February 2015 Newsletter: Homeless Youth - Vulnerabilities and Health-Related Issues
As a follow-up to last month’s MECP webinar on “The Vulnerability of Homeless Youth,” this month’s MECP newsletter invites you to explore additional vulnerabilities and health related issues associated with homeless youth. Our first featured article, provided by the Center for Social Innovation, delves into the unique physical and psychological health needs that homeless youth endure and provides recommendations for assisting youth in accessing health services. Our second featured article, contributed by the International Association for Adolescent Health, offers an overview of the potential consequences homelessness has on youth and suggests strategies for law enforcement to better assist this population.
3rd Wednesday at 2PM Eastern Bi-Monthly Webinar Series: The Vulnerability of Homeless Youth
MECP’s bi-monthly webinar series was presented by Tammy Hopper from the National Safe Place, and Sergeant Byron Fassett with the Dallas Police Department. The focus of this webinar was to define and recognize the profiles of high-risk homeless youth, discuss solutions and effective agency responses for working with homeless youth, and identify national resources for law enforcement and the populations they serve.
To view this webinar recording and other MECP presentations, please visit here.
Health Needs of Youth Experiencing Homelessness
Wayne Centrone, N.M.D., M.P.H., Vice President, Design Lab, Center For Social Innovation
Homelessness affects people of all ages from all walks of life. From “rough sleepers” living on the streets, to families living in cars or in shelters, to tenuously housed individuals who survive by “couch surfing”—it is clear that there is no single homogenous group of people experiencing homelessness. Often overlooked in discussions of homelessness are issues affecting youth and young adults. Youth who are homeless are a distinct group compared to the larger population of adults experiencing homelessness. Youth experiencing homelessness include runaways, street youth, foster care system “aged out” youth, youth exiting the juvenile justice system and youth who are thrown out of their homes for a number of different reasons.[i] This broad definition of youth experiencing homelessness involves an age range of roughly 12-25 years of age.[ii]
Youth experiencing homelessness face many health challenges and developmental complications – from issues of identity and identity formation,[iii] to difficulty developing interpersonal relationships, a sense of purpose, and a vision for their future. In addition, compared to their housed counterparts, youth experiencing homelessness are disproportionately affected by physical health conditions and exhibit much higher rates of mental health conditions, substance use and misuse, suicidal ideation, and high-risk behaviors.[iv]
Homeless youth experience alarmingly disproportionate level of physical and psychological health problems due to housing instability and high-risk behaviors.[v] Their lack of early intervention, preventive care, and health insurance make them more susceptible than their housed peers to a multitude of illnesses poor health outcomes. High-risk behaviors also place them at greater risk for complications from simple infections and other health concerns. In addition to the complex challenges of lacking access to supportive services, youth experiencing homelessness suffer from an extraordinary degree of stress and trauma.
The trauma of life on the streets, along with the background dysfunction that predates youth homelessness, are contributing factors that lead to greater levels of stress, anxiety and behavioral challenges. Youth experience traumatic stress when they are exposed to disruptive and violent events, and are unable to cope with the aftermath of their experiences.[vi] Traumatic events linked to a life of youth homelessness include physical or sexual assault, experiencing or witnessing violence or victimization, or sudden loss of a parent or guardian. Studies indicate that mental health and behavioral disorders are also strongly linked back to the family of origin, and may be strong contributors to family conflict and homelessness.[vii]
Behavioral problems like conduct disorder or oppositional defiant disorder may be even more prevalent in homeless youth populations than mental health and psychiatric disorders.[viii] Dealing with traumatic events and daily life on the streets or in shelters can have a strong negative impact on the health of young people. The constant struggle to get basic needs met and the day-to-day challenges of living with housing instability may be causally linked to depressive symptoms. Studies have consistently demonstrated a higher prevalence of depression in homeless youth than among housed peers or the general adolescent population.[ix]
A number of studies have demonstrated that youth who are homeless engage in higher risk sexual behaviors including multiple partners, survival sex and sex work/prostitution. Research shows that 40 percent of homeless youth report having had a sexually transmitted infection.[x] Only 8 percent of their housed peers report, “ever having a sexually transmitted infection.” Equally disturbing are the high rates of injection drug use, with study rates varying from a little over 15 percent to almost 35 percent among homeless youth.[xi] Additionally, over 80 percent of street youth reported smoking tobacco in the last 30-days, compared to 47 percent in a housed matched peer group.[xii] Finally, homeless youth are 5 times more likely to have been beaten and at much higher risk of experiencing a violent threat against their life.[xiii]
Collectively and individually, these behaviors put youth experiencing homelessness at much higher risks for musculoskeletal, dermatological, gastrointestinal, genitourinary and respiratory tract infections, and communicable diseases like HIV and other sexually transmitted infections. Homeless youth are all too often unable to get the treatment and medication they need, and face rapid decompensation from treatable conditions.
Youth on the streets engage in high-risk behaviors for various reasons, trading sex for protection and food (also known as survival sex), or engaging in illegal activities to obtain money, food or shelter.[xiv] Because youth who experience homelessness lack financial resources, they may engage in risky or illegal activities to survive. These “survival activities” put these homeless youth at much higher risks for health related complications and criminalization and repeated incarcerations. The cycle of incarceration and repeated victimization seems to be strongly linked to under diagnosed and poorly managed psychiatric disorders. One study of 1,800 detained youth found that nearly two thirds of the males surveyed and three-quarters of the females interviewed met diagnostic criteria for one or more psychiatric disorders.[xv] Additionally, for many homeless youth, drugs and alcohol are mechanisms to help cope with the stress of living on the streets.
One particularly vulnerable population of youth experiencing homelessness are youth who self-identify as a gender or sexual minority. Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth comprise an estimated 10 percent of the general youth population.[xvi] Among homeless youth, however, studies that have estimated sexual and gender minority prevalence as high as 35 percent.[xvii] LGBTQ youth often leave home because of their sexual or gender orientation, or are forced out because of a poor understanding of the youth’s sexuality on the part of family members. One third of LGBTQ youth who experience homelessness describe having experienced violent physical assault when they “came out.”[xviii] LGBTQ homeless youth also report experiencing sexual violence at a rate 7.4 times higher that of their heterosexual peer group.[xix] In addition, LGBTQ homeless youth have twice the rates of sexual abuse and sexual victimization when compared to heterosexual homeless peers.[xx] Even more alarming is the degree of sexual exploitation and violence faced by transgender homeless youth. Transgender homeless youth often describe a chronic history of early family separation and social isolation. This family disruption often leads to early homelessness and unemployment – forcing transgender youth into sex work and very high-risk behaviors.[xxi]
The culture and social practices of youth who experience homelessness can act as barriers to seeking health care services. Other barriers are associated with systems of care, including lack of transportation to access services, lack of appropriate facilities for homeless youth to receive services, and lack of personal knowledge and advocacy for engaging care. Studies have demonstrated that some youth experiencing homelessness find it difficult to trust physicians and medical providers for fear that they will be judged or that police and social services will become involved.[xxii] Removing the barriers youth experiencing homelessness to access care is a complex formula of strengthening relationships between providers and the youth they serve, engaging trust, modifying points of entry into care engagement, and training providers and staff in the cultural competencies of homeless and underserved youth.
Youth living in the desperate circumstances and challenges of homelessness represent a diverse group with complex needs, varied backgrounds, and extensive opportunities. Regardless of how they became homeless, youth are burdened by a lack of access to stable, affordable housing. Without a clear pattern of housing stability in their lives, youth who are homeless may have difficulty breaking the cycle repeated housing instability. Perhaps the most important health intervention needed by youth experiencing homelessness is housing. Building supportive services around stable housing will allow youth to secure a path to future filled with hopes and dreams.
What Do We Know About Transition Age Youth?
Why are U.S. Youth “Homeless?”
Overview of Homeless Youth
Health of Homeless & Abandon Youth
What do we know about effective programs for transition age youth?
Adapting Services Practice for Working with “Youth Identified” Homeless
Homeless Service Providers: Creating Bridges for Service Delivery
Homeless Youth and Young Adults Considerations
Understanding and Helping Vulnerable and Homeless Youth
Meera Beharry MD, FAAP, Assistant Professor of Pediatrics, Texas A & M Health Science Center
The homeless youth population in the United States has been estimated to be anywhere from 500,000 to 1.6 million youth. There are multiple issues associated with being able to obtain an accurate count of any homeless population. Specific to homeless youth is the fact that many do not identify as “homeless” and often move from the home of one friend or family member to another.
Homeless youth have higher rates of mental illness, sexually transmitted infections as well as other infections associated with crowded conditions (such as lice, scabies and tuberculosis) than their housed counterparts do. Additionally, homeless youth are more likely to have poor control of chronic medical conditions, such as asthma and diabetes. Approximately 20-40% of homeless youth identify as lesbian, gay, bisexual or transgender. Their sexual orientation may have led to them being kicked out of their home and may contribute to further victimization once they are on the streets.[xxiii]
Though adolescents vary, there are some general principles that may help law enforcement in properly identifying and assisting young people. As most girls start puberty between the ages of 9 or 10, they also achieve their full adult height by the age of 12 or13. Furthermore, these young females may appear older due to their clothing, make-up and overall appearance. Unfortunately, statistics have shown that girls, who go through puberty early, are at higher risk of sexual abuse and victimization than those who go through puberty later in life.[xxiv] Whereas boys generally begin puberty later around the age of 10, and continue puberty until the ages of 16 to 18. Therefore, many children will achieve an adult appearance long before reaching the age of majority. On the contrary, some youth will appear younger than their biologic age. Issues such as malnutrition or chronic illness may cause youth or young adults to appear younger however, physicians may be able to help determine the approximate age of a person when there is doubt.
In the past, it was believed that the brain developed at the same time that the body did. Recent work through the National Institute of Mental Health has provided evidence that the teenage brain continues to develop until the early 20’s.[xxv] The area within the brain that experiences the most change during adolescence is the pre-frontal cortex, which functions as “the CEO” of the brain. While this area is still developing, adolescents and young adults are more likely to make decisions based on the “primitive” brain centered at the limbic system. They are more likely to take risks, overestimate the rewards of engaging in risky behaviors and be more prone to operate from a “fight or flight” response. This concept has been summarized by stating that the “lizard brain” (primitive limbic system) is dominant over the “wizard brain” (pre-frontal cortex) at this stage of life. Interestingly, researchers have demonstrated that many adolescents, especially those who have experienced trauma in their life, are more likely to interpret a frightened facial expression as anger.[xxvi] It is easy to see how that can lead to an escalation of a tense situation when a teen’s lizard brain is in control of their actions.
During this time of brain development, teens tend to care more about what their peers think than what adults think. There is a strong desire to fit in, which may lead to impulsive acts or crimes committed because of peer pressure. Teens with social or emotional issues who are introduced to drugs are more likely to continue to use drugs to help cope with their problems. This can lead to other unhealthy or high-risk behaviors, which may increase their risk of victimization and homelessness.
Not surprisingly, when youth are on the street, there are opportunities for them to come into contact with law enforcement when they engage in “survival sex” (exchanging sex for food, clothing or shelter), perpetrate crimes or are victims of crime. Auerswald and Eyre observed that youth are more likely to exit the street when they are in these states of crisis or “disequilibrium.”[xxvii]
Edinburgh et al developed a 10 question tool (table) that can be used by law enforcement to identify homeless youth who are victims of abuse or otherwise in need of medical care.[xxviii]
The 10-Question Screening Tool Used by Law Enforcement with Runaway Youth
Instructions: Write the youth’s answers to the following 10 questions in narrative form:
- Why did you leave home?
- How long have you been away from home?
- Who have you been staying with while away from home?
- Did someone touch you in a way you did not like or sexually assault you when you were away from home?
- Do you have health issues that you need medical care for now?
- Has anyone hurt you or tried to hurt you while you were away from home?
- Are you afraid at home? If yes, why? Will you be safe at home? Use a 0–10 scale to quantify safe feeling (In this scale, 0 is safest and 10 is least safe).
- Do you have someone you can talk to at home or school?
- Do you drink or do drugs?
- Are you a member of a gang?
The authors found that many youth disclosed substance use and abuse in addition to reporting safety issues. This can provide another opportunity to get young people into needed treatment.
By using the tools and principles above and partnering with organizations serving children - local children’s hospitals, emergency rooms, Child Protective Services, Child Advocacy Centers, homeless shelters and National Safe Place locations - law enforcement can help homeless youth receive appropriate care, exit the street and prevent chronic homelessness for vulnerable youth. As was discussed by Tammy Hopper from the National Safe Place in the recent MECP Webinar on the Vulnerability of Homeless Youth, understanding the principles of trauma informed care in collaboration with training on how to work with youth and others who have experienced trauma can help “de-escalate” a situation and prevent further trauma. More information about trauma informed care and training programs can be found at the National Association of State Mental Health Program Directors http://www.nasmhpd.org/TA/NCTIC.aspx and the Substance Abuse and Mental Health Services Association http://www.samhsa.gov/nctic.
March 9th – March 11th: Child Sex Trafficking: Law Enforcement Response. Hosted by, the U.S. Department of Justice, Office of Justice Programs and Office of Juvenile Justice and Delinquency Prevention in North Easton, MA, this training is designed to provide law enforcement investigators, human trafficking task force members and social service providers with the information necessary to properly understand, recognize, and investigate cases involving child sex trafficking and exploitation.
March 23rd –March 26th: 31st International Symposium on Child Abuse. The International Symposium on Child Abuse is an informative and innovative multidisciplinary conference, which offers more than 130 workshops presented by internationally recognized experts from all facets of the child maltreatment field. Professionals receive practical instruction, the latest research and information, and the opportunity to develop and enhance their skills and knowledge.
April 28th – April 30th: Crimes Against Children In Indian Country Conference. The National Criminal Justice Training Center’s 9th Annual Multi-Disciplinary Approaches to Prevent Crimes Against Children in Indian Country (CACIC) Conference will be held at the Black Bear Casino Resort in Carlton, MN. The conference was formed in response to the often-unmet needs of Native youth. The advisory/planning committee is made up of representatives from a wide range of tribal and non-tribal law enforcement, government, and social service agencies.
[i] Farrow, J. A., Deisher, R. W., Brown, R., Kulig, J. W., & Kipke, M. D. (1992). Health and health needs of homeless and runaway youth. A position paper of the Society for Adolescent Medicine. Journal of Adolescent Health, 13, 717–726
[ii] Toro, P. A., Dworsky, A., & Fowler, P. J. (2007). Homeless youth in the United States: Recent research findings and intervention approaches. Paper presented at the 2007 National Symposium on Homelessness Research, Washington, DC. Retrieved May 7, 2009, from huduser.org/publications/homeless/p6.html
[iii] Erikson E. Identity, youth, and crisis. New York: Norton; 1968
[iv] Ennett ST, Federman EB, Bailey SL, Ringwalt CL, Hubbard ML. HIV-risk behaviors associated with homelessness characteristics in youth. Journal of Adolescent Health 1999;25:344–353. [PubMed: 10551665]
Kamieniecki GW. Prevalence of psychological distress and psychiatric disorders among homeless youth in Australia: A comparative review. Australian & New Zealand Journal of Psychiatry 2001;35:352–358. [PubMed: 11437809]
Molnar, B. E., Shade, S. B., Kral, A. H., Booth, R. E., & Watters, J. K. (1998). Suicidal behavior and sexual/physical abuse among street youth. Child Abuse and Neglect, 22(3), 213–222
[v] Feldman J, Middleman AB. Homeless adolescents: common clinical concerns. Seminars in Pediatric Infectious Diseases. 2003;14:6–11
[vi] National Child Traumatic Stress Network. (2007). Trauma among homeless youth. Culture and Trauma Brief, 2(1). Retrieved May 7, 2009, from http://www.nctsnet.org/nctsn_assets/pdfs/culture_and_trauma_brief_v2n1_HomelessYouth.pdf National Health Care for the Homeless Council. (2005). Preventing chronic homelessness among youth. Healing Hands, 9(5), 5–6
[vii] Toro, P. A., Dworsky, A., & Fowler, P. J. (2007). Homeless youth in the United States: Recent research findings and intervention approaches. Paper presented at the 2007 National Symposium on Homelessness Research, Washington, DC. Retrieved May 7, 2009, from huduser.org/publications/homeless/p6.html
[viii] Bao WN, Whitbeck LB, Hoyt DR. Abuse, support, and depression among homeless and runaway adolescents. Journal of Health and Social Behavior 2000;41:408–420. [PubMed: 11198565]
[ix] Toro, P. A., & Goldstein, M. S. (2000, August). Outcomes among homeless and matched housed adolescents: A longitudinal comparison. Presented at the 108th Annual Convention of the American Psychological Association, Washington, DC
[x] Sherman, 1992
[xi] Greene JM, Ennett ST, Ringwalt CL. Substance use among runaway and homeless youth in three national samples. American Journal of Public Health 1997;87:229–35. [PubMed: 9103102]
[xii] Kipke et al., 1997
[xiii] Ensign, B. J. and Santelli, J. (1998) Health status and access to care: Comparison of adolescents at a school-based health clinic with homeless adolescents. Archives of Pediatrics and Adolescent Medicine 152(1), 20±24
[xiv] Van Leeuwen, J., Mendelson, B., Hopfer, C., Kelly, S., Green, J., & Petersen, J. (2005.) Substance use and corresponding risk factors among homeless and runaway youth in Denver, Colorado. (Manuscript submitted for publication.)
[xv] Teplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K., & Mericle, A. A. (2002), Prevalence of psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59, 1133–1143
[xvi] Dempsey, 2004
[xvii] Kruks, G. (1991). Gay and lesbian homeless/street youth: Special issues and concerns. Journal of Adolescent Health, 12, 515–518
Tenner, A. D., Trevithick, L. A., Wagner, V., & Burch, R. (1998). Seattle YouthCare’s prevention, intervention and education program: A model of care for HIV-positive, homeless, and at-risk youth. Journal of Adolescent Health, 23, 96–106
Whitbeck, L. B., Chen, X., Hoyt, D. R., Tyler, K. A., & Johnson, K. D. (2004). Mental disorder, subsistence strategies, and victimization among gay, lesbian, and bisexual homeless and runaway adolescents. Journal of Sex Research, 41, 329–342
[xviii] Thompson, S. J., Safyer, A. J., & Pollio, D. E. (2001). Differences and predictors of family reunification among subgroups of runaway youths using shelter services. Social Work Research, 25(3), 163–172
[xix] Cochran et al., 2002
[xx] Rew, L., Whittaker, T. A., Taylor-Seehafer, M. A. and Smith, L. R. (2005), Sexual Health Risks and Protective Resources in Gay, Lesbian, Bisexual, and Heterosexual Homeless Youth. Journal for Specialists in Pediatric Nursing, 10: 11–19. doi: 10.1111/j.1088-145X.2005.00003
[xxi] Crossroads, National Youth Advocacy Coalition
[xxii] Farrow, J. A., Deisher, R. W., Brown, R., Kulig, J. W., & Kipke, M. D. (1992). Health and health needs of homeless and runaway youth. A position paper of the Society for Adolescent Medicine. Journal of Adolescent Health, 13, 717–726
[xxiii] Beharry MS. “Health issues in the homeless youth population.” Pediatric Ann. 2012 Apr; 41(4):154-6
[xxiv] Boynton-Jarrett et al. “Childhood abuse and age at menarche.” Adolescent Health. 2013 Feb; 52(2):241-7
[xxv] National Institute of Mental Health. “The Teen Brain: Still Under Construction” http://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/index.shtml
[xxvi] Spinks, Sarah. Frontline Producer. “One Reason Teens Respond Differently to the World: Immature Brain Circuitry.” http://www.pbs.org/wgbh/pages/frontline/shows/teenbrain/work/onereason.html
[xxvii] Auerswald CL, Eyre SL. “Youth homelessness in San Francisco: a life cycle approach.” Social Science Med. 2002; 54(10):1497–1512
[xxviii] Edinburgh, L. et al. “The 10-Question Tool: A Novel Screening Instrument for Runaway Youth” Journal of Juvenile Justice. Volume 1, Issue 2. Spring 2012. http://www.journalofjuvjustice.org/jojj0102/article06.htm