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Child Neuropsychology
A Journal on Normal and Abnormal Development in Childhood and
Adolescence
ISSN: 0929-7049 (Print) 1744-4136 (Online) Journal homepage: https://www.tandfonline.com/loi/ncny20
A systematic review of cognitive functioning
among young people who have experienced
homelessness, foster care, or poverty
Charlotte E. Fry, Kate Langley & Katherine H. Shelton
To cite this article: Charlotte E. Fry, Kate Langley & Katherine H. Shelton (2017) A systematic
review of cognitive functioning among young people who have experienced homelessness, foster
care, or poverty, Child Neuropsychology, 23:8, 907-934, DOI: 10.1080/09297049.2016.1207758
To link to this article: https://doi.org/10.1080/09297049.2016.1207758
© 2016 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group
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Citing articles: 10 View citing articles
A systematic review of cognitive functioning among young
people who have experienced homelessness, foster care, or
poverty
Charlotte E. Fry
a
, Kate Langley
a,b
and Katherine H. Shelton
a
a
School of Psychology, CardiffUniversity, Cardiff, UK;
b
MRC Centre for Neuropsychiatric Genetics and
Genomics, CardiffUniversity, Cardiff,UK
ABSTRACT
Young people who have experienced homelessness, foster care, or
poverty are among the most disadvantaged in society. This review
examines whether young people who have these experiences
differ from their non-disadvantaged peers with respect to their
cognitive skills and abilities, and whether cognitive profiles differ
between these three groups. Three electronic databases were
systematically searched for articles published between 1 January
1995 and 1 February 2015 on cognitive functioning among young
people aged 15 to 24 years who have experienced homelessness,
foster care, or poverty. Articles were screened using pre-deter-
mined inclusion criteria, then the data were extracted, and its
quality assessed. A total of 31 studies were included. Compared
to non-disadvantaged youth or published norms, cognitive perfor-
mance was generally found to be impaired in young people who
had experienced homelessness, foster care, or poverty. A common
area of difficulty across all groups is working memory. General
cognitive functioning, attention, and executive function deficits
are shared by the homeless and poverty groups. Creativity
emerges as a potential strength for homeless young people. The
cognitive functioning of young people with experiences of imper-
manent housing and poverty has been relatively neglected and
more research is needed to further establish cognitive profiles and
replicate the findings reviewed here. As some aspects of cognitive
functioning may show improvement with training, these could
represent a target for intervention.
ARTICLE HISTORY
Received 5 February 2016
Accepted 24 June 2016
Published online
1 August 2016
KEYWORDS
Homelessness; Foster care;
Poverty; Cognition; Youth
Young people who have experienced homelessness, foster care, or poverty are among
the most vulnerable in society due to experiences including unstable housing, disrupted
schooling, scant resources, and inadequate social and psychological support (Bradley &
Corwyn, 2002; Haber & Toro, 2004; Stein, 2005). They may also have multiple risk
factors which could accumulate to increase the likelihood of unfavorable outcomes
(Sameroff, Seifer, Baldwin, & Baldwin, 1993). Masten, Miliotis, Graham-Bermann,
Ramirez, and Neemann (1993) proposed a continuum of risk in which those with
CONTACT Charlotte E. Fry FryC1@cardiff.ac.uk School of Psychology, CardiffUniversity, Tower Building, 70
Park Place, Cardiff, CF10 3AT, UK
Supplemental data for this article can be accessed https://doi.org/10.1080/09297049.2016.1207758.
CHILD NEUROPSYCHOLOGY, 2017
VOL. 23, NO. 8, 907–934
https://doi.org/10.1080/09297049.2016.1207758
© 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
greater exposure to adversity and more risk factors present are less likely to adapt
successfully compared to young people without such exposure. In general, homeless
young people are considered to be at the extreme end of this continuum due to being
exposed to multiple adverse experiences and stressors, in addition to the stress of
homelessness itself (Buckner, 2008; Masten et al., 1993).
However, there is no consensus on the cognitive profiles of homeless young
people and whether these are consistent with a continuum of risk. Cognitive func-
tioning could be an important factor in increasing the risk for becoming homeless,
as well as presenting barriers to exiting homelessness, for example by contributing to
the breakdown of family relationships (Backer & Howard, 2007; Milburn et al.,
2009). Poverty and homelessness tend to be intertwined, including a high prevalence
of a history of poverty among homeless adults (Patterson, Moniruzzaman, & Somers,
2015). Similarly, studies of young people aging out of care found an increased
likelihood of homelessness (Courtney & Dworsky, 2006;Dworsky,Napolitano,&
Courtney, 2013; Fowler, Toro, & Miles, 2009),andstudiesofhomelessadultshave
identified a high level of foster care in childhood (Patterson et al., 2015;Roosetal.,
2014). Together, this suggests that members of each of these groups may be at
different points on the same trajectory. In other words, poverty and foster care
groups include a disproportionate number of people “at risk”for homelessness,
theoretically placing the groups at different points along the same continuum of
risk (Masten et al., 1993). This indicates that there are factors common to young
people who have experienced homelessness, foster care, or poverty, including
instability at home and school, reduced access to resources and opportunities, and
a relative lack of social support (Bradley, Corwyn, McAdoo, & Garcia Coll, 2001;
Milburn et al., 2009). However, less is known about how these factors relate to
cognitive development and consequently result in poorer outcomes.
To date, there has not been a review or synthesis of the literature on cognition in
these groups of young people, making it difficult to establish any commonalities in
cognitive profiles. Cognitive skills can be referred to as thinking skills that underlie
academic competence and successful adaptation (Sternberg et al., 2000). It is possible
that, in the context of disadvantage, cognitive skills and abilities may constitute a key set
of “tools”that set apart those who adapt well and make effective use of the resources
available to them and those who do not (Masten & Coatsworth, 1998). Domains of
cognition include memory, attention, verbal ability, and higher-order thinking pro-
cesses known as the executive functions. This review focuses on cognitive functioning
in young people who have experienced homelessness, comparing them both to young
people with similar adverse experiences (i.e., poverty and foster care) who are at risk for
homelessness, and to young people who have not had these experiences.
The United Nations (UN) defines “youth”as the period of 15 to 24 years of age
(United Nations, 2007), encompassing both late adolescence and emerging adulthood
(18 to 25 years of age; Arnett, 2000). There is evidence that late adolescence and
emerging adulthood form a sensitive period of development, with numerous changes
occurring in the brain; the frontal lobes in particular are still developing (Blakemore,
2012). Thus, it is important to consider the cognitive profiles of particularly vulnerable
groups of young people, including those who have experienced homelessness, foster
care and poverty with a view to developing appropriate interventions and support.
908 C. E. FRY ET AL.
Homelessness
It has been estimated that there are over 100 million children and youth living on the
streets worldwide (Thomas de Benitez, 2007). This is likely to be an underestimate of
the true figure, as homelessness often encompasses not only those who live on the street
but also those living in unsuitable accommodation, such as motels or youth hostels
(Toro, Dworsky, & Fowler, 2007), and those who live peripatetically with acquaintances
and friends (Reeve & Batty, 2011). It is possible that aspects of cognitive functioning
among young people who have experienced homelessness contribute to problems with
securing and maintaining accommodation. This may be because of problems or deficits
in the ability to make informed decisions, problem-solve and plan, along with the
potential issue of limited social skills (Backer & Howard, 2007).
There remains a distinct paucity of research on the cognitive profiles of homeless
youth during late adolescence and emerging adulthood, especially compared to home-
less adults and children within homeless families (Parks, Stevens, & Spence, 2007). The
only previous systematic review in this area, Parks et al. (2007), identified just two
studies conducted with homeless adolescents that met very broad inclusion criteria:
one, which was published outside the date range of this review, compares glue-sniffing
street youth with street youth who do not sniffglue (Jansen, Richter, & Griesel, 1992),
while the other uses self-ratings of ability rather than objective cognitive tests (Ryan,
Kilmer, Cauce, Watanabe, & Hoyte, 2000).
Foster Care
In 2013, just over 400,000 children and youth were in foster care in the United States
(US), with around 50,000 leaving care between the ages of 16 and 20 years (US
Department for Health and Human Services, 2014). Some estimates indicate that 30
to 40% of young people in care experience four or more changes of placement, with up
to 10% experiencing ten or more placements (Stein, 2005). Young people leaving care
are at high risk of becoming homeless, which is likely to be exacerbated by cognitive
impairment (Backer & Howard, 2007; Kerman, Wildfire, & Barth, 2002). Indeed, the
prevalence of language delays and cognitive delays among children in foster care has
been reported to be 57% and 33% respectively, compared to 4 to 10% in the general
population (Leslie et al., 2005).
Reviews of young people in foster care have typically used academic tests or educa-
tional attainment as an index of cognitive development rather than objective cognitive
tests (e.g., Stein, 2005). Young people who have experienced foster care are more likely
to have experienced disrupted schooling, with potential implications for academic
attainment (Pecora et al., 2006). Therefore, it is probably more instructive to focus on
measures of cognitive functioning, including memory, attention, planning, and pro-
blem-solving.
Poverty
Just over 75 million children and youth live in poverty in the world’s wealthiest
countries (UNICEF Innocenti Research Centre, 2014). Young people living in poverty
CHILD NEUROPSYCHOLOGY 909
are likely to lack not only financial resources but also material, social, and cultural
resources (Bradley et al., 2001). The poorest children and adolescents in some of the
wealthiest countries are at risk for reduced memory capacity, impaired cognitive devel-
opment and lower educational achievement (UNICEF Innocenti Research Centre,
2010). Indeed, many studies have demonstrated cognitive deficits in low socioeconomic
status (SES) children compared to high SES children (Brooks-Gunn & Duncan, 1997).
A systematic review of cognitive functioning for an adolescent age group living in
poverty has not been published. Bradley and Corwyn’s(2002) comprehensive review
investigates the effect of SES on children’s development and identifies a link between
SES and both IQ and verbal ability. It remains to be established if this finding
generalizes to adolescence and emerging adulthood.
Mental Health
It is well established that there are higher rates of mental illness in those who have
experienced homelessness, foster care, or poverty than in the general population
(Akister, Owens, & Goodyer, 2010; Hodgson, Shelton, van den Bree, & Los, 2013;
Patel & Kleinman, 2003). For example, Hodgson, Shelton, and van den Bree (2014)
found that among young people who have experienced homelessness, 88% screened for
any current mental health disorder and 73% for comorbid mental health disorders,
compared to 32% and 12%, respectively in the age-matched general population.
Specifically, the prevalence of anxiety disorders was 49% vs. 4%, 42% screened for
substance dependence vs. 11%, rates of post-traumatic stress disorder (PTSD) were 36%
vs. 5%, prevalence of mood disorders was 19% vs. 2%, and psychosis was present in 7%
vs. 0.2%. Poor mental health has a well-documented relationship with lower levels of
cognitive functioning in both psychiatric and general populations (see e.g., Castaneda,
Tuulio-Henriksson, Marttunen, Suvisaari, & Lönnqvist, 2008). Indeed, Baune, Fuhr,
Air, and Hering (2014) reviewed the literature on neuropsychological functioning in
adolescents and emerging adults with major depressive disorder (MDD) and found a
broader range of cognitive deficits in those with MDD compared to the controls. A
recent meta-analysis also found that adolescents with MDD display impaired perfor-
mance on tasks of executive function compared to their healthy peers (Wagner, Müller,
Helmreich, Huss, & Tadić,2015). It is especially important to examine relationships
between mental health and cognitive functioning in disadvantaged populations, such as
young people who have experienced homelessness, foster care, or poverty. While
cognitive skills and abilities have been found to be associated with adaptive behavior
(Clark, Prior, & Kinsella, 2002), these groups are more likely to face challenging
situations—as well as to have higher rates of mental illness—than their peers without
these experiences, which may compromise adaptation and recovery from adversity.
Potential Implications
Although there are mixed findings for the effectiveness of cognitive skills training
(Klingberg, 2010; Melby-Lervåg & Hulme, 2013; Morrison & Chein, 2011; Shipstead,
Redick, & Engle, 2012), there is some evidence that it may be beneficial to low SES
children (Jolles & Crone, 2012). There is also tentative evidence to suggest that
910 C. E. FRY ET AL.
cognitive skills training in certain domains can lead to broader benefits, for example in
academic performance (Holmes & Gathercole, 2014). These findings suggest that
aspects of cognitive functioning may be a good target for intervention, which could
in turn lead to broader long-term benefits for young people who have experienced
homelessness, foster care, or poverty.
Given the lack of synthesized data in this area, the aim of this study is to review and
synthesize across three literatures to address four key questions:
(1) Do young people who have experienced homelessness, foster care, or poverty
differ from young people without such experiences with respect to cognitive
skills and abilities?
(2) If they do differ, which are the areas of cognitive functioning that are impaired
and/or enhanced?
(3) Does cognitive functioning differ between the three groups?
(4) Among the studies included in this review, is cognitive functioning associated
with mental health disorders in young people who have experienced home-
lessness, foster care, or poverty?
Method
This systematic review was completed according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA; Liberati et al., 2009) guidelines, a
checklist for ensuring the transparent reporting of systematic reviews that is recognized
worldwide. An electronic search of Web of Science (Thomson Reuters), MEDLINE and
PsycINFO (via Ovid) was conducted. Articles published from 1 January 1995 to 1
February 2015 were searched using the search strategy detailed in the supplementary
materials. A manual citation search was also conducted.
Papers were screened using inclusion and exclusion criteria decided in advance. Only
journal articles were included; other types of publication were excluded. Although the
UN’sdefinition of youth as those between the ages of 15 to 24 years was initially used
(United Nations, 2007), a number of studies using wide age bands meant that the age
criteria had to be reconsidered. Because of the relative lack of research on youth in these
areas, studies were not excluded if they overlapped the target age range of 15 to
24 years, and the mean age was 11 years or older, as this is often the recognized
onset of adolescence (Spear, 2000).
Having removed duplicates, studies were screened by title and abstract. A total of
100 studies were subsequently subjected to full-text screening; articles that did not meet
the inclusion criteria were excluded. All stages were checked independently by two
researchers and any discrepancies were resolved by discussion. For some studies, more
information was needed if they were to be included. In this instance, the corresponding
authors of the papers were contacted. Two authors kindly provided the data requested
(Flouri, Mavroveli, & Panourgia, 2013; Staiano, Abraham, & Calvert, 2012). A manual
citation search of the 26 included studies yielded 5 additional studies which met
inclusion criteria, making a total of 31 included studies.
CHILD NEUROPSYCHOLOGY 911
The information extracted consists of study/participant characteristics, relevant
descriptive and inferential statistics, putative risk(s) and outcome(s) of interest, how
the authors interpreted their results, and any relations with mental health identified.
Where studies had not used relevant comparison groups, comparisons with published
norms were made where possible (see Table 1).
An adapted version of the Newcastle Ottawa Scale (NOS; Wells et al., 2000) was used
to assess the quality of the methodology and reporting in the included studies. Each
study was categorized by design as case-control, cohort, or norm-comparison, and
assessed on items relating to three areas: selection (i.e., definition of homelessness,
foster care, and/or poverty, representativeness, selection of comparison group), com-
parability (i.e., controlling for relevant factors), and outcome (i.e., method of assess-
ment, follow-up/non-responders). One star was awarded where the criteria were met
(e.g., where cognitive performance was assessed using validated objective cognitive
tests). Two stars could be awarded for comparability (e.g., controlled for education
and other factors). The maximum number of stars that could be awarded differed by
design, as some criteria were not applicable. Ratings from two or more independent
researchers were compared, averaging 95% agreement, with disagreements resolved by
discussion to reach consensus. In their comprehensive review of quality assessment
tools, Deeks et al. (2003) recommended only the NOS and 5 other tools for use in
systematic reviews out of 194 tools identified, based on their coverage of core internal
validity criteria.
The authors decided that it would be inappropriate to conduct meta-analyses on the
data yielded by this review because the studies were too heterogeneous in terms of
definitions of homelessness, foster care, and poverty, cognitive tests used, design, and
type of sample (Egger, Smith, & Sterne, 2001).
Results
A total of 31 articles are included in the review; 22 used samples of young people who
had experienced poverty, 6 used samples of young people who had experienced home-
lessness, and 3 used samples of young people who had experienced foster care. The
majority of these studies were conducted in the US (n= 18), with the rest conducted in
South America (n= 4), Canada (n= 2), Sweden (n= 2), Israel (n= 2), the United
Kingdom (UK; n= 1), the Caribbean (n= 1), and the Seychelles (n= 1). Of the studies
14 are based on cross-sectional design, while another 10 use longitudinal methods. The
remainder use a retrospective design (n= 3) or are randomized control trials (n= 4).
All-male samples were used in 3 studies, 2 of which used military conscription data, and
the third because of anticipated differences between male and female street children.
Cognitive Domains and Tests
The majority of studies investigate general cognitive functioning (n=1
8),howeverthere
is also good representation of individual cognitive domains: executive function (n=10),
learning and memory (n= 10), attention (n= 7), and language (n= 3). Often, studies
assessed more than one domain. Learning and memory are intrinsically linked, with
different types of learning often falling under the umbrella of non-declarative memory
912 C. E. FRY ET AL.
Table 1. Characteristics and Key Findings of Studies Included in the Systematic Review.
Study Country
Age range
(years) Sample size and groups used Cognitive domains Cognitive tests Key findings
Homelessness
Borges-
Murphy
et al. (2012)
Brazil 11–16 16 youth in shelters; 11 age-
matched controls
Selective attention; Memory Non-verbal dichotic listening
test; Memory for verbal and
non-verbal stimuli
Homeless youth had significantly lower
mean scores than age-matched controls.
Dahlman et al.
(2013)
Bolivia 10–17 36 street-involved male youth;
31 housed low SES male
youth
Executive function; General
cognitive functioning;
Creativity
WCST-64; Children’s Color
Trails Test; Leiter-R;
Alternative Uses Task
Street youth performed at a similar level to
low SES youth on tests of executive
function and general cognitive
functioning, yet significantly
outperformed low SES youth on a test of
creativity/divergent thinking.
Pluck et al.
(2015)
Ecuador 10–17 37 former street youth General cognitive
functioning
WASI Block Design and Matrix
Reasoning
Former street youth had very low mean
raw scores
a
.
Rafferty et al.
(2004)
US 11–17 45 formerly homeless youth;
86 low SES youth who were
never homeless
General cognitive
functioning
WISC-R Similarities No significant difference between groups
with both scoring about 1 SD below the
normative mean
a
.
Rohde et al.
(1999)
US 16–21 50 street youth General cognitive
functioning
WAIS-R Street youth performed within the average
range, with stronger performance IQ
scores compared to verbal IQ scores
a
.
Saperstein
et al. (2014)
US 18–22 55 homeless youth enrolled in a
residential and employment
program
Verbal memory; Working
memory; Attention;
Processing speed;
Executive function
WMS-IV; CVLT-II; WAIS-III;
D-KEFS, selected subtests
64% of homeless youth scored 1 SD below
the normative mean in at least one
cognitive domain, with particular
impairments in memory and working
memory. Full scale IQ in the low average
range, approximately 1 SD below the
normative mean
a
.
Foster care
Berger et al.
(2009)
US 7–17 342 young people who have
experienced out-of-home
placement;
2111 young people who have
not experienced out-of-home
placement
General cognitive
functioning
Kaufman Brief Intelligence
Test
No relationship found between out-of-
home placement experience and
cognitive functioning. Mean raw scores
for both groups were just over half of
the maximum score on both subtests
b
.
(Continued )
CHILD NEUROPSYCHOLOGY 913
Table 1. (Continued).
Study Country
Age range
(years) Sample size and groups used Cognitive domains Cognitive tests Key findings
Kira et al.
(2012)
US 11–17 12 youth who have experienced
foster care (out of a larger
sample who have
experienced “attachment
traumas”)
General cognitive
functioning; Working
memory
WISC-IV Foster care experience significantly
negatively related to working memory.
Full scale IQ for the whole sample (all
“attachment traumas”) just over 1 SD
below the normative mean
a
.
Vinnerljung
and Hjern
(2011)
Sweden 18 (inferred) 1551 male youth who have
experienced foster care;
464,848 male youth from the
majority population
General cognitive
functioning
Military conscription
intelligence test
Youth who had experienced foster care
performed just over 0.5 SDs below
majority population youth.
Poverty
Alaimo et al.
(2001)
US 12–16 2063 youth from a
representative national
sample (NHANES-III)
General cognitive
functioning
WISC-R
Block Design and Digit Span
Poverty Index Ratio (higher = higher
income) significantly positively
associated with cognitive functioning.
Campbell et al.
(2002)
US 21 23 young adults from low SES
families who had not
received any intervention
General cognitive
functioning
WAIS-R Both mean full-scale IQ and verbal IQ low
average compared to norms, whereas
performance IQ within the average
range
a
.
Chappell and
Overton
(2002)
US 15–24 268 youth in 10th grade, 12th
grade, or college;
median split into low SES and
high SES groups but nfor
each group not given
Reasoning Overton’s Selection Task,
General solution score
High SES students scored significantly
higher than low SES students.
Coles et al.
(2002)
US 13–17 53 youth from low SES families
who had not been prenatally
exposed to alcohol
Sustained attention Continuous Performance
Test-type task
Non-exposed low SES youth scored over 1
SD below the mean of a normative
sample
c
.
Evans and
Schamberg
(2009)
US 17–18 195 young adults,
approximately half below the
poverty line and half middle
SES,
exact nnot given
Working memory Simon game Proportion of childhood spent in poverty
significantly negatively related to
working memory in young adults. Middle
SES young adults had a higher average
working memory span than low SES
young adults.
Flouri et al.
(2013)
UK 10–19 280 secondary school students
eligible for free school meals;
1083 secondary school
students not eligible for free
school meals
General cognitive
functioning
Raven’s Standard Progressive
Matrices Plus
Eligibility for free school meals significantly
associated with lower cognitive
functioning.
(Continued )
914 C. E. FRY ET AL.
Table 1. (Continued).
Study Country
Age range
(years) Sample size and groups used Cognitive domains Cognitive tests Key findings
Goldberg et al.
(2011)
Israel 16–17 811,487 youth from a national
sample
General cognitive
functioning
Modified Otis-type intelligence
test; Verbal analogies; Non-
verbal analogies
SES significantly positively related to
cognitive functioning.
Hackman et al.
(2014)
US 10–18 304 youth recruited from
schools;
SES assessed as a continuous
measure
Working memory Corsi Blocks; Spatial Working
Memory; Object Two-back;
WISC-IV Digit Span
Backwards
Low parental education significantly
associated with lower scores on working
memory tasks.
Hemmingsson
et al. (2007)
Sweden 18–20 44,995 males from a national
sample,
54.9% low SES, exact nnot
given
General cognitive
functioning
Military conscription cognitive
test
As a general pattern, there were higher
percentages (60–70%) of low SES males
in the lower IQ bands (below average)
than in the higher IQ bands (30–50%).
Howell et al.
(2006)
US 13–17 53 youth from low SES families
who had not been prenatally
exposed to alcohol
General cognitive
functioning
WISC-III Non-exposed low SES youth had mean full-
scale IQ scores in the borderline range,
with verbal and performance IQ scores
just falling into the low average range
a
.
Ivanovic et al.
(2000)
Chile 17–19 16 non-undernourished low SES
young adults
General cognitive
functioning
WAIS (Spanish) All IQ scores for non-undernourished low
SES young adults within the average
range
a
.
Johnson et al.
(2010)
Canada 19–26 132 low SES young adults
without speech/language
impairment
Language; General
cognitive functioning
Peabody Picture Vocabulary
Test-III; WAIS-III, selected
subtests
Higher family SES and maternal education
in childhood were associated with higher
scores on a language task in young
adulthood. Childhood language scores
significantly predicted occupational SES
in young adulthood. Full-scale IQ for
young adults without speech or
language impairment was average
compared to norms
a
.
Kobrosly et al.
(2011)
Seychelles 17 463 youth from a national
sample (SCDS)
Executive function;
Learning; Attention;
Memory; Working
memory
CANTAB,
selected subtests
SES significantly positively associated with
performance on all tasks.
(Continued )
CHILD NEUROPSYCHOLOGY 915
Table 1. (Continued).
Study Country
Age range
(years) Sample size and groups used Cognitive domains Cognitive tests Key findings
Kramer et al.
(1995)
US 12–16 849 youth from a national
sample (NHANES-III)
General cognitive
functioning
WISC-R Digit Span and Block
Design
Family income significantly positively
related to performance. Maternal
education below high school level
significantly associated with lower
cognitive functioning.
Lupien et al.
(2001)
Canada 15–16 24 low SES high school
students;
34 high SES high school
students
Memory; Language;
Selective attention
Declarative memory task;
Verbal fluency task; Visual
detection task
No significant differences between low SES
and high SES students on memory or
language tasks. Low SES students
significantly outperformed high SES
students on selective attention task.
Myerson et al.
(1998)
US 14–21 2726 high school and college
students from a national
sample (NLSY)
General cognitive
functioning
Armed Forces Qualification
Test
SES significantly positively related to
cognitive functioning in both high school
and college students.
Ornoy et al.
(2010)
Israel 12–16 27 low SES youth who had not
been prenatally exposed to
drugs; 51 high SES youth
who had not been prenatally
exposed to drugs
General cognitive
functioning
WISC-III Non-exposed high SES youth had
significantly higher scores on the
majority of subtests than non-exposed
low SES youth. Scores on the Picture
Arrangement subtest did not
significantly differ between the two
groups.
Robey et al.
(2014)
US 14–16 46 youth from low SES families
who had not been prenatally
exposed to drugs
Prospective memory;
Executive function;
Working memory; Verbal
memory; Attention;
General cognitive
functioning
Memory for Future Intentions
Task; D-KEFS Color-Word
Interference Test; CANTAB
Spatial Working Memory;
CVLT –Children’s Edition;
Conners’Continuous
Performance Test II; WASI
Matrix Reasoning and
Vocabulary
Non-exposed low SES youth made
approximately twice as many between-
search errors on a working memory
task
d
, scored between average and
mildly atypical on a test of sustained
attention
e
, and scored within 1 SD of the
normative mean on tests of executive
function
f
and verbal memory
g
. Full-scale
IQ within the average range
a
.
Skoe et al.
(2013)
US 14–15 33 high school students from
low SES families; 33 high
school students from high
SES families
Working memory; General
cognitive functioning
WASI; Woodcock–Johnson
Test of Cognitive Abilities
Numbers Reversed and
Auditory Working Memory
Students with low maternal education
scored significantly lower on working
memory than students with high
maternal education, however IQ for both
groups did not significantly differ and fell
within the average range
a
.
(Continued )
916 C. E. FRY ET AL.
Table 1. (Continued).
Study Country
Age range
(years) Sample size and groups used Cognitive domains Cognitive tests Key findings
Staiano et al.
(2012)
US 15–19 54 low SES school students,
baseline scores used (before
intervention)
Executive function D-KEFS Design Fluency and
Trail Making
As a total D-KEFS score was calculated by
summing the raw scores on the two
subtests, no comparisons could be made.
Tine (2014)US 17–21 21 low SES college students;
18 high SES college students,
pretest scores for the control
group used
Selective attention d2 Test of Attention High SES college students significantly
outperformed low SES college students
at pre-test.
Walker et al.
(2005)
Jamaica 17–18 64 non-stunted youth from low
SES neighborhoods who had
not received any intervention
Reasoning; Working
memory; Language;
General cognitive
functioning
Raven’s Standard Progressive
Matrices Digit Span
Backwards; Corsi Blocks;
Peabody Picture Vocabulary
Test; WAIS
Non-stunted low SES youth had extremely
low scores (below the 5th percentile) on
a test of cognitive functioning compared
to normative data
h
. Working memory
raw scores within 1 SD of the normative
mean
i
.
Note.
a
Flanagan and Kaufman (2009);
b
Bain and Jaspers (2010);
c
Chen, Hsiao, Hsiao, and Hwu (1998);
d
De Luca et al. (2003);
e
Strauss, Sherman, and Spreen (2006);
f
Homack, Lee, and Riccio
(2005);
g
Donders (1999);
h
Raven (2000);
i
Wilde, Strauss, and Tulsky (2004). CANTAB = Cambridge Neuropsychological Test Automated Battery; CVLT = California Verbal Learning Test;
D-KEFS = Delis–Kaplan Executive Function System; NHANES-III = National Health and Nutrition Examination Survey; NLSY = National Longitudinal Survey of Youth; SCDS = Seychelles Child
Development Study; SES = socioeconomic status; WAIS = Wechsler Adult Intelligence Scale; WASI = Wechsler Abbreviated Scale of Intelligence; WCST-64 = Wisconsin Card Sort Test –64
Card Version; WISC = Wechsler Intelligence Scale for Children; WMS = Wechsler Memory Scale.
CHILD NEUROPSYCHOLOGY 917
(Squire, 2004). Tests used to assess these cognitive domains varied greatly: from those
used for military conscription tests to memory paradigms. Full details of the tests used in
each article can be found in Table 1.
Definitions
Homelessness
Definitions of homelessness ranged from those literally living on the street to the
formerly homeless. Four studies had samples of current or former street youth
(Borges-Murphy, Pontes, Stivanin, Picoli, & Schochat, 2012; Dahlman, Bäckström,
Bohlin, & Frans, 2013; Pluck, Banda-Cruz, Andrade-Guimaraes, Ricaurte-Diaz, &
Borja-Alvarez, 2015; Rohde, Noell, & Ochs, 1999), with varying requirements for
duration, but all samples were generally unsupervised by adults and had no stable
place to stay. Only two used comparison groups: low-income housed youth recruited
from similar programs (Dahlman et al., 2013), and age-matched adolescents (Borges-
Murphy et al., 2012). Saperstein, Lee, Ronan, Seeman, and Medalia (2014) recruited
young adults enrolled for at least one month in a residential and vocational support
program for homeless young people. As this scheme was designed to facilitate transition
to independent living and the majority of participants were in employment, these young
people were in a relatively more stable position than those living on the street. In
Rafferty, Shinn, and Weitzman’s(2004) study, formerly homeless adolescents had spent
between one night and 56 months in emergency shelters. The comparison group had
been on welfare in the six months prior to recruitment and had not been in shelter in
the past month.
Foster Care
The definitions provided by studies in the foster care category demonstrate considerable
heterogeneity. Vinnerljung and Hjern (2011) identified participants through the
National Child Welfare Register in Sweden. Data for those who had entered foster
care before 7 years of age and had remained in care for at least 12 years prior to turning
18 were compared to both an adoption group and a majority population group.
Participants in Kira, Somers, Lewandowski, and Chiodo’s(2012) study were asked
about foster care experiences as part of the Cumulative Trauma Scale. Foster care was
classed as an attachment disruption and therefore a potentially traumatic event. Berger,
Bruch, Johnson, James, and Rubin (2009)defined out-of-home care as having been
removed from home between the initial and follow-up assessments (approximately
2.5 years). However, this included group homes, emergency shelters, psychiatric hospi-
tals, residential treatment facilities, detention centers, and temporary accommodation.
This heterogeneity and overlap with the homeless populations in other studies makes
interpretation of the results for foster care difficult.
Poverty
Almost all of the included studies indexed poverty using SES. Indicators of SES are
diverse across studies: parental education (n= 15), parental occupation (n= 7) and
family income (n= 10) are used either in combination or isolation. One study uses
eligibility for free school meals. A handful of studies use indicators to calculate ratios
918 C. E. FRY ET AL.
(n= 3) such as a poverty index ratio, where annual family income and family size are
compared to the federal poverty line (see e.g., Alaimo, Olson, & Frongillo, 2001). Some
studies use indexes (n= 6), for example the Hollingshead Social Status Index
(Hollingshead, 2011). Neighborhood SES is assessed in six studies, either as a single
indicator or in combination with other indicators of SES. The indicators are measured
in different ways: some are split into categories or levels, others use a median split, and
still others use a continuous measure.
Quality Assessment
Overall ratings range from between one out of six stars (n=1) to six out of seven stars
(n= 4), with the majority of studies receiving at least half of the total stars available
(total available differs depending on design, see Table 2). Twelve studies scored 70% or
greater overall. However, several studies do not present basic demographic and descrip-
tive data. Reporting of definition and duration of homelessness, foster care, or poverty
is variable, and several studies have limitations associated with sampling. Often, studies
use convenience sampling (e.g., from a local hostel or other support program) or the
sampling methods are not sufficiently described. For example, some studies recruited
participants from poor or low-income neighborhoods or describe participants as being
from poor backgrounds without offering further explanation. Many studies do not
attempt to control for number of years of education. Relevant comparison groups are
lacking in a third of studies (n= 11). Although many studies use standardized tests, the
measures reported vary greatly. In addition, whether the scores are raw or converted to
standard scores is inconsistent. This limits the extent to which comparisons can be
made across studies.
Comparisons to Young People Who Have Not Experienced Homelessness, Foster
Care, or Poverty
Seven of the included studies compare young people who have experienced home-
lessness, foster care, or poverty to a control group who have not had these experiences.
Young people from low SES families tend to perform at a lower level on tests of general
cognitive functioning (Chapell & Overton, 2002; Ornoy et al., 2010; but see Skoe,
Krizman, & Kraus, 2013), and working memory (Skoe et al., 2013) than their high
SES counterparts. No differences are found in memory or language performance
(Lupien, King, Meaney, & McEwen, 2001). One low SES group demonstrated superior
performance compared to the high SES group on a selective attention task (Lupien
et al., 2001), though Tine (2014) found the opposite result. Young people who have
experienced homelessness demonstrate poorer performance on selective attention and
memory tasks compared to age-matched controls (Borges-Murphy et al., 2012). In the
foster care category, Vinnerljung and Hjern (2011) found impaired general cognitive
functioning in young people who have experienced foster care compared to the general
population. Overall, young people who have experienced homelessness, foster care, or
poverty seem to show cognitive difficulties to a greater extent than their peers without
these experiences.
CHILD NEUROPSYCHOLOGY 919
Table 2 Quality Assessment of Included Studies Using Adapted Newcastle Ottawa Scale.
Selection Comparability Outcome
Study Design
Definition /
ascertainment of
exposure Representativeness
Selection of non-
exposed /controls
Definition
of controls
Based on
study design
or analysis
(max. 2 stars)
Assessment
of outcome
Same method of
ascertainment
Follow-up/
non-
responders
Homelessness
Borges-Murphy et
al. (2012)
Case-control - - - - - ★★ ★ -
Dahlman et al.
(2013)
Case-control ★-★★-★★ ★ -
Pluck et al. (2015) Norm comparison - - - ★★ -
Rafferty et al.
(2004)
Case-control ★-★★-★★ ★ ★
Rohde et al.
(1999)
Norm comparison ★--★★ ★
Saperstein et al.
(2014)
Norm comparison - - ★★ ★ -
Foster care
Berger et al.
(2009)
Cohort ★-★-★★ -
Kira et al. (2012) Cohort - - ★-★★ -
Vinnerljung &
Hjern (2011)
Cohort ★★★ -★★ ★
Poverty
Alaimo et al.
(2001)
Cohort ★★★ -★★ -
Campbell et al.
(2002)
Norm comparison ★★ -★★ -
Chappell &
Overton (2002)
Cohort ★-★★
★★ -
Coles et al. (2002) Norm comparison - - - ★★ -
Evans &
Schamberg
(2009)
Cohort ★-★-★★ -
Flouri et al.
(2013)
Cohort ★★★ -★★ ★
Goldberg et al.
(2011)
Cohort ★★★ -★-★
(Continued )
920 C. E. FRY ET AL.
Table 2 (Continued).
Selection Comparability Outcome
Study Design
Definition /
ascertainment of
exposure Representativeness
Selection of non-
exposed /controls
Definition
of controls
Based on
study design
or analysis
(max. 2 stars)
Assessment
of outcome
Same method of
ascertainment
Follow-up/
non-
responders
Hackman et al.
(2014)
Cohort ★-★-★★ ★
Hemmingsson et
al. (2007)
Cohort ★★★ -★-★
Howell et al.
(2006)
Norm comparison ★--★★ -
Ivanovic et al.
(2000)
Norm comparison ★-★★ --
Johnson et al.
(2010)
Norm comparison ★★ -- ★-
Kramer et al.
(1995)
Cohort ★★★ -★★ ★
Kobrosly et al.
(2011)
Cohort ★★★ -★★ ★
Lupien et al.
(2001)
Case-control ★-★★★★-★-
Myerson et al.
(1998)
Cohort ★★★ -★★ -
Ornoy et al.
(2010)
Case-control ★----★★ ★ -
Robey et al.
(2014)
Norm comparison - - - ★★ ★
Skoe et al. (2013) Case-control ★-★★
★★★★ -
Staiano et al.
(2012)
Norm comparison - - - - ★-
Tine (2014) Case-control ★-★★-- ★★ -
Walker et al.
(2005)
Norm comparison - - - ★★ ★
Note. “★”denotes a star awarded for an item; “–” denotes a star not awarded for an item ; gray denotes that the item is not applicable (dependent on design). The maximum number of stars
that can be awarded differs by design: case-control = 9, cohort = 7, norm comparison = 6
CHILD NEUROPSYCHOLOGY 921
Comparisons to Norms
A further nine studies were compared to available norms (two by the authors them-
selves) for the cognitive tests used (see Table 1). The performance of young people who
have experienced poverty tends to be below the normative averages in the domains of
general cognitive functioning (Campbell, Ramey, Pungello, Sparling, & Miller-Johnson,
2002; Howell, Lynch, Platzman, Smith, & Coles, 2006; Walker, Chang, Powell, &
Grantham-McGregor, 2005; but see Ivanovic et al., 2000) and sustained attention
(Coles, Platzman, Lynch, & Freides, 2002; Robey, Buckingham-Howes, Salmeron,
Black, & Riggins, 2014). Conversely, young people who have experienced poverty are
comparable with norms on tests of verbal memory and executive function (Robey et al.,
2014). Performance on tests of working memory is variable (Robey et al., 2014; Walker
et al., 2005). In the homeless category, Saperstein et al. (2014) found impaired perfor-
mance compared to norms in their sample on tests of general cognitive functioning,
executive function, working memory, attention, and verbal memory. General cognitive
functioning was also found to be low in Pluck et al.’s(2015) sample of former street
youth. However, Rohde et al. (1999) found general cognitive functioning to be within
the average range of performance among street youth. Collectively, the poverty groups
tend to show performance below the normative averages across a range of cognitive
domains, albeit with inconsistencies, and there is some evidence of low general cogni-
tive functioning among homeless young people.
Associations with Cognitive Functioning
Eleven studies investigate the relationship between experiences of poverty or foster care
and cognitive functioning. The relationship between homelessness and cognitive func-
tioning is not examined in any study. Higher levels of poverty are consistently asso-
ciated with impairments in general cognitive functioning (Alaimo et al., 2001; Flouri
et al., 2013; Goldberg et al., 2011; Johnson, Beitchman, & Brownlie, 2010; Kramer,
Allen, & Gergen, 1995; Myerson, Rank, Raines, & Schnitzler, 1998), working memory
(Evans & Schamberg, 2009; Hackman et al., 2014), and language (Johnson et al., 2010),
as well as executive function, attention, learning and memory (Kobrosly et al., 2011).
One study reports a greater percentage of low SES young men in the lower IQ bands
than in the higher IQ bands (Hemmingsson, Essen, Melin, Allebeck, & Lundberg,
2007). Neighborhood SES is not found to be associated with working memory
(Hackman et al., 2014). The results for foster care are mixed: while Kira et al. (2012)
found an association between foster care and working memory with a small sample
(n= 12 with experience of foster care), Berger et al. (2009) found no relationship
between having experienced out-of-home care and general cognitive functioning.
Altogether, poverty is consistently associated with many aspects of cognitive function-
ing; evidence for a link between foster care and cognition is less clear.
Comparisons among Young People with Similar Experiences
Two studies compare young people who have experienced homelessness to housed
young people in low SES families (Dahlman et al., 2013;Rafferty et al., 2004). In both
922 C. E. FRY ET AL.
cases, no differences are observed between the two groups in terms of general cognitive
functioning, though both groups performed below average. Dahlman et al.’s(2013)
sample is also comparable on measures of executive function; yet the homeless group
outperformed the low SES group on a measure of creativity. No other studies make
direct comparisons between groups with similar experiences.
Looking across studies, all groups show impairment on working memory tasks
(Evans & Schamberg, 2009; Hackman et al., 2014; Kira et al., 2012; Robey et al., 2014;
Saperstein et al., 2014; Skoe et al., 2013). Those who have experienced homelessness or
poverty also demonstrate poorer performance on tasks assessing general cognitive
functioning, attention, and executive function (Campbell et al., 2002; Howell et al.,
2006; Kobrosly et al., 2011; Ornoy et al., 2010; Pluck et al., 2015; Saperstein et al., 2014).
Relationships with Mental Health
The majority of studies (88%) found cognitive functioning and mental health to be
related (Table 3). All but one study (Berger et al., 2009) found relationships between
aspects of mental health and general cognitive functioning (seven out of eight). In one
study (Saperstein et al., 2014), 64% of homeless young people with a broad range of
mental health disorders also scored one standard deviation (SD) or more below the
normative mean in one or more cognitive domains, with particular difficulties in verbal
and working memory. A negative relationship was found between depressive symptoms
and verbal IQ in homeless youth (Rohde et al., 1999). While Kira et al. (2012) found a
negative indirect relationship between PTSD and both working memory and general
cognitive functioning in young people who have experienced foster care, Pluck et al.
(2015) found a positive association between PTSD and general cognitive functioning in
street youth. Two studies found general cognitive functioning to be negatively asso-
ciated with internalizing symptoms and/or externalizing problems in low SES young
people, though one found this association for parent-reported problems only (Flouri
et al., 2013; Ornoy et al., 2010). No relationship was found between general cognitive
functioning and internalizing symptoms and/or externalizing problems in the foster
care group (Berger et al., 2009). Finally, intelligence was found to moderate the
relationship between SES and hospitalization for schizophrenia such that for those
with average to high intelligence there is no relationship, but for those with low
intelligence, high SES is associated with schizophrenia (Goldberg et al., 2011).
Generally, mental health and cognitive functioning were found to be associated in
young people who have experienced homelessness, foster care, or poverty, but some
of these relationships are more complex than expected.
Discussion
This systematic review examines cognitive functioning in both young people who have
experienced homelessness, foster care, or poverty, and who have not had such experi-
ences. A total of 31 studies were eligible for inclusion. The search strategy was
deliberately broad in an attempt to access all of the relevant studies. By synthesizing
evidence across three bodies of literature, this review makes comparisons both within
groups of youth who have experienced homelessness, foster care, and poverty and
CHILD NEUROPSYCHOLOGY 923
Table 3. Relations between Cognitive Functioning and Mental Health in Young People Who Have Experienced Homelessness, Foster Care, or Poverty.
Study Cognitive domain
Aspect of mental
health Test or criteria used Relationship
Homelessness
Dahlman
et al.
(2013)
General cognitive
functioning;
Executive
function
Emotion symptoms
(pain, worry,
sadness, anxiety,
fear)
Strengths and Difficulties Questionnaire No differences between groups. Does not assess potential relationships
between cognitive functioning and emotion symptoms.
Pluck et al.
(2015)
General cognitive
functioning
PTSD UCLA PTSD Index Street youth with probable PTSD outperformed those without probable
PTSD on tests of general cognitive functioning.
Rohde et al.
(1999)
General cognitive
functioning
Anxiety; Depression;
Suicidal behavior
State-Trait Anxiety Inventory; Center for
Epidemiologic Studies Depression Scale;
Current, lifetime, and history of suicide
Verbal IQ negatively related to current depressive symptoms but not to
anxiety or suicidal behavior. No association found between
performance IQ and any mental health measure.
Saperstein
et al.
(2014)
General cognitive
functioning;
Verbal memory
Working memory;
Attention;
Executive
function
Axis I disorders Beck Depression Inventory; Beck Anxiety
Inventory
Symptom Checklist-90 Revised
63.6% of homeless youth with mental health disorders screened for
cognitive impairment. Cognitive impairment and mental health
disorder predict worse outcomes than either alone.
Foster care
Berger et al.
(2009)
General cognitive
functioning
Internalizing/
externalizing
behavior
Child Behavior Checklist No relationship found between general cognitive functioning and
internalizing or externalizing behavior.
Kira et al.
(2012)
General cognitive
functioning;
Working memory
PTSD Clinician Administered PTSD Scale-2; Clinical
interview
PTSD negatively indirectly related to performance on tests of working
memory and general cognitive functioning.
Poverty
Flouri et al.
(2013)
General cognitive
functioning
Emotional and
behavioral
problems
Strengths and Difficulties Questionnaire General cognitive functioning significantly negatively associated with
emotional symptoms and conduct problems.
Goldberg
et al.
(2011)
General cognitive
functioning
Schizophrenia ICD-10 For those with an average to high IQ, SES not related to schizophrenia. For
those with a low IQ, high SES associated with schizophrenia
Ornoy et al.
(2010)
General cognitive
functioning
Internalizing/
externalizing
problems
ADHD
Child Behavior Checklist; Youth Self-Report
Conners’Rating Scales
General cognitive functioning scores significantly negatively correlated
with ADHD and parents’report of internalizing and externalizing
problems. No relationship found between general cognitive functioning
and self-reported internalizing and externalizing problems.
Note. ADHD = attention deficit hyperactivity disorder; ICD-10 = International Statistical Classification of Diseases and Related Health Problems –10th Edition; PTSD = post-traumatic stress
disorder; SES = socioeconomic status; UCLA PTSD Index = University of California, Los Angeles PTSD Index.
924 C. E. FRY ET AL.
between these groups and comparatively advantaged young people, which has not been
done before. In the foster care literature in particular, no reviews include studies where
cognitive functioning is assessed using objective tests. Reviews in the poverty literature
tend to focus on predominantly child or adult studies (Bradley & Corwyn, 2002;
Hackman & Farah, 2009). Finally, though Parks et al. (2007) systematically review the
literature on cognitive functioning in homeless young people, only two studies were
found in the adolescent age range despite using extremely broad criteria, and compar-
isons with other relatively disadvantaged groups are not made.
Overall, young people who have experienced homelessness, foster care, or poverty
tend to demonstrate poorer performance on cognitive tasks than young people who
have not had these experiences, or are found to show below average performance
compared to published norms. Poverty is consistently associated with performance
across a wide range of cognitive domains, while the findings for foster care are
mixed. Only two studies found potential strengths: selective attention among young
people who have experienced poverty (Lupien et al., 2001; though see Tine, 2014), and
creativity among young people living on the street (Dahlman et al., 2013). It could be
the case that creativity, or divergent thinking, is more adaptive than convergent think-
ing (e.g., as assessed by set shifting) in deprived and risky environments such as the
street (Cohen, 2012). Alternatively, greater creativity could increase the risk of home-
lessness through its relationship with greater impulsivity (Feist, 1998), via increased
risk-taking behavior, for example.
Working memory emerges as a likely impairment for all groups, with poorer
performance on attention and executive function tasks apparent in young people who
have experienced homelessness and poverty. General cognitive functioning is most
consistently impaired in young people who have experienced poverty or homelessness,
with conflicting findings for the foster care group. Where direct comparisons are made
between disadvantaged groups, no differences in performance were found for low SES
young people and homeless young people on tests of general cognitive functioning and
executive function, though the performance of both groups is below average compared
to norms. However, as the effect sizes are small, it is debatable as to whether the sample
sizes used in these studies are large enough to have been able to detect a difference.
In the studies that assess mental health in addition to cognitive functioning, relation-
ships are identified between mental health and general cognitive functioning, attention,
executive function, and memory. Generally, mental health problems (depression, PTSD,
internalizing symptoms, externalizing problems) are associated with lower levels of
cognitive functioning, with two exceptions (Goldberg et al., 2011; Pluck et al., 2015;
see Table 3). In homeless young people, 64% of those with one or more psychiatric
disorders also demonstrate impaired cognitive functioning compared to norms, espe-
cially in verbal and working memory (Saperstein et al., 2014). However, this is only a
preliminary examination of the relationship between cognition and mental health in
young, disadvantaged populations. More research is required to understand the inter-
play between cognitive functioning and mental health in vulnerable young people.
The results suggest that at least some young people who have experienced home-
lessness, foster care, or poverty have less well-developed cognitive skills and abilities
than those who have not had such experiences. Whether cognitive difficulties precede
or develop as a result of homelessness, foster care, or poverty experiences, or indeed
CHILD NEUROPSYCHOLOGY 925
both, is undetermined. However, what is clear is that these young people are likely to be
especially vulnerable, particularly given the relationships found with mental health
problems. Shared difficulties among groups with similar experiences, such as in working
memory, suggest that there may be factors common to all disadvantaged groups that are
related to cognitive functioning. When directly compared, homeless and poverty groups
appear not to differ in levels of cognitive functioning. However, in terms of stressful
experiences and exposure to risk factors, the particular samples used could be argued to
be similar, which theoretically places them in fairly close proximity on the continuum
of risk (Masten et al., 1993). Alternatively, as previously noted, the studies may not
possess enough statistical power to detect any differences in cognitive functioning that
might be present.
In practice, services for groups with adverse experiences (e.g., homeless young
people) do not routinely assess cognitive functioning (Solliday-McRoy, Campbell,
Melchert, Young, & Cisler, 2004). Cognitive functioning also tends to be neglected in
research on vulnerable young people, with most studies focusing on factors such as
trauma, substance use, and mental health (e.g., Toro et al., 2007). The evidence
presented here suggests that cognitive functioning may be associated with experiences
of homelessness, foster care, or poverty. Two factors that have been identified as
resilience-promoting factors are parental support and cognitive functioning (Cutuli &
Herbers, 2014; Masten et al., 1999). Young people who have experienced homelessness
or foster care are likely to have inadequate support from parents (Milburn et al., 2005),
and due to added pressures such as needing to work multiple jobs, young people in
poverty may receive limited time with and support from parents compared to those
who are not impoverished.
In addition, some cognitive skills may show improvement with training (see e.g.,
Løhaugen et al., 2011). Although this is still a controversial area of research (Klingberg,
2010; Melby-Lervåg & Hulme, 2013; Morrison & Chein, 2011; Shipstead et al., 2012),
cognitive skills training can be of particular benefit to low SES children (Jolles & Crone,
2012). Furthermore, there is recent evidence of some generalization beyond trained
tasks in a naturalistic setting; participants demonstrated some improvement in both
working memory (on trained and untrained tasks) and academic performance in
schools following teacher-delivered working memory training (Holmes & Gathercole,
2014). Although most research has focused on working memory training, it may be that
other types of cognitive skills training are more feasible and potentially more effective;
further investigation is required. Aspects of cognitive functioning may therefore con-
stitute a potentially promising target for intervention. Late adolescence and emerging
adulthood could represent an opportunity to intervene in order to enhance or increase
cognitive functioning among young people as this period encompasses a sensitive period
of brain development (Steinberg, 2005). By improving their cognitive functioning,
young people who have experienced homelessness, foster care, or poverty may be better
able to adapt and subsequently experience more success not only in terms of education
and employment, but also in everyday living (Sternberg et al., 2000).
There are some limitations to note. Despite broad inclusion criteria, the searches
yielded few studies, especially in the homelessness and foster care literatures. The
definitions and duration of the experiences of homelessness, foster care, and poverty
vary considerably between studies, making it difficult to draw firm conclusions. Related
926 C. E. FRY ET AL.
to this, the groups of interest in some studies may have included participants from
other disadvantaged groups. For example, one study, which had a broad definition of
out-of-home care, likely also included those that were homeless as well as those who
had experienced foster care (Berger et al., 2009). The majority of included studies score
50% on their quality assessments, with 12 scoring more than 70% overall. Many studies
scored poorly on representativeness though, using convenience sampling or sampling
methods that are not fully described. Often, reporting quality is not sufficient to merit
awarding a star in a given category. Comparison groups are not used in one third of the
studies.
Attempts have been made to reduce the risk of bias when conducting this review by
having several stages cross-checked by other researchers, which were then compared
and discussed. Possible sources of bias include limiting searches to those articles
published in English, as well as including only journal articles. Although the majority
of journal articles are peer-reviewed and thus meet many standards for quality, it could
be argued that valuable information on the groups of interest was available in the gray
literature, that is, research and reports by governments and organizations (such as
charities) that are unlikely to have been peer-reviewed. Nevertheless, the focus of this
review is objective cognitive tests, which are more likely to be found in journal articles.
The markedly high initial return of more than 20,000 articles did raise some concerns,
but the search strategy was deliberately broad due to attempting to bridge three separate
literatures relating to cognitive functioning.
Considering the potential importance of cognitive skills for adaptation and the
added vulnerability which cognitive impairment may confer, the relative paucity of
research on cognitive functioning in young people with experience of adversity needs
to be addressed. In particular, there needs to be more investigation of cognitive
functioning in young people who have experienced homelessness or foster care,
making comparisons with both disadvantaged and non-disadvantaged groups. The
relationship between cognitive difficulties and mental health issues in young people
who have experienced homelessness, foster care, or poverty also warrants examina-
tion, as the presence of both has been shown to predict worse outcomes than either
in isolation (Saperstein et al., 2014). As most research among vulnerable young
people focuses on impairment or negative outcomes, an assessment of areas of
strength is required to fully explore resilience and positive/adaptive development
in this age group, and may offer valuable avenues for intervention. Studying cogni-
tion in young people whose cognitive development is likely disrupted is valuable for
cognitive and developmental psychology more broadly, as it enables the discovery of
potential risk and protective factors to typical cognitive development (Rutter &
Sroufe, 2000).
Conclusion
The cognitive performance of young people who have experienced homelessness, foster
care, or poverty tends to be below that of their non-disadvantaged peers. The evidence
presented in this review highlights the importance of cognitive functioning, which may be
neglected in vulnerable populations in favor of more immediate needs (Backer & Howard,
2007). Cognitive functioning in young people who have had adverse experiences
CHILD NEUROPSYCHOLOGY 927
apparently attracts little research attention, with a particular dearth of research on
cognitive functioning in young people who are homeless or in foster care. Studies instead
tend to focus on factors such as mental health, substance abuse, and trauma (e.g., Toro
et al., 2007). While these factors are important, cognitive functioning and its potential for
positive adaptation should not be ignored. More research is needed in this age range with
well-defined groups to both provide a clearer picture of cognitive profiles in disadvantaged
young people and investigate how cognitive functioning interacts with mental health, with
implications for educational and occupational outcomes.
Acknowledgements
The authors would like to thank Sam Austin at Llamau as well as Amy Smith, Bethan Phillips,
Charlotte Deeley, Chloe Sayer, and Mariam Afifi for their assistance during the review process.
The authors would also like to thank Stella Mavroveli Ph.D., Amanda Staiano Ph.D., and Sandra
Calvert Ph.D., who provided the additional information requested, as well as Catherine Jones
Ph.D. for providing valuable comments on an earlier version of the manuscript. We are grateful
to two anonymous reviewers for their helpful suggestions.
Disclosure Statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by the Economic and Social Research Council [grant number ES/
J500197/1]; and Llamau [grant number 507790], a charity supporting homeless young people
across Wales.
ORCID
Charlotte E. Fry http://orcid.org/0000-0002-1221-1281
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