Homelessness and housing instability — viva

Opening

The examiner presents a four-year-old girl with a recurrent asthma exacerbation whose mother discloses the family has been sleeping on a relative's lounge room floor for six weeks since an eviction. The address on file is wrong and two appointments were missed. The candidate is asked to outline the approach to her care. [4] [1]

Branch 1 — The guiding principle and the continuum

• What principle frames your duty to this child, and what does it require? Lead with housing as a determinant of child health: stable, safe, adequate housing predicts physical illness, developmental delay, mental-health difficulty and educational underachievement, and the harm is biologically embedded through toxic stress. [4] [3]
• How would you classify this family's position on the housing continuum, and why does the continuum matter? The slide from stable housing through insecurity to overt homelessness is fluid and bidirectional — families move between stages, often several times a year, and the harm accumulates. [3]
• Why should housing be screened at every encounter, not only in crisis? Housing is a vital sign; the hidden iceberg of insecurity is far larger than the visible tip of overt homelessness, and families rarely volunteer the information. [1]

Branch 2 — The five domains of clustered morbidity

• What domains of harm would you expect and screen for in this child? Expect five: physical health (asthma, infection, skin), growth and nutrition (food insecurity, faltering growth), development and education (delay, absenteeism), mental health and behaviour (anxiety, externalising), and access and continuity (lost GP, records, prescriptions). [3]
• Why is broad screening the defensible default? Because the harm clusters — a child who presents with asthma may also carry untreated developmental delay, iron deficiency and a fractured vaccination record. [3]
• What does Keen's prospective data add about the durability of the mental-health harm? Childhood housing insecurity predicts anxiety and depression into adulthood, so the harm must be treated actively and early. [7]

Branch 3 — The toxic-stress mechanism

• How does housing instability become biological harm? Through chronic, unpredictable stress that repeatedly activates the stress response without a safe, predictable buffer, eroding the caregiver buffer and embedding in HPA dysregulation and inflammation. [7]
• How does parental mental health mediate the child harm? A stressed parent is less able to co-regulate the child; supporting the parent is a direct child-health intervention. [4]
• What did Keen's inflammation study show, and why does it matter? Adolescent housing insecurity predicts elevated inflammation over time — a measurable biological signature of the social adversity. [7]

Branch 4 — Safeguarding, domestic violence and the portable summary

• How would you screen for domestic and family violence, and why? Ask directly and sensitively — housing instability and violence are tightly entangled, and the two must be screened for together. [15]
• When has the situation crossed from social need into safeguarding? When a family is sleeping rough with children, when violence is present, or when the child is at acute risk — activate the child-protection pathway. [15]
• What is the portable health summary, and why is it the key continuity intervention? A record of diagnoses, medications, vaccines, growth and referrals that travels with the family — Carroll's data show that administrative fracture destroys continuity, and the portable summary is the counter-measure. [10]

Branch 5 — Housing advocacy and the intervention evidence

• What evidence supports housing intervention as a clinical treatment? Bovell-Ammon's pilot randomised trial showed housing medically complex families was associated with improved family health — housing is healthcare. [13]
• How would you advocate for this family's housing? Link warmly to housing services, support the priority-housing application with a medical letter documenting the health case, and coordinate with social work. [13]
• What is the paediatrician's role beyond the individual encounter? Advocate for housing as a child-health determinant, support community-based services, and recognise that housing advocacy is clinical advocacy, not work beyond scope. [3] [15]