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Study Flow of the Moving to Opportunity Long-term Follow-up Evaluation of Adolescents aTarget respondents for the adolescent long-term evaluation included all baseline residents of randomized households who were aged 0 through 8 years at randomization from 1994 to 1998, aged 13 through 17 years at selection in December 2007, and aged 13 through 19 years at interview from June 2008 to April 2010. All adolescents in the eligible age range who lived at baseline in households containing 3 or fewer youth between 10 and 20 years were targeted for follow-up, whereas a random 3 were targeted from baseline households with 4 or more youth. A weight of n/3, for which n equals the number of eligible youths in the baseline household, was used to adjust for the undersampling of youths from baseline households containing more than 3 eligible youth. Phase 1 data collection refers to the efforts made to contact and interview all target respondents until the end of the field period, at which point a random 35% of eligible target respondents (those who had not yet been interviewed, were not deceased or incapacitated, had not declined to participate) were selected for a more intensive Phase 2 data collection effort that included expanded tracing efforts and increased financial incentives. A weight of 1/.35 was used to adjust for the undersampling of the Phase 2 hard-to-recruit youths who were interviewed. BFor the 693 families excluded before randomization, the number excluded for each reason listed above is not known.

Abstract Importance Youth in high-poverty neighborhoods have high rates of emotional problems. Understanding neighborhood influences on mental health is crucial for designing neighborhood-level interventions. Objective To perform an exploratory analysis of associations between housing mobility interventions for children in high-poverty neighborhoods and subsequent mental disorders during adolescence. Design, Setting, and Participants The Moving to Opportunity Demonstration from 1994 to 1998 randomized 4604 volunteer public housing families with 3689 children in high-poverty neighborhoods into 1 of 2 housing mobility intervention groups (a low-poverty voucher group vs a traditional voucher group) or a control group.

The low-poverty voucher group (n=1430) received vouchers to move to low-poverty neighborhoods with enhanced mobility counseling. The traditional voucher group (n=1081) received geographically unrestricted vouchers. Controls (n=1178) received no intervention. Follow-up evaluation was performed 10 to 15 years later (June 2008-April 2010) with participants aged 13 to 19 years (0-8 years at randomization). Response rates were 86.9% to 92.9%. Main Outcomes and Measures Presence of mental disorders from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) within the past 12 months, including major depressive disorder, panic disorder, posttraumatic stress disorder (PTSD), oppositional-defiant disorder, intermittent explosive disorder, and conduct disorder, as assessed post hoc with a validated diagnostic interview. Results Of the 3689 adolescents randomized, 2872 were interviewed (1407 boys and 1465 girls).

Compared with the control group, boys in the low-poverty voucher group had significantly increased rates of major depression (7.1% vs 3.5%; odds ratio (OR), 2.2 95% CI, 1.2-3.9), PTSD (6.2% vs 1.9%; OR, 3.4 95% CI, 1.6-7.4), and conduct disorder (6.4% vs 2.1%; OR, 3.1 95% CI, 1.7-5.8). Boys in the traditional voucher group had increased rates of PTSD compared with the control group (4.9% vs 1.9%, OR, 2.7 95% CI, 1.2-5.8). Trimble gps pathfinder office crack. However, compared with the control group, girls in the traditional voucher group had a decreased rate of conduct disorder (0.3% vs 2.9%; OR, 0.1 95% CI, 0.0-0.4). Conclusions and Relevance Interventions to encourage moving out of high-poverty neighborhoods were associated with increased rates of depression, PTSD, and conduct disorder among boys and a reduced rate of conduct disorder among girls. Better understanding of interactions among individual, family, and neighborhood risk factors is needed to guide future public housing policy changes.

Introduction Observational studies have consistently found that youth in high-poverty neighborhoods have high rates of emotional problems even after controlling for individual-level risk factors. These findings raise the possibilities that neighborhood characteristics affect emotional functioning and neighborhood-level interventions may reduce emotional problems. Available data from observational studies are unclear and subject to selection bias and the possibility of reverse causality (ie, families with emotional problems end up in poorer neighborhoods).

Despite this uncertainty, presumptive neighborhood effects have been characterized, causal pathways have been hypothesized, and interventions have been implemented. It is important to evaluate these causal claims regarding neighborhood effects experimentally. The US Department of Housing and Urban Development (HUD) enacted a housing mobility experiment known as the Moving to Opportunity for Fair Housing Demonstration by randomizing volunteer low-income public housing families with children to receive vouchers to move to lower-poverty neighborhoods., An interim evaluation 4 to 7 years after randomization showed that the intervention caused families to move to better neighborhoods with lower poverty and crime rates and increased social ties with more affluent people. Significant reductions in psychological distress and depression were also found among adolescent girls in the intervention group vs the control group but increased behavior problems were found among adolescent boys in the intervention group vs the control group. Given the importance of these sex differences, clinically significant mental disorders were included in a long-term (10-15 years after randomization) follow-up assessment. Prior long-term follow-up reports documented effects on improved neighborhood characteristics, reduced adult extreme obesity and diabetes, and improved adult subjective well-being.

No detectable effects on economic self-sufficiency were found. Although long-term evaluation found significantly reduced psychological distress among adolescent girls, measures of mental disorders were not examined in previous reports. The primary objectives of the Moving to Opportunity study were to move families to lower-poverty neighborhoods and increase educational achievement and economic self-sufficiency. Mental disorders were measured as post hoc outcomes.

The current report presents the first exploratory analyses evaluating long-term associations of housing mobility randomization with mental disorders among participants who were in early childhood at randomization and adolescence at follow-up. Study Design Families (n=4604) in the Moving to Opportunity study were recruited by public housing authorities from 1994 to 1998. Families had to reside in public or project-based assisted housing in high-poverty census tracts (40% of families in poverty) in Baltimore, Boston, Chicago, Los Angeles, or New York; be eligible for Section 8 housing; and have 1 or more children age younger than 18 years. Census tracts contain 2500 to 8000 people and are defined by the US Census Bureau to be “homogeneous with respect to population characteristics, economic status, and living conditions.” Housing authorities sent recruitment letters, held information sessions, and asked families to complete applications within 4 weeks of the invitation. Signed consents and baseline questionnaires were obtained during intake sessions prior to randomization.

Families were then randomized into 1 of 3 groups using a computerized random-number generator: a low-poverty voucher group, a traditional voucher group, or a control group. In the low-poverty voucher group, families were offered a standard rent-subsidy voucher restricted to low-poverty census tracts (. Measures Baseline head-of-household questionnaires focused largely on sociodemographics and neighborhood experiences (eg, social networks and crime victimization). Mental disorders were not assessed. Item-level missing data on the variables assessed was less than 5% for all but 5 variables (low birth weight; hospitalization before first birthday; baseline health problems that restricted normal activities; parent educational level; whether someone read to the child more than once daily during his/her early childhood; 5.5% to 11.2% missing).

There were no missing values on the intervention variables. Item-level missing data were imputed using multiple imputation using SAS software. The long-term assessment included the Composite International Diagnostic Interview (CIDI), a widely used psychiatric diagnostic evaluation tool known to have good concordance with clinical diagnoses of mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) ( DSM-IV).

The CIDI questions were read word-for-word and responses recorded in prespecified (mostly yes/no) format. Diagnoses were generated by CIDI algorithms operationalizing DSM-IV inclusion criteria. Diagnoses were made for DSM-IV disorders present within the past 12 months. Item-level missing data were less than 1% for each symptom question and were recoded conservatively to assume the symptom was absent. We focused on 6 DSM-IV/CIDI disorders: mood (major depression), anxiety (panic, posttraumatic stress), and disruptive behavior (oppositional-defiant, intermittent explosive, conduct). Bipolar disorder was also assessed, but was not analyzed due to low prevalence and insufficient statistical power to detect meaningful associations (eTable 1 in ).

Statistical Analysis Sample size was determined by the Moving to Opportunity study budget ($70 million Congressional authorization, additional vouchers from local housing authorities, and counseling donated by nonprofit agencies). Randomization was designed to yield equal numbers of families within cities using vouchers in each intervention group. The number of families in the control group invited was set to equal the mean number invited in the 2 intervention groups. As voucher use percentages were determined only after randomization, proportions randomized across groups were modified during the study to adjust for observed rates of voucher use. The HUD determined that this design would yield 80% power to detect an effect of $2000 in increased earnings in each intervention group with a one-sided α of.05.

6(pE-4,exhibit,E4) Post hoc power calculations showed that the long-term follow-up sample of adolescents had at least 80% power to detect an odds ratio (OR) for each of the 6 mental disorders considered herein of 1.4-1.8 (eTable 1 in ). Intention-to-treat logistic regression analysis was used to estimate associations of the interventions with the outcomes. Across-time variation in the intervention vs control group selection ratios from 1994 to 1998 was corrected for by weighting.

Case-level multiple imputation based on 20 pseudosamples was used to adjust for the fact that not all baseline participants completed follow-up interviews. The Taylor series method implemented in SUDAAN was used to adjust for weighting and clustering (cities, housing projects, families). The significance of sex differences was assessed by estimating a logistic regression equation to predict each disorder that included dummy variables for each intervention, a dummy variable for sex, and 2 dummy variables for the interactions of interventions with sex. A 2-degree-of-freedom χ 2 test was used to evaluate the significance of the interactions. In cases for which the test was significant, associations of the interventions with the disorder were considered separately for each sex. The evaluation of sex differences was carried out because significant sex differences had been found in previous interim evaluations. The 6 mental disorders were considered separately because risk factors vary across these disorders., The Benjamini-Hochberg method was used to adjust significance tests across outcomes for the false discovery rate.

Logistic regression coefficients and standard errors were exponentiated to create ORs and 95% confidence intervals. Mental disorder prevalence estimates in the intervention and control groups were used to calculate absolute risk (AR) and absolute risk reduction (ARR). The jack-knife repeated replications method in SAS was used to generate confidence intervals for the estimates of AR and ARR. Statistical significance was evaluated using a 2-sided α of.05. Response Rates The 3689 adolescents assessed were aged 0 through 8 years (median age, 4 years) at baseline and aged 13 through 19 years (median age, 16 years) at the time of long-term follow-up interviews. A total of 2872 adolescents were interviewed (1407 boys and 1465 girls from 2134 families), including 1165 in the low-poverty voucher group (843 families), 799 in the traditional voucher group (615 families), and 908 in the control group (676 families), out of the 3689 eligible in the baseline sample (77.8% participation rate).

An additional 643 adolescents were randomly excluded (188 from families with 4 eligible respondents and 455 due to difficult recruitment) and 174 were lost to follow-up (including 18 deceased). The weighted response rates were 92.9% (low-poverty voucher group), 86.9% (traditional voucher group), and 89.4% (control group) using the American Association of Public Opinion Research definition.

(p51) Respondents were more likely to be girls and non-Hispanic black but did not differ significantly from nonrespondents on other baseline personal, family, and neighborhood characteristics (eTable 2 in ). Sample Characteristics Baseline sociodemographic characteristics of adolescents were largely comparable across the 3 groups for both boys and girls. Most respondents were non-Hispanic black (61.8%-66.2% of groups) or Hispanic (27.7%-33.2% of groups). The majority of respondents were ages 0 through 5 years at baseline (82.2%-87.9% of groups), with mean age of 3.6 years in each group and range of 0 through 7 years in the low-poverty voucher group and 0 through 8 years in traditional voucher and control groups. The majority of baseline families received Aid to Families with Dependent Children (79.1%-85.1% of groups).

Mean baseline neighborhood poverty rates were 53.6% to 54.9%. Mental Disorder Prevalence Within the Past 12 Months The most prevalent mental disorders within the past 12 months were found to be intermittent explosive disorder (14.2% of boys and 16.0% of girls) and oppositional-defiant disorder (6.8% of boys and 8.4% of girls), followed by major depressive disorder (5.5% of boys and 7.9% of girls), posttraumatic stress disorder (PTSD) (4.4% of boys and 6.6% of girls), conduct disorder (4.3% of boys and 1.6% of girls), and panic disorder (4.1% of boys and 3.7% of girls) (eTable 3 in ). Associations of Interventions With Mental Disorders Among Boys and Girls Combined Adjusting for the false discovery rate, respondents in the low-poverty voucher group had significantly elevated prevalence of PTSD (7.2% 95% CI, 5.7%-8.6%; OR, 1.8 95% CI, 1.2-2.7) compared with the control group (4.2% 95% CI, 3.2%-5.2%).

None of the other 11 comparisons of low-poverty or traditional voucher groups with the control group was significant. Odds ratios comparing the low-poverty voucher group with the control group were in the range 0.7-1.6 ( P =.13.84). Odds Ratios comparing the traditional voucher group with the control group were in the range of 0.9-1.1 ( P =.70). After adjusting for the false discovery rate, the ORs comparing the low-poverty and traditional voucher groups with the control group varied significantly by respondent sex for 3 of the 6 outcomes: major depression (χ 2 2 = 14.1, P =.007), PTSD (χ 2 2 = 9.0, P =.03), and conduct disorder (χ 2 2 = 11.7, P =.01). Odds ratios were not significantly different by sex for panic disorder (χ 2 2 = 6.2, P =.08), oppositional-defiant disorder (χ 2 2 = 4.4, P =.16), or intermittent explosive disorder (χ 2 2 = 1.3, P =.60). Based on these results, the remaining analyses focused on major depression, PTSD, and conduct disorder separately for boys and girls. Associations of Interventions With Mental Disorders Among Girls Adjusting for the false discovery rate, girls in the traditional voucher intervention group had a significantly reduced rate of conduct disorder in the traditional voucher group (0.3% 95% CI, −0.1%-0.7%; OR, 0.1 95% CI, 0.0-0.4) compared with the control group (2.9% 95% CI, 1.1%-4.7%).

The number needed to treat (NNT) (inverse of ARR) among girls was 38 for conduct disorder. None of the other 5 comparisons between intervention and control groups was significantly different, with ORs in the range 0.5-1.2 ( P =.06.40). Discussion Our post hoc exploratory analysis found that interventions to encourage moving out of high-poverty neighborhoods were associated with increased depression, PTSD, and conduct disorder among adolescent boys and reduced conduct disorder among adolescent girls randomized at ages 0 through 8 years.

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Article Information Corresponding Author: Ronald C. Kessler, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115. Retraction and Replacement: This article was retracted and replaced on June 17, 2016, to fix errors in the abstract, text, Table 4, Table 5, and the References (see for the retracted article with corrections shown). Author Contributions: Drs Kessler and Ludwig had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Kessler, Duncan, Gennetian, Katz, Kling, Sanbonmatsu, Ludwig. Acquisition of data: Gennetian, Sanbonmatsu, Ludwig.

Analysis and interpretation of data: Kessler, Duncan, Gennetian, Katz, Kling, Sampson, Sanbonmatsu, Zaslavsky, Ludwig. Drafting of the manuscript: Kessler. Critical revision of the manuscript for important intellectual content: Duncan, Gennetian, Katz, Kling, Sampson, Sanbonmatsu, Zaslavsky, Ludwig. Statistical analysis: Kessler, Duncan, Katz, Kling, Zasavsky, Ludwig.

Obtaining funding: Katz, Kling, Ludwig. Study supervision: Kessler, Gennetian, Sampson, Sanbonmatsu, Zaslavsky, Ludwig. Administrative, technical, or material support: Gennetian, Sanbonmatsu. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.