resources around homelessness and links to some of the organizations that Katie and Jacki have just mentioned in responding to your questions. All that is there for you. It will also go out in a recording, an email that you'll get probably at the beginning of next week. Please stand by for that.

We're so glad that you appreciate it. We see your comments in the chat, very appreciative. We do have a mailing list that's also linked in the resource handout. You can access, and I just want to say a special thank you to Katie Volk and Dr. Jacki Hart. What incredible information about this really incredibly important topic that has always been important, but now even more important than ever. Head Start, not only do you sleeve up, but you roll up both sleeves in order to do this really hard work, but it's so important to children and families.

Close