ArticlePDF AvailableLiterature Review

Abstract

Youth homelessness is a growing concern in the United States. Despite difficulties studying this population due to inconsistent definitions of what it means to be a youth and homeless, the current body of research indicates that abuse, family breakdown, and disruptive family relationships are common contributing factors to youth homelessness. Moreover, the experience of homelessness appears to have numerous adverse implications and to affect neurocognitive development and academics, as well as mental and physical health. Substance use, sexually transmitted infections, and psychiatric disorders are particularly prevalent in this population. Whereas some of these problems may be short-lived, the chronic stress and deprivation associated with homelessness may have long-term effects on development and functioning. Further, difficulties accessing adequate and developmentally-appropriate health care contribute to more serious health concerns. Suggestions for future research and interventions are discussed.
REVIEW PAPER
The Mental and Physical Health of Homeless Youth:
A Literature Review
Jennifer P. Edidin Zoe Ganim Scott J. Hunter Niranjan S. Karnik
ÓSpringer Science+Business Media, LLC 2011
Abstract Youth homelessness is a growing concern in the United States. Despite diffi-
culties studying this population due to inconsistent definitions of what it means to be a
youth and homeless, the current body of research indicates that abuse, family breakdown,
and disruptive family relationships are common contributing factors to youth homeless-
ness. Moreover, the experience of homelessness appears to have numerous adverse
implications and to affect neurocognitive development and academics, as well as mental
and physical health. Substance use, sexually transmitted infections, and psychiatric dis-
orders are particularly prevalent in this population. Whereas some of these problems may
be short-lived, the chronic stress and deprivation associated with homelessness may have
long-term effects on development and functioning. Further, difficulties accessing adequate
and developmentally-appropriate health care contribute to more serious health concerns.
Suggestions for future research and interventions are discussed.
Keywords Youth homelessness Mental health Substance use Sexually transmitted
infections
Background
The number of youth living without their families and permanent shelter is a growing
concern in the United States and overseas [1]. Research suggests that on any given night in
the United States there are 1.6–2 million homeless youth living on the streets, in shelters,
or in other temporary accommodation [2,3]. The prevalence of youth homelessness,
however, is difficult to determine due to a number of factors, which include the lack of a
J. P. Edidin (&)S. J. Hunter N. S. Karnik (&)
Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
e-mail: jedidin@yoda.bsd.uchicago.edu
N. S. Karnik
e-mail: nkarnik@uchicago.edu
Z. Ganim
Department of Education and Early Childhood Development, Victoria, Australia
123
Child Psychiatry Hum Dev
DOI 10.1007/s10578-011-0270-1
consistent definition of homelessness in the literature, as well as the population’s transient
nature and the impermanence of their homeless status [4,5].
Homeless youth are a heterogeneous population and are described by a variety of terms
in the literature. These terms include runaways (i.e., youth who have spent more than one
night away from home without parental permission), throwaways (i.e., youth who have been
forced to leave home by their parents), street youths (i.e., youth who live in high risk non-
traditional locations such as under bridges and in abandoned buildings), and systems youth
(i.e., youth who have previously been involved in government systems such as foster care or
juvenile justice) [4,6]. For the purposes of this paper, we use the term ‘‘homeless youth’’ to
refer to all of these groups. Additionally, we define a homeless person as anyone who lacks a
fixed, regular, and adequate nighttime residence; and whose primary nighttime residence is
a supervised shelter designed to provide temporary living accommodation, including
emergency shelters, transitional housing, or a place not designed for regular nighttime
human habitation (e.g., such as under a bridge or in a car). This is based on the definition
established by the U.S. Congress, which is used by the U.S. Federal Government [7].
In addition to the mixed terminology, research has not consistently operationalized what
it means to be a youth. The United Nations defines ‘‘youth’’ as including all people
between the ages of 15 and 24 years [8]. Studies of homeless youth, however, have
included participants that range in age between 12 and 17, 19, 21, or 24 years.
The overall impermanence and chronicity of homelessness, as well as the relative
inconsistency of the definition of homelessness across studies, has further contributed to
the difficulty in determining prevalence [9]. Research conducted with 59 homeless youth in
Texas found that the length of time spent living on the streets varied from 2 months to
8 years [3]. A study of 50 homeless youth in Los Angeles aged 18–23 years found that
12% of youth had been homeless for \1 year, 56% for 1–5 years, and 32% for more than
5 years [10].
The absence of consistent definitions in studies of homeless youth makes it difficult to
accurately determine the number of individuals in this population. Although this is due, in
part, to the nomadic, transient nature of homeless youth, it can also be attributed to various
other factors. In particular, the literature lacks clear, consistent definitions of the constructs
of homelessness, youth, and chronicity. This shortcoming limits researchers’ ability to
draw conclusions about this vulnerable population as a whole and to make comparisons
about subgroups of homeless youth.
Another weakness of the literature is that researchers have used various methodologies
to study the characteristics of this population, as well as prevention and intervention
programs. This makes it difficult to compare results of studies and perform meta-analyses
to synthesize data. It is, therefore, difficult to draw empirically-supported conclusions
about many of the issues that homeless youth face.
As such, this paper seeks to review the findings from studies of homeless youth and
organize them; several themes emerged. First, various studies have examined the causes of
homelessness in unaccompanied youth. A second focus of the research has been to char-
acterize homeless youth and the implications of homelessness. These studies are concerned
with issues of neurocognitive functioning, academic achievement, high risk behaviors and
activities, financial and legal issues, abuse and violence on the street, and mental and
physical health. A third theme of the literature is health care, which includes the topics of
access to, utilization of, and barriers to care. Finally, there is a small, but slowly growing,
set of studies that has examined prevention and intervention programs designed for
homeless youth. The authors conclude with a discussion of the implications of the research
and future directions.
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Causes of Youth Homelessness
There is no single cause for homelessness; however, most of the reasons named by youth
can be grouped into three broad inter-related categories: family breakdown, which includes
behaviors of parents and youth, economic problems, and residential instability [11,12].
The most common reason that young people leave home is due to disruptive family
relationships or family breakdown [13]. This may include poor family functioning,
unstable home environments, socioeconomic disadvantage, and separation from parents or
caregivers [14]. Parental drug and alcohol use is a frequently cited reason for leaving home
among young people, as it is often associated with parental abandonment, family violence,
and neglect, as well as sexual, physical, and psychological abuse [1518]. An Australian
study of 302 homeless young people (12–20 years-old) found that family conflict or family
breakdown was evident in all of the participants’ explanation about why they left home
[19]. Only a small group of individuals in this study described a simple cause and effect
relationship between one issue (e.g., drug use) and homelessness. Moreover, only 20% of
the participants indicated that their own drug use was either a primary or secondary cause
of their homelessness [19].
Trauma and Abuse
Homeless youth experience high rates of trauma and abuse prior to their experience of
homelessness. Studies indicate that this group endorses notably high rates of abuse by
family and non-family members, rape, and assault [20]. Abusive family relationships are
particularly detrimental, because they have been associated with subsequent mental health
problems and risky behaviors [21]. Abuse may be verbal, emotional, physical, or sexual in
nature. Although the findings of studies vary, homeless youth report greater exposure to
abuse and neglect prior to leaving home relative to their housed peers [22,23]. U.S.
Government agencies report that sexual abuse rates prior to leaving home in this popu-
lation range from 17 to 35% and the rate of physical abuse is reported to be as high as 60%
[13]. A Seattle based study of 328 youth (12–21 years-old) living on the streets or in
shelters, supports these high figures. Eighty-two percent of participants reported past
experiences of physical abuse, 26% endorsed sexual abuse, and 43% described family
neglect [24].In a more recent study, 50% of the participants had witnessed intrafamilial
abuse, 50% had been physically abused, 39% had been sexually abused, and 68% had
experienced verbal abuse [15]. Many of these youth had been victims of multiple types of
abuse. Specifically, 71% reported histories of at least 3 different kinds of abuse and 18%
indicated that they had experienced more than 5 kinds of abuse [15].
Although various studies have found that a significant number of homeless youth have
histories of abuse, there is evidence that suggests that the relation between trauma,
including abuse, and homelessness may be bidirectional in nature. That is, homelessness
may precipitate, or be a consequence of, trauma [20]. Youth who experience abuse during
childhood may leave home in order to avoid it; however, this may simply shift the types of
abuse that they experience [20]. Alternatively, homelessness may increase the risk for
abuse, particularly specific types of abuse, beyond that which would be expected based on
abuse during childhood [25]. As homelessness is associated with numerous stressful,
isolating, and marginalizing experiences, youth may place themselves in situations that
increase their risk for further abuse [25].
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At-Risk Groups
Specific groups of individuals may also be at-risk for becoming homeless. Studies indicate
that youth who have been involved in the foster care system and lesbian, gay, bisexual, and
transgender (LGBT) youth may be particularly vulnerable to homelessness [26]. Many
youth in the foster system become homeless when they ‘‘age out’’ of foster care at 18 years-
old. As a result, this subpopulation is older than the general population of homeless youth.
When youth in the foster care system become emancipated at 18 years-old, many do not
have adequate financial and social supports to allow obtainment of independent housing
and, consequently, become homeless [10]. A study of youth in the Michigan foster care
system, found that approximately 30% of emancipated youth experienced decreasingly
stable or continuously unstable housing situations in the 3 months following their release
[26]. Within these groups, non-white youth were more likely to have unstable living situ-
ations [26]. This was associated with an increased risk for victimization, school dropout,
emotional problems, and behavior problems; however, it is of note that 22% of the youth
were placed in foster care initially, because of behavior problems [26,27].
LGBT youth are another group at-risk for homelessness. The relative proportion of
homeless youth who identify as LGBT depends on the study and where it was conducted.
A 2006 review of the literature found that between 20 and 40% of homeless youth identify
as LGBT [28]. Within this population, family conflict is a primary cause of homelessness
[28]. For many of these youth, coming out to a parent preciptates a negative reaction,
which may prompt them to runaway or parents to kick the child out of the family home
[28]. Ultimately, the variability in the causes of youth homelessness and its onset may
differentially impact youth and their mental and physical health.
The Implications of Homelessness in Youth
Homelessness has been associated with numerous adverse outcomes across multiple
domains. The detrimental effects of homelessness on cognitive and academic functioning,
financial stability, and mental and physical health have been consistently noted in the
literature. Whereas some of these effects may be short-lived and limited to the period of
homelessness, others are more enduring in nature.
Neurocognitive Development
Adolescence and early adulthood are periods of marked social, psychological, and physical
development. Among the changes that occur during this time is rapid brain development.
Specifically, increases in myelination during this time allow for greater connectivity among
the different regions of the brain, improved speed, increased efficiency, and enhanced
modulation of the timing and synchrony of neuronal firing [29,30]. Additionally, significant
maturation of the prefrontal cortex, the area principally responsible for executive func-
tioning, occurs during this time. Executive functioning includes the processes of strategy
identification, decision making, inhibition, reasoning, working memory, planning, and
organization, as well as behavior and emotion regulation [29,3134]. Research has identified
that the prefrontal cortex undergoes a protracted period of development, which continues
from early childhood well into the mid-twenties. In addition to overall increases in prefrontal
cortical volume, improved coordination between the prefrontal cortex and the limbic system,
structures that control memory, emotion regulation, and motivation, also occurs [30,35,36].
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Because of the numerous changes in the structure and function of the brain that occur
during adolescence and young adulthood, there is greater potential for the environment to
affect development [32]. Maturational changes that occur in the structure of the brain are
associated with improvements in decision making and emotional regulation, as well as
decreases in disinhibition and impulsivity. It is due to the relative immaturity of these
regions of the brain that youth are more likely to engage in reckless and risky behaviors
[37,38]. Moreover, the period of rapid brain development during adolescence and young
adulthood helps to explain behaviors, such as poor decision making, recklessness behav-
iors, risk taking, and emotional outbursts, which are typical of this developmental period,
and are believed to reflect the periodic instability of the neural systems that are growing
and increasing in their sophistication, as well as control [37,38].
Generally, parents, teachers, and other significant adults assist adolescents and young
adults in their development of decision making and reasoning skills; however, homeless
youth often do not have access to supportive adult relationships. Consequently, they make
decisions about how and where to live during a time when their decision making and
problem solving skills are immature [39]. These youth are at greater risk of making bad
decisions and operating in high risk situations compared to their housed peers [40].
Few studies have examined cognitive functioning in homeless youth and most have
looked at young accompanied minors. The limited research in this area indicates that
deficits occur across multiple domains. Impairments have been found in visuomotor and
problems solving skills, judgment, logical thinking, and processing speed [41]. Addi-
tionally, studies of homeless children have found lower scores on tests of verbal abilities
[42]. Significant deficits in attention have also been observed in homeless youth with abuse
histories [41]. Because the current body of literature does not include longitudinal studies,
it is unknown whether cognitive deficits precede homelessness or is a consequence of it.
Studies that have examined the effects of poverty on cognitive functioning indicate that
factors common to homelessness and poverty, such as food insufficiency, negatively
impact cognitive functioning [43]. Additionally, some youth may be genetically predis-
posed for low cognitive ability, which may be further amplified by the stressors, and lack
of supports and resources characteristic of homelessness.
Although studies of homeless adults indicate that cognitive functioning improves once
individuals are housed, it is not known whether cognitive deficits in children and ado-
lescents improve if stable housing is achieved. Research that has examined the effects of
stress on cognitive functioning in children suggests that the effects may be permanent;
specifically, stress appears to increase the speed at which the prefrontal cortex develops
and stunts neural growth [44].
Academic Achievement
In contrast to the small number of studies that have examined the impact of homelessness
on neurocognitive functioning, many more studies have looked at the effects of home-
lessness on academic achievement and school performance; however, the findings from
these studies have been inconsistent. For example, some research indicates that homeless
youth experience high rates of suspensions, missed school days, and absenteeism, but
others studies have found that the rates of these problems are comparable to those found
among low-income youth [4548]. As such, some researchers contend that poverty, and
not homelessness, account for the pattern of academic problems observed.
One consistent predictor of academic difficulties among homeless youth is the high rate
of school mobility, the transfer from one school to another, in this population [45,49].
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Studies have repeatedly found that high rates of school mobility and poor school atten-
dance are associated with lower levels of academic achievement, which is predictive of
lower levels of academic success and school failure [50]. Stressful events that are common
among homeless youth, such as parental substance abuse and psychopathology, are also
associated with low levels of achievement [45]. Poor academic achievement is evidenced
by slower achievement growth rates and lower levels of achievement on standardized tests
in reading, spelling, math, and science [4648,50,51]. Additionally, a large number of
homeless youth fail and must repeat a grade [41,45,51]. In one study of children living in
a shelter, 45% had repeated a grade, 25% had failed a class, and 42% endorsed currently
failing or doing sub-par work [45]. These results were supported by another study that
found that twice as many homeless youth repeated a grade as housed youth [51].
For youth who struggle to meet academic demands, it remains unclear whether they
receive adequate support services, as findings from studies have been inconsistent. Several
studies indicate that homeless youth are more likely to be placed in special education
programs, but others have found that fewer homeless children receive the special education
supports that they need [45,47]. Some researchers suggest that the small number of
homeless youth who receive accommodations is due, at least in part, to the unmet need for
academic assessments that determine whether accommodations are needed [48].
As a result of this combination of difficulties meeting academic demands and the lack of
adequate support services, many homeless youth are at risk for school failure and dropout.
Some studies have found that as few as 20 to 30% of homeless youth graduate from high
school [1,52]. It is of note that the high school dropout rate appears to differ depending on the
region of the country being reviewed. In a study that examined the educational status of
homeless youth in multiple cities across the United States, while only 64% of homeless youth
in Austin and 54% in St. Louis were enrolled in or had graduated from high school, 88% of
homeless youth in Los Angeles were enrolled in or had graduated from high school [53].
Youth who do not graduate from high school lack not only a degree, which is often
required to attain a job, but also adequate job skills [52]. Large numbers of homeless youth
are, therefore, unemployed [52]. For youth who are able to find a job, they are more likely
to work in low paid, often menial jobs, without benefits or health insurance, and with
limited opportunities for savings. They are also less likely to be familiar with community
resources, as well as their legal and housing rights. To compound the issue, once people
turn 18 years old they are often unable to access free or affordable education [54]. In the
United States, many young people are supported by their parents well into their twenties. In
fact, in 2009, approximately half of all American young people aged 18–24 lived with their
parents [55]. Studies suggest that at least one quarter of youth receive some form of
financial support from their families [56]. The lack of financial support for homeless youth
can further compound the issues of homelessness and lead to extended periods of time
spent on the streets, with very limited resources or opportunities available.
Violence and Trauma
Research indicates that, compared to the general population, homeless youth are at a greater
risk of being the victims of violence [57]. As mentioned previously, many youth experience
trauma and abuse prior to becoming homeless. Whereas youth experience high rates of
physical and sexual abuse by family members prior to becoming homeless, many continue to
be victimized subsequent to becoming homeless, just by different perpetrators [20]. In one
study, homeless youth with a history of abuse prior to running away were more than twice as
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likely to experience verbal and physical abuse by a partner during adolescence and emerging
adulthood [25]. Females are at particular risk for violence and trauma [20].
As a result of physical assault and trauma homeless youth tend to endure more physical
injuries and psychological consequences than their housed peers. For example, homeless
youth have an elevated risk of acquired traumatic brain injury [59]. Living on the streets
also has been found to increase the risk of mortality by up to 11 times that of the general
population [58]. Psychological sequelae are also common in this population [20]. Trauma
has been associated with a range of negative psychological consequences that include
anxious and depressive symptoms, anger and irritability, and sexual concerns [20].
Health
Histories of abuse, unstable and often dangerous living situations, limited financial and
emotional resources, engagement in substance use and high-risk sexual activity, and
irregular patterns of sleep and eating contribute to the poor physical and mental health
commonly found among homeless youth [6063]. This population often has more
advanced illnesses than their housed counterparts due to the lack of prevention and early
intervention, which in turn results in illnesses that are more expensive and complicated to
treat [64]. These youth are at high risk for infectious diseases, such as influenza, hepatitis,
and sexually transmitted infections (STIs) [59]. Diabetes and dental problems are also
common in this population. Further, many homeless youth present with skin and respi-
ratory diseases, such as asthma and pneumonia, which are typically contracted while living
on the streets or in crowded emergency shelters [64].
Sexually Transmitted Infections
Another common health problem among homeless youth is sexually transmitted infections.
A substantial number of homeless youths engage in high-risk sexual behaviors, which
place them at greater risk of contracting STIs, including the human immunodeficiency
virus (HIV) [59,60,65]. Studies indicate that many homeless youth have sex with multiple
partners, as well as engage in unprotected sex, survival sex, and prostitution [23,6669]. In
one study, 70% of the sample endorsed unprotected sex in the past 3 months [70]. Other
research suggests that high-risk sexual behavior is associated with greater chronicity of
homelessness. In other words, individuals who experience more days of homelessness are
more likely to engage in high-risk sexual behaviors [71]. Homeless youth also make their
sexual debut 2–3 years earlier, at 12 to 13 years-old. Consequently, they are more likely to
engage in high-risk sexual behavior for longer and are more likely to contract an STI
[1,23]. In fact, the prevalence of HIV is 3 to 30 times higher among homeless youth [72].
Gender differences in STIs have been observed in many studies. Research indicates that
STI rates range from 11.3% in males to 62.7% in females [52,73]. This may be accounted
for by higher rates of unprotected sex among females, which has been found in some
studies [74]. Whereas high-risk sexual behavior in females appears to be associated with
lower levels of self-esteem, in males it is associated with poor decision-making skills [70].
In order to better understand the factors that contribute to the high rates of STIs among
homeless youth, recent studies have examined the influence of social networks on sexual
risk-taking behaviors [74,75]. These studies have found that a larger network of peers who
engage in pro-social behavior (i.e., have more friends who attend school, have jobs, and
get along with their parents) is associated with lower levels of engagement in risky sexual
behaviors among homeless youth [74]. The same study found that problematic social
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networks do not contribute to high-risk sexual behaviors [74]. Another aspect of social
networking that has been studied is the use of the Internet to maintain social relationships.
Rice et al. [75] found that youth who used the Internet to communicate with their street
peers were more likely to seek exchange sex; and youth who engaged in exchange sex were
more likely to seek partners online. Consequently, these youth were at the highest risk for
contracting HIV. In contrast, use of the Internet to maintain relationships home-based social
networks was associated with significantly less risk [75]. More specifically, individuals who
communicated with family members were significantly less likely to seek sex exchange and
more likely to have been recently tested for HIV. Recent HIV testing was also associated
with communication with home-based peers [75]. Overall, these studies found that the
social networks of homeless youth are more diverse than previously believed and that their
makeup can significantly affect high-risk behaviors and exposures to STIs [74,75].
Substance Use
Studies have consistently found that substance use is more prevalent in homeless youth
than housed youth [6,23,62,76]. The high rates of use are consistent across geographical
regions, cultures, and ethnicities [19,62]. Both episodic heavy use and poly-substance use
is common [77].
The prevalence of substance use varies across studies, and ranges from 70 to 90% [23,
76,78]. A recent study conducted in San Jose, California compared the drug use of 42
homeless youth with a high-school sample and found that levels of substance use were
twice as high among homeless youth [76]. Interviews with the youth revealed that 88% of
participants currently used at least one substance, with the most common being alcohol
(76%), tobacco (76%), and marijuana (69%). More than a quarter of homeless youth
reported methamphetamine use and smaller numbers used cocaine, LSD, heroin, and
ecstasy. Using the Rutgers Alcohol Problem Index (RAPI), a modified structured clinical
assessment tool, Ginzler et al. [77] found even higher rates of substance use. Ninety-four
percent of participants used tobacco and alcohol, 97% used marijuana, 73.4% used
amphetamines, 55.5% used crack/cocaine, and 39.5% used heroin in the past year.
Various factors, such as gender, length of homelessness, and age influence substance
use patterns. For example, more males than females use alcohol, marijuana, cocaine, meth,
and crack [68,79]. While gender differences exist for substance of choice, most research
indicates that the prevalence of substance use disorders is similar in men and women [80].
Age is another factor that influences substance use patters. A study of drug use in an older
(C21 years-old) and younger (\21 years-old) sample of street youth found that whereas
older youth were more likely to use crack and engage in injection drug use, younger youth
were more likely to have engaged in binge drinking [79]. Other studies have also found
that older age is associated with higher levels of heroin use and lower levels of marijuana
use [81]. Length of homelessness also affects substance use; increased length of home-
lessness is associated with higher rates of substance use [82].
Youth not only use substances regularly, but many also meet criteria for substance use
disorders. For example, Ginzler et al. [77] reported that 86.1% of the 197 homeless youth
sampled met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-
IV) criteria for dependence or abuse for at least one substance, including alcohol, over the
past year. More specifically, 57.8% met the DSM-IV criteria for an alcohol abuse or
dependence diagnosis, 56.1% endorsed marijuana abuse, 38.1% reported amphetamines/
cocaine abuse, and 18% met criteria for heroin abuse [77].
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The use of substances is also more frequent, heavier, and begins earlier, with factors such
as age, gender, and length of homelessness seeming to influence patterns of use [69,78,83]. In
a sample of 285 homeless youth, participants used substances a mean of 22.7 days out of the
previous 30 days [40]. Other studies have found that a little less than half of homeless youth
use substances regularly, with approximately one-third of youth using substances on a daily or
weekly basis [69,84]. Many homeless youth also engage in heavy use, which includes the use
of multiple substances, large quantities of substances, and intravenous drug use (IDU). In fact,
a recent study found that 33.8% of homeless youth abused multiple substances in the past
3 months [84]. Intravenous drug use is relatively less common, but studies indicate that a
notable number of homeless youth use drugs intravenously. For example, Carlson et al. [66]
found that 25% of the participants in their sample had engaged in IDU in the past 3 months.
Although homeless youth often begin to use substances in their pre- and early teens, IDU
typically is delayed until the late teens or early twenties [18,62,85].
As with risky sexual behavior, drug use is associated with social networks. Research has
found that a large number of problematic peers (i.e., peers who are gang involved, steel,
have been arrested, or have overdosed) put youth at particular risk for engaging in heavy
drug use [74]. Further, a larger number of face-to-face relationships relative to other
homeless youth who use drugs is associated with heroin, methamphetamine, alcohol, and
marijuana use [75].
The high rates of substance use have proven to be detrimental. In addition to the direct
risks of substance use, homeless youth who use substances are more likely to experience
mental health sequelae, such as depression and anxious coping, and engage in other high-
risk behaviors [78,86,87]. This, in turn, puts them at risk for various health problems.
Specifically, individuals who engage in IDU are at increased risk for contracting HIV [86,
87]. Substance use also increases the likelihood that individuals will engage in risky sexual
behaviors. This puts them at risk for STIs, as they are less likely to use a condom, as well
as more likely to have sex with a larger number of partners and partners who are ‘‘high-
risk’’ [68,78,88]. In fact, research suggests that substance use is a strong predictor of HIV
[89,90]. Further, substance use is associated with higher levels of psychological distress,
which is already a problem for many homeless youth [38,91].
Mental Health
The literature has consistently reported high levels of psychiatric disorders among homeless
youth including depression, anxiety, substance use, posttraumatic stress disorder, and
psychosis [92]. The lifetime prevalence of psychiatric disorders is almost as twice as high
for homeless youth compared with their housed peers [80,93]. A study of 364 homeless
adolescents in Seattle, aged 13–21 years (mean age 16.4 years) used standardized measures
to assess mental health status [1]. Youth were assessed using the Diagnostic and Statistical
Manual-III-Revised version (DSM-III-R) categories, the Youth Self Report (YSR), and
other standardized indices of anxiety, depression, and self esteem [94,95]. The researchers
found that the overall rates for psychiatric disorders of were high, with two thirds of the
sample having at least one diagnosis based on the DSM-III-R criteria [1]. More specifically,
53% met the criteria for Conduct Disorder or Oppositional Defiant Disorder, 32% for
Attention Deficit Hyperactivity Disorder, 21% for mood disorders, 21% for mania or
hypomania, 12% for Post Traumatic Stress Disorder, and 10% for Schizophrenia [1].
Clinically significant anxiety and mood disorders are particularly prevalent in this
population [41,42,52]. One of the most common anxiety disorders among homeless youth
is Post Traumatic Stress Disorder, with studies indicating that one-quarter to one-third of
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homeless youth meet criteria for this disorder [52,96]. Mood disorders, including Major
Depressive Disorder and Bipolar Disorder, are also prevalent among this population. A
study by Busen and Edgebretson found that 41% of this population met the criteria for
Major Depressive Disorder [52] and 41% met the criteria for Bipolar Disorder. When
compared to males, females were more likely to be diagnosed with anxiety and affective
disorders, 42 and 28% versus 21 and 12%, respectively [80].
Given the high rates of mood disorders that are reported in the literature, it is perhaps
not surprising that there are also markedly high rates of suicidal ideation, attempts, and
completed suicide [93,97]. While some pre-existing mental and physical health problems
associated with abusive and neglectful pre-street backgrounds may contribute to suici-
dality, these issues are typically intensified by the high risk lifestyle of street living [4].
Substantial variability in suicidal ideation and attempts has been noted across studies was
noted [93]. In a 2001 review, 40–80% of homeless youth endorsed suicidal ideation and
23–67% reported that they had attempted suicide [93]. The findings of more recent studies
are comparable [52,62]. For example, in a study of 100 homeless males aged 16–19 years
in Ottawa, 21% reported a past suicide attempt, while 43% reported lifetime suicidal
ideation [98]. This large discrepancy in prevalence rates may be due the absence of a
consistent definition of a ‘‘true’’ suicide attempt. In particular, inclusion of non-fatal self-
harming behaviors and thoughts in the operationalized definition of suicidal ideation or
attempt may inflate numbers in some studies [93]. Alternatively, the discrepancy may be
due to the lack of a consistent timeframe around the suicide attempts and ideation.
Similar to the high rates of internalizing symptoms (i.e., mood and anxiety disorders),
disruptive behavior disorders and externalizing disorders are also prevalent among
homeless youth. The overall rates of disruptive behavior disorders suggest that the majority
of homeless youth meet criteria for at least one of these disorders. Some studies indicate
that approximately three-quarters of homeless youth meet life-time criteria for Conduct
Disorder [42,96,99]. Attention Deficit Hyperactivity Disorder is also common, with one
study finding almost one third of participants meeting criteria for diagnosis [52]. The
relative prevalence rates of disruptive behaviors disorders is also notable, as research has
suggested that they are four times more common in homeless youth than housed youth
[42,96,99]. In contrast to the gender differences that exist in internalizing symptoms,
males are more likely to be diagnosed with externalizing disorders [80].
Many homeless youth meet the criteria for multiple diagnoses [80,93]. One study found that
the rates of dual diagnoses (comorbid substance-use and other psychiatric disorders) among
homeless youth ranged from 35 to 38% [23,80,93]. A more recent study found even higher
rates of comorbidity, with 76% of the sample meeting criteria for multiple diagnoses [52].
Notably, the assessment of mental health problems in homeless youth is problematic for
various reasons. First, it is often difficult to determine whether a homeless person’s mental
status is caused by a pre-existing mental disorder, the demands of homelessness, chronic
stress, substance abuse, or a combination of these factors [100]. The assessment tools that
are employed in studies to diagnose psychiatric disorders may also contribute to some of
the inconsistent findings in the research. Whereas some studies use non-standardized
scales, others use a small subset of questions from standardized or other scales, in a
piecemeal fashion. As such, the reliability of the assessment tools may be poor. It is of note
that the research that does use standardized measures consistently reports higher rates of
psychiatric disorders among homeless youth relative to those who are housed [101].
Moreover, some studies conceptualize psychiatric symptoms as continuous variables and
do not indicate whether criteria have been met for a psychiatric diagnosis. In contrast,
others use psychiatric diagnoses.
Child Psychiatry Hum Dev
123
There are many factors that have been implicated in the development of mental illness
among homeless youth. These include external factors that predate the homelessness
including: lack of parental care, sexual and physical abuse, parental conflict, and parental
psychiatric disorder [102]. Individual characteristics, such as resilience, have also been
associated with lower levels of psychological distress more broadly [103]. Other factors
that occur subsequent to a homeless episode, for example, social support, substance use,
and length of homeless episode, also have been linked to psychological distress and mental
illness [102,103]. Gay, lesbian, and bisexual homeless youth also report higher rates of
depression and suicide attempts than their heterosexual counterparts [89]. Additionally, it
is notable that some of the behaviors and activities in which homeless youth engage can
affect emotional well-being. For example, a history of survival sex, which is common
among homeless youth, is predictive of depressive symptoms [104]. It is unclear whether
these symptoms precede the lack of housing or are the effect of the chronic stress of being
homeless on emotional, intellectual, and behavioral processes [30]. A better understanding
of the temporal order of these factors would be helpful in guiding future intervention
research.
Access to Health Care
Despite the high rates of health related concerns faced by homeless youth, they are often
disinclined to access services [101]. Various factors appear to contribute to their reluc-
tance. Homeless individuals as a group must contend with multiple barriers to accessing
healthcare, which can be financial, structural, or personal in nature [9]. Common financial
barriers include a lack of health insurance and an inability to pay for transportation [9,68,
82,105]. One study, for example, found that 65% of homeless youth did not have health
insurance [52]. Although free health insurance (e.g., Medicaid) and free healthcare is
available, fulfilling eligibility requirements is often complicated by structural factors, such
as an inability to show evidence of a fixed permanent address, birth certificate, or photo
identification [105]. Some studies suggest that homeless youth are reluctant to access
healthcare services, because of difficulty navigating the healthcare system, few clinic sites,
lack of coordination among providers, specific hours for homeless youth, and long wait-
lists [9,106,107]. Additionally, many of the clinics that serve homeless individuals
integrate child and adult services, which some homeless youth reports makes them
uncomfortable [9].
Homeless youth may also be unwilling to seek professional health care for more per-
sonal reasons, such as embarrassment and lack of knowledge [82]. In fact, one study of
homeless young people aged 14–24 years-old found that participants were most likely to
seek health advice from other homeless youth. This was followed by self-treatment and, if
self-treatment failed, then individuals accessed health clinics [108]. The negative beliefs of
homeless youth about the health care system appear to be due, in part, to a fear that they
will encounter discriminatory attitudes and negative judgments by health professionals [9,
107,109]. These concerns might be warranted, as research with medical students has
indicated that they hold more negative attitudes towards homeless people at the end of their
medical training than when they began [110]. Another reason that many youth do not
access healthcare is that they do not believe that they have a problem or need help
[82,106]. This appears especially true of youth with substance use problems.
Prioritization of treatment for certain disorders is cited as another barrier to health care
services [107]. Many youth report that some medical and mental health conditions, such as
Child Psychiatry Hum Dev
123
bipolar disorder, receive priority care and result in a lack of services for individuals with
other problems. As a result, youth with less critical and dangerous symptoms are less likely
to receive care [107].
In contrast to the findings that suggest that homeless youth are reluctant to access
healthcare services, some studies have found that if services are accessible, youth will use
them. This is particularly true for experienced homeless youth [82]. For example, one study
found that 99% of participants in the study used healthcare services in the past 3 months
when it was readily accessible [66]. Youth appear to access services primarily for preg-
nancy, mental health issues, trauma, STIs, and substance use problems, as well as chronic
conditions and dental problems [9]. Unfortunately, because many youth do not seek health
care early, they are at risk for more serious health concerns and emergency situations.
Youth are also more likely to seek services at agencies that cater to or specifically serve
homeless youth [107]. Additionally, support and information from family, friends, and
other homeless youth support help-seeking behaviors [107]. Improving access by mini-
mizing barriers may ultimately lead to improved mental and physical health among this
population.
Intervention and Prevention Programs
Despite the numerous studies that show homeless youth are an uniquely vulnerable pop-
ulation, with high rates of mental health, physical, and substance use problems, few pre-
vention and intervention studies exist. In a review of the intervention literature, Slesnick
et al. [111] found 12 studies that evaluated treatment effectiveness. These studies targeted a
variety of different outcomes. Five studies looked exclusively at STD or HIV interventions.
Two studies examined drug and alcohol use. Four studies included mental health out-
comes. Five of the studies included interventions that targeted multiple areas of func-
tioning [111]. The authors further categorized these studies into case management and
vocational training interventions, substance use interventions, and STD/HIV prevention
and intervention programs.
The findings indicated that overall the interventions currently available ineffectively
address the various risk factors and presenting problems confronted by homeless youth.
This may be attributed, in part, to the targeted nature of many studies [111]. Homeless
youth face a variety of stressors and risk factors from a lack of basic necessities, such as
inadequate food and shelter, to more complex psychological and medical problems.
Interventions that target only one aspect of an individual’s life will likely not effect
meaningful change; rather, a more holistic approach to intervention is required [111].
Moreover, given that homeless youth frequently report that poor coordination of services
impedes their access to care, interventions that incorporate and synchronize services may
be more effective [9,106,111]. Another finding was that motivational interventions
appeared to be ineffective with street youth. General distrust of service providers and
complex presenting problems likely require longer-term interventions that allow for the
development of more trusting relationships with providers, as well as time to address the
range of issues with which homeless youth present [111].
A more recent review of the literature retrieved only 11 intervention studies [112]. This
also encompassed various types of treatment: case management, independent living, brief
motivational interviewing, cognitive behavior therapy, living skills, supportive housing,
and peer-based interventions. Outcome measures were also varied and included service
utilization, housing, employment, educational achievement, days homeless, life domains,
Child Psychiatry Hum Dev
123
social support, and general health [112]. Based on the U.S. Preventive Services Task Force
Work Group rating system, which assesses intervention definition, use of an appropriate
control group, random assignment, and psychometric soundness of the measures, among
other factors, seven of these studies were considered to be of poor quality [112]. In addition
to the poor quality of the studies, the heterogeneity of the interventions, participants,
methods, and outcome measures precluded the possibility of significant findings [112]. The
authors also observed that most intervention studies of homeless youth examined substance
use and have not considered issues of well-being, quality of life, living skills, and social
support [112].
Even if current prevention and intervention programs were effective, numerous chal-
lenges to implementation exist [113]. In particular, there is a notable lack of awareness of
the problem of homelessness among at a local level, which makes it difficult to serve them.
Additionally, funding for prevention and intervention programs is scarce, especially during
economic downturns [113]. The lack of knowledge and funding has made it difficult to
develop and subsequently implement prevention and intervention programs [113]. None-
theless, high quality research is needed to develop effective, empirically-supported pre-
vention and intervention programs [112].
Research: Limitations and Ethical Issues
Limitations
Although there is growing body of literature in the area of homeless youth, it is weakened
by a variety of limitations. First, studies lack theory and consistent definitions of home-
lessness [21]. Variations exist in what qualifies individuals as youth and homeless (e.g.,
street youth, youth who live in shelters, youth who live in unstable housing with family or
friends), as well as in length of homelessness [21,41,50]. These differences may affect the
nature of the sample and the generalizations that can be made from the results of the
research.
A second limitation of the current research pertains to data collection. Many studies
have utilized measures that are not psychometrically sound and are, consequently, fun-
damentally problematic. Whereas some measures are not reliable or valid, others have not
been standardized for use with homeless youth [21]. Another failing of the current research
is that it rarely employs multi-method, multi-informant data collection [21]. In particular,
many studies use self-report measures without incorporating other methods of data col-
lection [3,38,85,104]. The inclusion of informants is perhaps the more difficult problem
to address, as parents frequently act as informants for minors; however, this can put
homeless youth at risk and may be ill-advised. As such, gathering data from other indi-
viduals with whom the youth is in contact, such as friends, acquaintances, social workers,
and case managers, may be one way to provide a more multidimensional understanding of
homeless youth.
Third, most studies of homeless youth have not used comparison groups; therefore, it is
unclear how homelessness or interventions relatively affect youth [21]. Haber and Toro
recommend that studies compare homeless youth to youth who face extreme levels of
poverty. They also suggest that studies could look at normative experiences of childhood,
adolescence, and emerging adulthood and compare homeless youth with a matched sample
[114].
Child Psychiatry Hum Dev
123
Concerns about participant samples are a fourth weakness of the homeless youth lit-
erature. Many studies use convenience sampling, which has produced rather homogeneous
study populations [3,38,53,62,71,78,80,85,111]. For example, many studies only
examine homeless youth in one city, one shelter in one city, or one subgroup of homeless
youth [45]. Studies conducted in different cities suggest, however, that homeless youth are
a heterogeneous population [53]. In fact, diversity exists with regard to a variety of dif-
ferent factors, including demographic data, degree of transience, level of education, and
substance use and addiction, among others [53]. Further, samples are frequently not ran-
dom [84,106]. For example, some samples include only individuals who seek medical and
mental health care [52,71,84,106]. These factors, in conjunction with small sample sizes
and high attrition rates, limit researchers’ ability to generalize results [2,71,85,89].
Nevertheless, the transient and covert nature of homelessness in unaccompanied youth has
made it difficult to assemble samples that reflect the overall population, as well as to gather
accurate information about their numbers and characteristics, particularly over time
[14,21,50,104]. Some researchers suggest that these obstacles may be insurmountable [14].
Ethical Issues
In addition to the numerous practical factors that make it difficult to conduct research with
homeless youth, there are also a variety of ethical considerations that have made it
uniquely complex and challenging to work with this population. These range from over-
arching issues such as the lack of guidelines to more specific aspects of conducting
research with unaccompanied minors. Cumulatively, it is likely that the various barriers
have made it too difficult for some researchers to pursue this type of work and, therefore,
has limited the current knowledge base.
One of the primary difficulties in working with homeless youth is the lack of guidelines.
That is there are no specific recommendations to guide research beyond those developed
for work with vulnerable populations [115]. Investigators and institutional review boards
(IRBs) may be uncertain about how best to protect the rights of participants. Although
researchers may refer to precedent when structuring and submitting their project, IRBs
often disagree with these solutions and may be reluctant to provide effective alternative
solutions [115].
Other, more specific methodological issues also exist. For example, concerns about the
consent and assent process often arise. Whereas most research with minors requires that a
parent or guardian provide consent and that youth provide assent, many researchers who
work with homeless youth believe that this population should be able to consent for itself
[115]. They contend that if 14 year-olds can consent for medical and mental health
treatment, then they should be able to consent to participate in studies [116]. Studies also
indicate that 14 year-olds are developmentally able to make informed decisions about
participation in research that is comparable to adults [116]. Although this may be the case,
few studies have examined the effects of participation in research without parental consent
[116]. Another reason to allow youth to provide consent is that the prerequisite of parental
consent may not only preclude many youth from participation, but it may also pose a
danger to some youth, particularly for those who left home to escape abuse [116]. To
address this issue of consent, some researchers request a waiver of parental consent [115].
For youth who reside in shelters, an advocate from the agency may be asked to provide
consent and confirm that the youth understand the assent form [See 117]. Another tactic to
encourage involvement in research is the use of oral consent. This may be appropriate
when the risks of the research are minimal, as it allays concerns about confidentiality [115].
Child Psychiatry Hum Dev
123
When taken together, these methods help to simultaneously preserve the rights of partic-
ipants and facilitate participation.
The use of incentives, specifically questions concerning the type and quantity of
compensation, is a frequent concern among those who study homeless youth. Researchers
have used various kinds of incentives including: money, gift cards, and food [115,116].
Concerns about the use of money as compensation are many. For youth who have very
little money, even a small amount of money may be coercive [116]. Additionally, given the
high rates of drug and alcohol use in this population, questions about the appropriateness of
money as an incentive have been raised [115]. If money is to be used, there is no consensus
about a proper or reasonable amount [115,116]. There is also no agreement about the
ethical use other types of incentives or whether incentives are appropriate at all, as any type
of incentive may be seen as coercive with this population [115]. Yet, participation in
research is needed to better understand and serve these youth. One way to address this issue
is to bring together homeless youth, individuals who work with these youth, and
researchers who specialize in this area to discuss proper and desired incentives [116]. A
community group such as this should address how to most appropriately encourage par-
ticipation and compensate participants without coercion.
In addition to ethical questions that exist with regard to methodology, there are also
issues that pertain to the role of the researcher and the nature of his or her relationship with
the youth. In many instances, the researcher is also a clinician—either a physician or
psychologist—who also may see the participant in the context of treatment. As such, a dual
relationship may occur [116]. The line between the role of the researcher and the clinician
may become blurred, which can result in a coercive relationship. This is a particular
concern given the inherent power differential in the relationship between the provider and
the patient, as well as between the researcher and participant [116]. Also unclear is the
degree of confidentiality that the researcher can guarantee. Unlike the clinical relationship
in which providers, particularly psychologists and psychiatrists, are trained to communi-
cate from the outset the limits of confidentiality in cases of suicide, homicide, and child
abuse, these exceptions are often not stipulated in consent forms [116]. Research with
homeless youth, however, frequently inquires about these issues. In the case of researchers
who have a dual relationship with a participant-patient, a youth may share information in
one context that he or she may not have shared in other. This raises the ethical dilemma
about how much confidentiality researchers can promise [116].
Conclusions, Implications, and Future Directions
Despite the large number of homeless youth in cities across the country, they are often
forgotten as they are out of view, living in temporary shelters or with friends and relatives.
Not only do these youth experience unstable housing, but most have faced extraordinary
adversity prior to their homelessness. Many youth have contended with economic hardship,
abuse, neglect, and a breakdown of the family. These experiences often lead to myriad
negative neurocognitive, academic, and health sequelae. The adverse outcomes of home-
lessness are often further exacerbated by the various barriers to healthcare services that
these youth face. As such, many homeless youth are at particular risk for more serious
physical and mental health problems.
Although a large number of gaps in the literature exist, there are several areas that are
particularly wanting. There is a paucity of research in the area of cognitive and psycho-
social development and functioning in homeless youth. Studies are needed that advance
Child Psychiatry Hum Dev
123
our understanding of the impact of homelessness on the unfolding of cognitive skills,
behavior, psychiatric functioning, and social networks. A better understanding of these
factors and the interplay among them will serve to guide the development of targeted
interventions that promote adaptive functioning.
One example of research in this area is a study currently being conducted by Hunter
et al. at the University of Chicago. Specifically, they have developed a biopsychosocial
model of high-risk behavior, which they are testing in a set of studies that examines
neurocognitive functioning and psychiatric functioning. By comparing the neurocognitive
functioning of homeless youth to the norms of the general population, as well as to other
groups that have known neurocognitive impairments, the study will be able to provide a
better understanding of the patterns of deficits in this population. The findings from this
study will provide information that will be used to inform interventions that target cog-
nitive functioning and coping skills.
The literature would also benefit from additional well-designed and well-implemented
studies is the area of prevention and intervention. This is broadly needed across areas of
medical and mental health, education, and adaptive skills. Given that targeted interventions
that focus on a single domain have proven ineffective, research that examines the effec-
tiveness of more holistic interventions is warranted [111]. Additionally, interventions that
help youth develop skills that support age-appropriate and healthy functioning across areas
may also be beneficial. Hunter et al. are developing an intervention designed to support the
acquisition of decision-making skills and improved executive functioning. The goal is that
this will lead to improved adaptive skills, decreased engagement in risky behaviors, and
consequently, lower levels of medical and mental health problems.
In addition to studies that areas address gaps in the literature, higher quality studies also
are needed. To do this, the fundamentals of research with homeless youth need to improve.
Researchers need to move beyond convenience samples and recruit from multiple sources
and preferably from multiple cities so that the findings generalize more broadly. Multi-
method, multi-informant data collection would further strengthen the studies. Moreover,
the measures employed should be psychometrically sound and appropriate for use with this
population. Longitudinal studies also would enhance our understanding of the experience
of homelessness, its impact on development, as well as the long-term effectiveness of
treatments.
Studies that implement innovative methodologies are also needed to better understand
the experience of homeless youth, as well as to provide effective services. Some
researchers have begun to do this [117,118]. As the majority of homeless youth use the
internet, technology of various kinds has been used to collect data [75]. Technology has
been employed to enhance our understanding of social networks and high-risk behaviors,
as well as more general behavior patterns and healthcare use. In two studies that used
online technology to evaluate the sexual behavior of homeless youth, increased time online
and use of online social networks were associated with increased exchange sex and
partner-seeking. They were also associated with some positive outcomes, including
increased awareness and implementation of HIV/STI prevention [75,117]. Additionally,
technology may be incorporated into intervention and prevention programs to support and
facilitate utilization of resources. It has already been used to better understand the ways in
which social networks could be incorporated into prevention programming [117]. In one
such study, networking technology was used to cultivate and support positive peer inter-
actions, which are important for peer-based prevention programs [117]. Intervention
research would benefit from examining other ways to employ technology to increase the
utilization of medical and mental health services among homeless youth.
Child Psychiatry Hum Dev
123
Most of the research with homeless youth to date has focused on deficits, pathology, and
problems. These factors may not only be orthogonal to more positive constructs such as
well-being and quality of life, but they do not capture the strengths of individuals. As a
result, it remains unclear whether individuals who become homeless or the experience of
homelessness unique sets of strengths. These positive attributes could potentially be
exploited for prevention and intervention programs. As such, future studies may benefit
from a focus on positive traits of homeless youth and positive outcomes.
Ultimately, homeless youth are a difficult population with which to conduct research, as
evidenced by the current state of the literature. Because these youth are marginalized, there
is a lack of awareness, particularly at the local level, about this population. This contributes
to a lack of funding to support studies that improve our understanding and treatment of this
population. The unseen nature of homeless youth also likely contributes to the inadequate
number and range of services to support homeless youth. Despite the multiple technical
and funding challenges in studying homeless youth, they are very much in need of
improved knowledge of their experience and services. By aggregating and qualitatively
synthesizing the findings from studies to date, we hope to raise awareness about this
population and the need for additional research. Researchers, in turn, will need to employ
creative techniques to study, assess, and treat these youth.
Summary
This paper examined youth homelessness in the United States with the goal of organizing
the current body of research. Homeless youth are a diverse population and have been
described in numerous ways in the literature. Inconsistent definitions of homelessness and
the utilization of diverse methodologies to study homeless youth make it difficult to
synthesize the current research and draw conclusions about the issues they face.
Studies of homeless youth fall into four main content areas: (1) causes of youth
homelessness, (2) characterizations of homeless youth and the implications of youth
homelessness, (3) healthcare, and (4) prevention and intervention programs. Research
indicates that numerous factors contribute to youth homelessness. These include family
breakdown, disruptive family relationships, and trauma and abuse. LGBT youth and
individuals involved in the foster care system also are at particular risk for homelessness.
Homeless youth are at risk for numerous adverse consequences. Specifically, neurocog-
nitive development, academic achievement, violence and trauma, and health all appear to
be negatively impacted by the experience of homelessness during childhood and adoles-
cence; however, the directionality of the relation between homelessness and these negative
outcomes has not been studied. Although substance use, medical problems, and psychiatric
disorders are prevalent in this population, homeless youth are often unwilling to seek
professional help due to difficulties accessing adequate, developmentally-appropriate, and
affordable health care. Few prevention and intervention studies have been conducted
despite the strong evidence that homeless youth are an uniquely vulnerable population; and
the quality of many of these studies is quite poor.
The current body of research has been limited by a variety of factors. In particular, a
lack of theory and inconsistent definitions, as well as methodological and psychometric
weaknesses, have played a role in the current state of the literature. Further, various ethical
challenges also have made it difficult to work with this population and have likely con-
tributed to the gaps in the literature. There are several areas that would particularly benefit
from future research. These include studies that examine the impact of homelessness on
Child Psychiatry Hum Dev
123
development, prevention and intervention programs, and positive characteristics of
homeless youth, among others. By reviewing and synthesizing the literature in the area of
youth homelessness, we hope that this paper brings attention to this population, as well as
precipitates additional research and funding.
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... Introduction Approximately 1 in 10 transitional age youth (TAY) between the ages of 18 to 24 experience homelessness every year in the United States (US), representing 3.5 million youth annually [1]. Prior research has consistently demonstrated an increased prevalence of mental health disorders among this population, including high rates of depression, anxiety, substance use and post-traumatic stress disorder (PTSD) [2][3][4][5]. Overall, the lifetime prevalence of psychiatric conditions among youth experiencing homelessness is twice that of their stably-housed peers [6]. Further, unstably housed TAY experience high rates of co-occurring substance use disorders with either anxiety, or affective disorders including major depressive disorder or bipolar disorder, a phenomenon known as dual diagnosis [7]. ...
... Studies have also demonstrated that suicidal ideation and attempt are markedly higher among unstably housed TAY. For instance, 40% to 80% of homeless youth report suicidal ideation, and 23% to 67% report at least one prior suicide attempt [3,6,8,10]. In San Francisco, one study found that the mortality rate among homeless TAY was 10-fold higher than stably-housed, age-matched peers, largely due to increased deaths from suicide and conditions associated with severe substance use disorder [11]. ...
... Results from the bivariate Poisson regression models are presented in Table 4. In adjusted Poisson regression models (1)(2)(3)(4)(5), those with symptoms of moderate or severe anxiety in the past two weeks were more likely to be at risk of clinical depression compared to those with minimal or mild symptoms of anxiety (adjusted risk ratio [aRR] = 1.62, 95% confidence interval [CI] = 1.23-2.12, P<0.001). ...
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The objective of this study was to identify the correlates of being at risk of clinical depression and examine the role of syndemic factors among marginally housed and homeless transitional age youth (TAY). From 2017–2018, 100 TAY between the ages of 18 and 24 in San Francisco were recruited from Larkin Street Youth Services into a cross-sectional study. Participants completed surveys on mental health, substance use, and HIV risk behaviors. A syndemic score ranging from 0–3 was calculated by summing dichotomous measures of moderate or severe anxiety in the past two weeks, PTSD symptoms in the past month and polysubstance use in the past three months. We used modified Poisson regression with robust error variances to identify the correlates of being at risk of clinical depression in the past week, all primary effects measures were modeled separately. Among 100 participants, the average age was 21 (SD = 1.7), 67% were male, 38% were Multiracial, 54% identified as gay, lesbian, bisexual or pansexual, 13% were unstably housed, 50% were homeless and 23% were living with HIV. The majority (74%) were at risk of clinical depression, 51% had symptoms of moderate or severe anxiety, 80% exhibited symptoms of PTSD and 33% reported polysubstance use. After controlling for age in years, gender, race/ethnicity and sexual orientation, factors independently associated with being at risk of clinical depression were; symptoms of moderate or severe anxiety (adjusted risk ratio [aRR] = 1.62, 95% confidence interval [CI] = 1.23–2.12, P
... The incidence of physical harassment and the high rate of trauma in these people have always been discussed. Findings of studies also show that substance abuse, sexually transmitted infections, childhood traumas, and gender are significantly associated with sexual assault among women and different types of injury and victimization in men [11,24,25]. Evidence also showed a high prevalence of drug abuse and another gender status among young people with a history of sexual abuse. ...
... Lack of insurance, expensive services, and limited services for this group are why they do not refer to receive medical services. The results also show that homeless people face significant barriers such as perceived structural (limited clinics, limited hours of activity, prioritized health conditions, and long waiting times) and social barriers (discrimination perceived by indifferent professionals, executives, and society) that impede their access to health care services [8,25,31]. Homeless people have always perceived many problems and experiences and have become part of today's society. The irresponsibility of governmental organizations and institutions has made charitable institutions important. ...
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Introduction Homelessness is increasing among young adults in large cities. According to the United Nations, there are more than one billion absolute or relative homeless people in the world. This study was conducted to explain the lived experiences of homeless youth in southeastern Iran. Materials and methods In this qualitative study, we recruited 13 participants in a big city, southeast Iran, in 2020. The participant was young homeless adults aged 18–29 years who were using homeless shelters provided by the municipality, sleeping in parks or on streets. Data were collected through in-depth and semi-structured interviews and three focus group discussions. Data were analyzed by conventional qualitative content analysis. Results The main category of “lonely, annoyed, and abandoned in society” and three subcategories of avoidance of/by society, comprehensive harassment, and lack of comprehensive support were extracted. The experiences of young homeless adults showed that they escaped from the community due to addiction, feeling like a burden to others, and social isolation, and not only have they been left without support in society, but they have also suffered from all kinds of physical and psychological harassments. Conclusion The lived experiences of homeless people show that in addition to appropriate facilities and living conditions, they require respect, reduced social stigma, discrimination, and favorable conditions for a return to life. Therefore, authorities should identify and settle their problems and needs.
... Homeless young adults are more likely to; initiate sex earlier (Ammerman, 2013;Maria et al., 2020;Misganaw & Worku, 2013), have multiple partners, use substances during sex, and are less likely to use a condom for varied reasons including desire for unprotected sex, inaccessibility, cost, and/or partner's disapproval of condom use (Ammerman, 2013;Edidin et al., 2012;Hudson & Nandy, 2012;Tevendale et al., 2008;Thompson & Pollio, 2006). ...
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Background Homelessness has become a major global and public health challenge, especially in low- and middle-income countries. This phenomenon predisposes young adults to severe psychosocial and health challenges. Aim To explore the sexual and reproductive health needs and behaviours of homeless young adults and challenges in accessing these services. Methods A semi-structured interview guide was used for data collection from in-depth interviews, focus group discussions, and key informant interviews. Data were collected between 01 June and 31 July 2020 from 30 participants using in-depth interviews, two focus group discussions involving 12 participants, and one key informant interview. Thematic analysis was used to analyse transcripts from the interviews. Results The findings show that certain behavioural patterns associated with homelessness impact the lives of homeless young adults in their sexual and reproductive health (SRH) choices, beliefs, and perspectives. This group faces several challenges in accessing sexual and reproductive health services (SRHS) such as modern contraceptives and abortion care. The high cost, and undesirable and unfriendly attitude of service providers in health facilities pose as barriers to accessing SRHS by homeless young adults. Conclusion Sustainable and proactive measures must be put in place to address the identified barriers. Timely delivery of accurate information and educative materials, ensuring affordability, and setting up of accessible and friendly facilities could improve SRHS for this group. Social and Public Policy Implications This study may inform and support policy guideline development to address homelessness and SRH needs of young adults in urban Ghana.
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Homelessness poses risks to the health and safety of young adults; particularly among sexual and gender minority (SGM) young adults. The current study sought to better understand service use and perceived safety in community and service settings among SGM and cisgender heterosexual (cis‐hetero) young adults experiencing homelessness. Data come from a mixed‐method, ecological momentary assessment study (n = 80; 43% sexual minority; 10% gender minority) in Los Angeles, California. Participants reported their current location (service vs. nonservice setting) and perceived safety. Multilevel modeling examined associations between identity, location, and perceived safety; qualitative interviews with 20 SGM participants added context to quantitative findings. Overall, service location was associated with greater perceived safety (β = .27, p < .001). Compared to cis‐hetero participants, cisgender sexual minorities (β = −.23, p = .03) and sexual and gender minorities (β = −.50, p = .002) reported lower perceived safety in service settings (vs. nonservice settings). Qualitative interviews revealed themes and subthemes detailing safe/unsafe spaces and interpersonal conflict in the community, and relationships with staff, peers, transphobia, and positive experiences in service settings. Overall, service settings (vs. community settings) are associated with greater perceived safety. Sexual and gender minority youth feel less safe in service settings (vs. cis‐hetero youth). Sexual and gender minorities must balance self‐expression and personal safety in community settings. Staff/client relationships, transphobia and positive experiences impact safety in service settings. Overall, service settings (vs. community settings) are associated with greater perceived safety. Sexual and gender minority youth feel less safe in service settings (vs. cis‐hetero youth). Sexual and gender minorities must balance self‐expression and personal safety in community settings. Staff/client relationships, transphobia and positive experiences impact safety in service settings.
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Sexual minority (SM) youth have twice the risk of experiencing homelessness compared to their heterosexual peers. Further, SM youth experiencing homelessness (YEH) report greater depression symptoms and substance use compared to heterosexual YEH. Housing First is an intervention that provides scattered-site individual apartments, without any prerequisite conditions for eligibility, and additional services to support long-term housing sustainment; however, few studies have examined the effectiveness of this approach for SM youth. The current study utilized data from a RCT that provided housing to young mothers experiencing homelessness to examine if treatment effects varied by mothers’ sexual identity. Mothers were randomly assigned to services as usual (i.e., provided a referral sheet of all services available in the community; SAU), Housing only (i.e., three months of utility and rental assistance; Housing), or housing and supportive services (integrates independent housing, Strengths-Based Outreach and Advocacy (SBOA), HIV prevention, and substance use/mental health counseling; Housing + SS). Latent growth curve models were estimated to assess how substance use and depression symptoms changed over the 12 months. SM mothers receiving SAU or Housing did not experience a significant change in substance use or depression symptoms. All groups of heterosexual mothers and SM mothers receiving Housing + SS had less substance use and depression symptoms at twelve months, with SM mothers in Housing + SS evidencing a steeper decline in substance use and depression symptoms. This study provides some of the first evidence that Housing First can mitigate the mental health and substance use concerns of SM YEH. Given SM’s higher rates of homelessness, substance use, and depression symptoms, Housing First should be further explored as an intervention to address their unique needs.
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Teens who experience homelessness are more likely to engage in risky sexual behavior, though less is reliably known about sexually transmitted infection (STI) testing rates in this group. We tested for differences in sexual behaviors and STI/HIV testing based on student homelessness and intersecting factors using data from the 2019 Youth Risk Behavior Survey administered in 7 states and 3 school districts. Students who experienced homelessness were more likely to report risky sexual behavior. Race moderated this link, suggesting that Asian students who experienced homelessness were at greater risk. Homelessness was linked to a greater likelihood of having been tested for STIs/HIV among those who seemed to be in groups recommended for testing. Student sex and lesbian, gay, and bisexual (LGB) identity did not moderate associations between homelessness and risky sexual behavior or STI/HIV testing. The overall sample demonstrated low STI testing rates, indicating a continued need to improve testing rates for all youth at risk for STIs/HIV.
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Mental health concerns have been well studied among youth experiencing homelessness, yet few studies have explored factors that contribute to well-being in this population. The current cross-sectional study examined rates and correlates of well-being among youth experiencing homelessness. This is a descriptive, secondary analysis of the baseline data from a clinical intervention study. Ninety-nine youth (aged 16−25) who were experiencing homelessness were recruited in Chicago. Approximately 40% of the sample reported average or above average well-being relative to existing benchmarks. Having medical insurance, a mobile phone, and a history of more severe childhood trauma were unique cross-sectional predictors of worse well-being (all ps < 0.034). A significant portion of our sample experienced well-being. Having access to certain resources may be counterintuitive indicators of poorer well-being among youth experiencing homelessness, perhaps because they are indicators of greater need or increased social comparison among these youth.
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Objectives The cognitive function of homeless children and adolescents may be overlooked, albeit understandably, when societal interventions focus on their immediate housing needs. Nevertheless, homelessness might be hypothesized to carry many risks for the developing mind and brain. We wanted to discover whether this hypothesis had been tested previously. Design A systematic review to examine whether cognitive impairments were reported in homeless children and adolescents. Setting Objective, systematic review of standard databases, examined by key word searches. Participants Children and adolescents. Main outcome measures Formal assessments of cognition. Results We found that in spite of there being many homeless children in the world, fewer than 2000 have been assessed cognitively and reported in the literature. Yet when compared with those who are domiciled, these children tend to have lower intellectual functioning and decreased academic achievement. Furthermore, adolescents evince cognitive impairments in the contexts of drug, physical, and sexual abuse. Conclusions We suggest that cognitive and mental health screening be incorporated into those intervention programs deployed to facilitate societal reintegration of homeless children and adolescents.
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Annotation: This article discusses the results and implications of a study of alcohol use and abuse among homeless adolescents in Hollywood, Calif. Abstract: The study defined "homeless adolescents" as "individuals 17 or younger who had spent the previous night in a formal shelter, in an improvised shelter, or on the streets." Ninety-three adolescents contacted through service and "street" sites for the homeless were interviewed using the Homeless Adolescent Interview Schedule. The schedule included sections on alcohol and other drug use, mental health, physical health, homelessness history, subsistence adaptation, family and social history, residential instability, criminal history, and victimization. The prevalence of alcohol abuse was exceedingly high among the sample compared to non-homeless samples of adolescents. Alcohol abuse, however, was only one among a host of problems that included disruptive family histories and unsatisfactory contact with social institutions. Solving only the alcohol-related problems of these adolescents will not end their homelessness. A broader perspective and a more integrated approach are required to guide policy relevant to this population. Specific recommendations are offered. To cite this abstract, use the following link: https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=123421 This study of homeless youth in Hollywood, found that 48.4% of the youth could be diagnosed as either alcohol users or alcohol dependent at some point in their lives. Even the non-abusers were at high risk of becoming problem drinkers. Most of the youth had not received any alcohol treatment and most were preoccupied with survival needs of food, shelter, and clothing. The researchers advocate that treatment for alcohol and drugs be offered with material help. An interesting observation was that alcohol users were less likely to utilize shelters than nonusers, probably due at least in part to the restrictive policies of the shelters. This is a cause for concern -- not using shelters puts the alcohol-using homeless youth out of the reach of help and in greater danger of victimization. https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=123421
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Despite the advances in understanding cognitive improvements in executive function in adolescence, much less is known about the influence of affective and social modulators on executive function and the biological underpinnings of these functions and sensitivities. Here, recent behavioral and neuroscientific studies are summarized that have used different approaches (cognition, emotion, individual differences and training) in the study of adolescent executive functions. The combination of these different approaches gives new insight into this complex transitional phase in life, and marks adolescence as not only a period of vulnerabilities, but also great opportunities in terms of training possibilities and interventions.
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Anecdotal evidence from those who work with homeless youth indicates that trauma permeates these young people's lives. This paper presents the findings from a study of 100 homeless youth regarding the presence of trauma in their lives, both before and during homelessness. Participants living in the Maritime Provinces volunteered to take part in a semi-structured interview lasting one to two hours. The interview questionnaire was conducted by a trained interviewer, and was composed of standardized and adapted survey instruments, as well as questions regarding demographics, experiences prior to becoming homeless, assistance received while dealing with stressors, and current needs. The results indicate that trauma is both a cause and a consequence of youth being homeless, as a large majority of participants experienced a number of types of highly stressful events both preceding and during homelessness, and that trauma in the lives of both male and female homeless youth should be understood as a pervasive reality with serious implications. Implications for service delivery are discussed.
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Part 1 society's forgotten children: runaway and homeless adolescents in America the Midwest homeless and runaway adolescent project. Part 2 The family lives of runaway and homeless adolescents: the early lives of runaways troubled generations getting along at home - the parent/caretaker-child relationship. Part 3 Taking chances -adolescents on their own: runaway adolescents getting by - survival strategies of runaway adolescents getting it on - sexuality, risky sex, and pregnancy getting hurt - victimization and trauma on the streets. Part 4 Nowhere to grow - the developmental consequences of running away: internalization problems among runaway and homeless adolescents substance use and externalization problems among runaway adolescents a risk-amplification developmental model for runaway and homeless adolescents growing up on society's margins.
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A large and heterogeneous sample of 364 homeless adolescents was interviewed about residential and family histories, as well as about their experiences while homeless.They were also administered a diagnostic interview and various self-report measures of emotional and behavioral functioning. Analyses were conducted to provide a better description of these youth, with a special focus on gender and age heterogeneity. Results of analyses suggested that homeless youth came from generally troubled backgrounds and had elevated rates of psychiatric disorders. For boys, their histories typically included physical abuse during childhood, physical assault on the street, and elevated rates of externalizing disorders. For girls, histories were more often marked by sexual abuse during childhood, sexual victimization on the streets, and elevated rates of internalizing disorders. Implications of these results for service delivery are discussed.
Article
Based on a study of sheltered homeless and low-income housed families, predictors of academic achievement among 174 English-speaking children age 6 and older were examined, focusing on housing status, mobility, and race/ethnicity. Days absent from school was hypothesized as the mediating link between homelessness and academic achievement. In multivariate analyses, a composite measure of academic achievement was independently predicted by child's gender (girls scoring higher than boys), race/ethnic status (non-Latino Whites scoring higher than children of color), age, and school mobility. Housing status was not associated with academic achievement. Results indicated that homeless and housed children had comparable rates of absenteeism and other school-related problems, which may explain why homeless and housed children were similar in terms of achievement. Although children of color were equivalent to non-Latino White children in terms of nonverbal intellectual ability, their lower academic achievement scores suggest that they are not reaching their academic potential.