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Pathways to youth homelessness
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Social Science & Medicine 62 (2006) 1–12 www.elsevier.com/locate/socscimed
Pathways to youth homelessness Claudine Martijn, Louise Sharpe The Clinical Psychology Unit (F12), School of Psychology, The University of Sydney, Camperdown, NSW 2006, Australia Available online 27 June 2005
Abstract Research documents high levels of psychopathology among homeless youth. Most research, however, has not distinguished between disorders that are present prior to homelessness and those that develop following homelessness. Hence whether psychological disorders are the cause or consequence of homelessness has not been established. The aim of this study is to investigate causal pathways to homelessness amongst currently homeless youth in Australia. The study uses a quasi-qualitative methodology to generate hypotheses for larger-scale research. High rates of psychological disorders were confirmed in the sample 35 homeless youth aged 14–25. The rates of psychological disorders at the point of homelessness were greater than in normative samples, but the rates of clinical disorder increased further once homeless. Further in-depth analyses were conducted to identify the temporal sequence for each individual with a view to establishing a set of causal pathways to homelessness and trajectories following homelessness that characterised the people in the sample. Five pathways to homelessness and five trajectories following homelessness were identified that accounted for the entire sample. Each pathway constituted a series of interactions between different factors similar to that described by Craig and Hodson (1998. Psychological Medicine, 28, 1379–1388) as ‘‘complex subsidiary pathways’’. The major findings were that (1) trauma is a common experience amongst homeless youth prior to homelessness and figured in the causal pathways to homelessness for over half of the sample; (2) once homeless, for the majority of youth there is an increase in the number of psychological diagnoses including drug and alcohol diagnoses; and (3) crime did not precede homelessness for all but one youth; however, following homelessness, involvement in criminal activity was common and became a distinguishing factor amongst youth. The implications of these findings for future research and service development are discussed. r 2005 Elsevier Ltd. All rights reserved. Keywords: Homeless; Youth; Psychological disorders; Pathways; Trauma; Australia
Introduction The prevalence of psychological disorders among homeless adults has consistently found that the vast majority of homeless people experience at least one psychological disorder (Buhrich, Hodder, & Teesson, 2000; Herman, Susser, Struening, & Link, 1997; Kamieniecki, 2001). Consistently, research has found that well in excess of 50% of homeless young people Corresponding author. Tel.: 9351 4558; fax: 9351 7238.
E-mail address: [email protected] (L. Sharpe).
have drug and alcohol problems (e.g. Goering, Tomiczenko, Sheldon, Boydell, & Wasylenki, 2002). Similarly, rates of mood disorders, psychotic disorders and trauma-related disorders have all been found to be over-represented amongst homeless youth (e.g., Cauce, Paradise, Ginzler, & Embry, 2000; Herman et al., 1997; Kamieniecki, 2001). The degree of psychological distress is also indicated by the high rates of suicidal behaviours in this group of disadvantaged youth. Indeed, Molnar, Shade, Kral, Booth, and Watters (1998) found that 48% of homeless young women and 27% of males had attempted suicide, and amongst those with a suicide
0277-9536/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2005.05.007
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attempt, there was an average of 6.2 and 5.1 attempts for women and men, respectively. Moreover, suicide attempts have been found to be independently predicted by a history of childhood trauma (Molnar et al., 1998). Research into the experience of trauma amongst homeless people has found that traumatic events are virtually universal (Buhrich et al., 2000). Many homeless people were the victims of childhood trauma. For example, in one recent study of homeless youth, only 33% of participants did not report a history of either physical or sexual abuse or both (e.g. Ryan, Kilmer, Cauce, Watanabe, & Hoyt, 2000). In addition, research confirms that histories of childhood trauma pre-dispose young homeless people to the risk of future victimisation (Noell, Rohde, Seeley, & Ochs, 2001; Stewart et al., 2004). Despite these findings, few studies have attempted to determine the specific role that trauma and its psychological sequelae have had in promoting the development of homelessness. It is often unclear from research whether traumatic experiences and/or psychological disorders are a cause or a consequence of homelessness. While it is important to know that psychological disorders are common among homeless youth, in order to develop services to meet the needs of this population, such findings do not enable us to identify the pathway(s) by which young people become homeless. That is, we are not able to place events in a temporal sequence to determine likely causal pathways to homelessness. Few investigations have examined the temporal relationship between the experience of trauma, the development of psychological disorders and homelessness. Two studies have investigated the temporal relationship of psychological disorders and other events in relation to the first onset of homelessness, with a view of determining likely causal factors. A UK study with homeless youth by Craig and Hodson (1998) found a significant difference between homeless youth and their control domiciled population in psychiatric disorders and childhood adversity. Craig and Hodson (1998) found that among the homeless subjects, 70% of psychiatric disorders begin prior to homelessness. They went on to develop tentative models that identified risk factors for becoming homeless. They concluded that childhood adversity, educational attainment and the prior existence of psychiatric disorders all independently increased the likelihood of homelessness. Similar results were found, yet significantly different conclusions made, in a study conducted in the USA by North, Pollio, Smith, and Spitznagel (1998) with homeless adults. In keeping with the findings of Craig and Hodson (1998), they found that there was a higher prevalence of psychiatric disorder amongst homeless adults and in most instances the onset of their disorder was prior to homelessness. However, they also compared the age of onset of psychiatric disorders for those
participants in the homeless and control group who had a psychological disorder. The age of onset was similar in the both groups, except for drug and alcohol problems which had their onset earlier in the homeless sample. North et al. (1998) concluded that while the onset of psychiatric disorders preceded homelessness, psychiatric disorders could not be assumed to have a causal role in the onset of homelessness. They argued that the occurrence of psychiatric disorders prior to homelessness is explained ‘‘yby the natural history of the disorders whose onset just happens to occur before a certain age, rather than causally associated with the development of homelessness.’’(p. 398). Their conclusion, while one interpretation of the available data, is open to question. Psychiatric illness should not be excluded as a risk factor for homelessness simply because the timing of the onset of psychiatric disorders was found to be the same between the control and homeless samples. The greater prevalence of psychiatric disorders in the homeless population prior to homelessness suggests that psychiatric illness cannot be excluded as a potential causal factor in youth homelessness. It is clear that further research is needed to establish the temporal relationship between different factors and the onset of homelessness. Notably, neither study assessed for post-traumatic stress disorder (PTSD), despite Craig and Hodson (1998) finding childhood adversity to be an important risk factor for homelessness. Childhood adversity was defined as the experience of neglectful (parental indifference, antipathy, parental control) or abusive (physical and/or sexual) situations in the family of origin. Many of these experiences are traumatic and may result in posttraumatic sequelae, including PTSD. In this context PTSD would seem to be an important disorder to assess. The present study aims to understand the individual transitions of young people, including childhood experiences and psychological disturbance, in relation to the onset of their homelessness. Specifically, the aim of the present study is to determine identifiable ‘pathways’ to homelessness amongst homeless youth and the subsequent trajectories of homeless youth. It is hypothesised that the experience of trauma will be a significant contributory factor in the pathway to homelessness for a large proportion of young people.
Method Participants Participants were recruited from four homeless youth services, run by a charity organisation in New South Wales, Australia. Homeless youth were defined as youth between 14 and 25 years (Kamieniecki, 2001), and either
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(a) living without family assistance; (b) in no accommodation at all; (c) in temporary or emergency accommodation; or (d) in other long-term supported accommodation for homeless people (House of Representatives Standing Committee on Community Affairs, 1995). Each service informed their clients of the study. Three of the services were in the central city area, while the remaining service was a medium-term (6 months) supported accommodation service for homeless youth set within a therapeutic community in a rural area. Forty-one homeless youth were approached to take part in the study and 35 volunteered (85%). Two participants did not complete the interview. Procedure Given the paucity of research in this area, a quasiqualitative methodology was considered both necessary and beneficial to allow the development of testable models. Other studies have employed such methodologies to develop models in under-researched areas, such as the life-cycle of homeless youth (Auerswald & Eyre, 2002) and the sexual health practices of homeless youth (Rew, Fouladi, & Yockey, 2002). Participants were interviewed in-depth about their life experiences for approximately 3 h, with the researcher keeping detailed notes. During this process, they completed a timeline to facilitate accurate recall of the temporal sequence of their life experiences (Wilson, Houston, Etling, & Brekke, 1996). The timeline was presented visually and comprised six dimensions: (a) family, (b) drug and alcohol use, (c) mental health, (d) housing, (e) trauma and (f) other information (e.g. criminal activity). The timeline was presented within a semi-structured interview adapted for youth, based on Buhrich et al. (2000). The interviewer and participant entered significant life events from each dimension at the time of the interview. Further, after the completion of the interview, the researchers used onset and recency data from the structured diagnostic interview to estimate the onset of diagnosable mental disorders. The interview included demographic information, experiences of trauma and childhood parental care, and the CIDI (World Health Organisation (WHO), 1997) or K-SADS (Kaufman, Birmaher, Brent, Ryan, & Rao, 2000) (depending on the age of the youth) to assess mood disorders, drug and alcohol dependence and PTSD. A psychosis screen was also used. As such, the interview consisted of a combination of closed questions and other open-ended questions. All young people were interviewed within a service by the first author who was trained in managing distress. Any participant who remained distressed following the interview or disclosed experiences of abuse which they had not previously disclosed were offered further assistance from staff in each service. Feedback from
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the participants indicated that they valued the opportunity to tell their stories. A number of participants disclosed traumatic experiences for the first time during the interview and in many cases requested that this information be made available to their treating caseworkers so that they could access services to deal with the psychological consequences of the trauma. The University of Sydney Human Research Ethics Committee approved the study and formal approval was granted by the charity. Participants were paid $20 to reimburse them for their time and effort. Measures (i) The Composite International Diagnostic Interview (CIDI) Version 10 (WHO, 1997) is a structured interview that is used to generate psychiatric diagnoses. ICD10 and DSM-IV diagnoses were generated, as were the age of onset of the diagnosis and recency data. The CIDI has been shown to have good interrater reliability and validity (Wittchen, 1994). (ii) The Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version, Version 10 (K-SADS) (Kaufman et al., 2000) was used for those participants under 18 years. This instrument also generates both ICD10 and DSM-IV diagnoses. The relevant sections of the K-SADS were administered to the participant (i.e. depressive disorders, drug and alcohol disorders and PTSD). The K-SADS has been shown to have good reliability and validity (Kaufman et al., 1997). Analysis Criteria (listed as 1–5 below) were developed to determine proximal factors for homelessness and enable the identification of different pathways to the onset of homelessness. Only experiences that had occurred prior to the onset of homelessness were considered. The presence of five main factors was assessed. (1) The first factor was the presence of a psychological disorder. A psychological disorder was considered to have been present if its onset preceded homelessness and it was a diagnosable disorder according to the diagnostic criteria employed. That is, diagnoses of depression and/or PTSD, according to either DSMIV or ICD-10. The diagnosis of psychosis was assumed if the person reported that they had been diagnosed by a psychiatrist with a psychotic illness and scored above the cut-off point on the psychosis screener. Age of onset for psychosis was gauged through self-report. (2) The second factor was ‘trauma’ which was defined by Criteria A of the PTSD diagnostic criteria in
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DSM-IV. Criteria A for PTSD diagnosis is as follows: ‘‘The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, (2) the person’s response involved intense fear, helplessness, or horror.’’ (American Psychiatric Association (APA), 2000). Trauma was identified separately from psychological disorders because the two could occur independently of each other, even though they might clearly be strongly related. (3) The third factor was ‘drug and alcohol problems’. These were categorised separately from psychological disorders due to the high incidence of drug and alcohol problems in this population and the fact that they bring with them a potentially different set of problems other than psychological disorders (e.g. involvement in crime, arguments with family, etc.). Both abuse and dependence were defined according to DSM-IV and/or ICD-10. The use of drugs in the absence of a diagnosis was not included as a factor. Cigarette smoking (i.e. nicotine dependence/abuse) was excluded. (4) The fourth factor was ‘crime’ which was defined as involvement in criminal activity resulting in police involvement and resulting in charges laid. (5) The final factor was ‘family problems’ which was defined as a factor in isolation due to the high rate of family conflict reported by the young people in the sample and its likely relevance (Craig & Hodson, 1998; House of Representatives Standing Committee on Community Affairs, 1995). Incidents such as the family no longer supporting youth by way of money/ shelter/food were considered to be neglect regardless of whether they resulted in state intervention. Specifically, participants were considered to have had ‘family problems’ if they endorsed questions indicating that there was abuse1 or neglect in the family of origin or if they had been taken into care. The incidence of each factor was entered onto each participant’s timeline. The temporal relationship between each factor and the onset of first homelessness was then determined. Those factors that occurred prior to the first episode of homelessness were deemed possible contributors to homelessness. These data were then investigated to determine whether or not the participants’ experiences could be grouped into a meaningful set of pathways that lead to homelessness. The identification of factors and the allocation of participants to pathways was conducted independently by the 1 Abuse, sufficient to meet Criterion A of DSM-IV for PTSD was included under trauma, rather than family problems.
two investigators. Discrepancies were resolved by reaching a consensus. Once a consensus was reached, the data were then re-rated again by the two raters, and then rated a final time by a party independent of the research. The intra-rater reliability was calculated using k coefficients (k ¼ .75). The inter-rater reliability was also good (k ¼ .75).
Results The participants were an average age of 19.9 years (SD ¼ 2.1). On average, participants had been first homeless at the age of 15.8 years (SD ¼ 2.8). Sixty-four percent of the sample was male, 88% single, only 6% had children, 96% were born in Australia or New Zealand, 60% had left school by the age of 16 years and 75% were receiving Youth Allowance (a government source of funding for young people living independently). Ninety percent of the sample had experienced at least one trauma, with an average of 2.2 traumas. Childhood sexual abuse was experienced by 20% of the sample (60% of the young homeless women) and physical abuse was reported by 51.5% of the sample.
Pathways to homelessness Five different pathways were identified. Each pathway is defined by the combination of precipitant factors for homelessness. In describing each pathway, characteristics of the young people in each pathway are described to give a sense of their experiences. Crime, which was initially developed as a separate factor, was removed following analysis of the data. There was only one case in which crime occurred prior to homelessness and it was therefore not considered to significantly represent the pathways identified in the sample. As can be seen in Fig. 1, pathway two (trauma and psychological problems with the absence of drug and alcohol) and pathway three (drug and alcohol) appeared to be the most common pathways to homelessness of the sample. Pathway five (trauma) was the leastcommon pathway and, as can be seen in Fig. 1, accounted for fewer subjects compared with all of the other pathways. The five pathways identified are described in detail below. Pathway one: Drug and alcohol, trauma with or without additional psychological problems Five of the six participants in pathway one were male. All participants in this pathway had experienced a trauma. For half of the participants the trauma preceded any history of drug and/or alcohol abuse/dependence; however, for the other half the trauma occurred
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25
Percentage
20
15
10
5
0 Pathway 1
Pathway 2
Pathway 3
Pathway 4
Pathway 5
Fig. 1. Proportion of subjects in each pathway.
following a history of drug and/or alcohol abuse/ dependence. For the participants where the trauma preceded drug and alcohol abuse/dependence, all three met criteria for cannabis abuse with two of the three also having problems with alcohol abuse/dependence. In contrast, the three young people for whom the drug and/ or alcohol abuse/dependence preceded the trauma all met criteria for multiple drug and/or alcohol abuse/ dependence, including cannabis, hallucinogens, ecstasy, and alcohol. In this pathway, only two of the group met criteria for psychological disorders prior to homelessness. In both cases, the young people met criteria for posttraumatic stress disorder, and in one case there was a co-morbid major depressive disorder. Pathway two: Trauma and psychological problems (the absence of drug and alcohol) Six of the eight participants in pathway two were male. In contrast to pathway one, for all participants in pathway two the trauma preceded any psychological disturbance. The most common psychological disorder was posttraumatic stress disorder, which occurred in six of the eight young people. Of those six, four had a comorbid diagnosis of major depressive disorder. The remaining two participants both met criteria for major depressive disorder.
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the eight cases, participants described their upbringing as neglectful, often reporting spending time living with relatives or friends. One additional participant described emotional abuse as a precursor to drug abuse. The remaining two participants did not report a history of family dysfunction preceding their drug and alcohol use. However, conflict within the family led both of these participants to be ‘thrown out’ of home. Interestingly, both these participants were the only two in this group who met criteria for alcohol dependence and abuse prior to their experience of homelessness. Some participants experienced psychological disorders: three met criteria for major depressive disorder, with two of these diagnoses preceding their drug abuse. One other participant developed schizophrenia, after having met the criteria for cannabis abuse. Pathway four: Family problems Of the seven participants in this pathway to homelessness, four were male. Five of the participants reported a history of neglect necessitating periods of absence from their familial home. In two cases, this resulted in lengthy periods in care during childhood. Of the other two participants, one reported a history of physical abuse, not sufficient to meet Criteria A for PTSD, and witnessing domestic violence in the home. The other participant reported emotional abuse throughout childhood. Surprisingly, of these seven young people, only one met criteria for any psychological disorder prior to homelessness, which was major depressive disorder. Further, none met criteria for drug or alcohol abuse or dependence prior to their first episode of homelessness. Pathway five: Trauma There were only two participants in this pathway, both of whom were female. In both cases, the trauma that they experienced was childhood sexual abuse within the family of origin. Interestingly, in both cases the trauma occurred early in childhood, with both young women reporting the onset of child sexual abuse at the age of 5 years. Neither participant developed any psychological disorder or drug or alcohol abuse or dependence prior to the onset of homelessness.
Pathway three: Drug and alcohol and family problems
Trajectories following first onset of homelessness
Five of the eight participants were male. All participants met criteria for drug abuse or dependence, with the exception of one participant who met criteria for alcohol dependence and abuse. One further participant met criteria for alcohol dependence and abuse in addition to drug dependence and addiction. In five of
The youth represented in each pathway to homelessness were re-visited to determine if the factors that preceded homelessness changed following homelessness. Each subject’s factors were entered on their timeline if the problem developed after they were homeless. The data were analysed in the same way as for pathways to
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homelessness, to determine if there were changes. Analyses were conducted in keeping with the previously developed criteria. Factors that were pre-existing (i.e. featured in the pathways to homelessness for an individual) were not included as factors in the trajectory. That is, a factor was only considered if its onset followed homelessness. There were five identifiable trajectories, as follows (see Fig. 2): Trajectory A: Trajectory B: Trajectory C: Trajectory D: Trajectory E:
Psychological with or without trauma. Psychological with or without trauma, and drug and alcohol. Psychological with or without trauma, drug and alcohol, and crime. Crime and/or drug and alcohol. Stable.
All participants with diagnoses of psychological or addictive disorders prior to homelessness fell into the trajectories A–D. That is, those individuals who at the point of becoming homeless had developed either a psychological disorder or a drug or alcohol problem all developed additional problems once homeless. The four cases that remained stable over time did not satisfy criteria for any psychological or addictive problem at the time of homelessness. Three of these individuals came from pathway four and one from pathway five. That is, these individuals had difficult childhoods, which they negotiated without developing significant psychological difficulties, but nonetheless became homeless. In contrast, the vast majority of the young people in the study (87.5%) deteriorated significantly once homeless (Fig. 3).
40 35 30
Percentage
25 20 15 10 5 0 Pathway A
Pathway B
Pathway C
Pathway D
Pathway E
Fig. 2. Proportion of subjects in each trajectory following the onset of homelessness.
Overall, with the exception of the individuals described above, the trajectories following the onset of homelessness are characterised by four main factors: drug and alcohol, psychological disorders, trauma and crime. The two most prevalent factors were drug and alcohol and psychological factors, the rates of which increased considerably following homelessness. Although crime was less prevalent (33%), given that there was a virtual absence of crime prior to homelessness, the increase once homeless should be highlighted. Interestingly, the two pathways representing the highest proportions of the sample were pathways B and C, both of which share psychological, trauma and drug and alcohol factors and differ only in the factor of crime.
Case examples The findings in this study have generated considerable data providing context to youth homelessness, which is often lost in purely quantitative research. Auerswald and Eyre (2002) argue that contextual and exploratory research is critical for the development of comprehensive understanding of minority populations, in particular. They further argue that qualitative research is descriptive and explanatory and necessary for investigating marginalised populations (Auerswald & Eyre, 2002). The following serves to illustrate the contextual information gathered during interviews, as well as to further contextualise the five pathways identified in this research, and the subsequent trajectories once homeless. All identifying information has been removed or significantly changed to preserve confidentiality. Pathway one: Drug and alcohol, trauma with or without psychological problems Simon was an 18-year-old male born in Tasmania. Simon lived with his mother and father up to the age of 7 years, after which he moved to NSW to live with his Aunt. Simon was moved away from his mother and father due to severe and recurring physical abuse from Simon’s father. The physical abuse began when Simon was five, when he sustained physical injuries requiring hospitalisation on several occasions, and developed PTSD as a result. Simon lived with his Aunt for 10 months after which time he returned to his parents in Tasmania and then shortly thereafter returned to live in NSW with both parents. Simon reported that the physical abuse continued until he was 16, during which time he continued to satisfy criteria for PTSD. Simon reported initial drug use at the age of 13 years and alcohol use at 14. Simon also satisfied criteria for alcohol and drug abuse and dependence at the age of 14, and continued to satisfy criteria for drug dependence at 18. Simon’s alcohol abuse and dependence abated when
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Factor
Pathway
Factor
7
Trajectory
D&A
1
D&A Psych 2
H
A
O
M
3
E Psych L
Trauma B E 4 S
S
Crime
Family 5
C
Fig. 3. Pathways to homelessness and trajectories following the onset of homelessness.
he was 16. However, Simon’s drug and alcohol use remained a source of conflict between him and his father. At the age of 16, his father kicked him out of home due to conflict over his drug and alcohol use. At the time of this argument, his father physically abused him sufficiently severely that his injuries required hospitalisation. After being discharged, Simon had
nowhere to live and moved in with one of his friends for a few days after which time he moved into a refuge for homeless youth. Once homeless, Simon began using speed daily, meeting criteria for an additional drug disorder. By 17, Simon had left school and remained homeless (in a series of refuges and/or on the streets) until the age of 18, when
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he sought services and was admitted to a medium stay residential program for homeless youth. As with many of the young people in pathway one originally, Simon had already developed both drug and alcohol and psychological difficulties before homelessness. However, these problems increased in number following homelessness (Trajectory B). Pathway two: Trauma and psychological problems (the absence of drug and alcohol) John was a 20-year-old Australian born male who lived with his father and mother until he was 16 years when he was kicked out of home. John reported that he had been sexually abused by his father at the age of six and several times thereafter. John satisfied criteria for PTSD from age six and continued to do so. John attempted suicide at the age of 16 years through selfmutilation with a knife. According to diagnostic criteria, John had his first severe major depressive episode at this point in time, which continued at interview. John reported being kicked out of home by his parents because of his aggressive behaviour at home and moved into a refuge for homeless youth when he was 16. Once homeless, John began using drugs including speed, LSD, and ecstasy on a weekly basis. By 17, John fulfilled criteria for alcohol abuse and the abuse of both hallucinogens and cocaine. Although John was intermittently homeless, he did return home for periods of time over the next year. At 18, due to his increasing violence against his mother, an apprehended violence order was taken out against him. By the age of 19, John was admitted to a psychiatric hospital for 4 months with a diagnosis of drug-induced psychosis and was subsequently diagnosed with schizophrenia (Trajectory C).
smoking cannabis daily and became involved with crime to support his drug habit. At 18, he was arrested for breaking and entering and served 6 months in jail. Following his release, he developed a problem with alcohol, and by age 19 met criteria for alcohol dependence and abuse (Trajectory D). Pathway four: Family with or without psychological problems Adam was a 19-year-old Aboriginal male who reported his first period of homelessness at the age of 14 years. Adam lived with his mother until the age of 12. His father left the family when Adam was three. Adam reported that he and his mother continually argued about Adam’s behaviour and did not have a good relationship. When Adam was 12, his mother no longer wanted to care for him, and Adam became a ward of the state. Adam’s grandmother took custody of him 1 month later and Adam lived with her until the age of 14. Adam’s first experience of homelessness was when he moved out of his grandmother’s house reporting that he and his grandmother continually argued. Adam moved into a refuge for 1 month. During his first month in a refuge, Adam was arrested for stealing cars. Over the next 2 years, he was involved with Juvenile Justice on at least four occasions. At 16, Adam developed cannabis abuse and dependence, and continued to have trouble with the law. His offences included car theft and during this time he was involved in a car accident. At 17 years, Adam developed a major depressive episode and shortly thereafter was arrested again for car theft and drunk driving and served 6 months in Juvenile Justice. On his release, he entered a residential program, but continued his drug use and by age 19 also met criteria for alcohol abuse (Trajectory C).
Pathway three: Drug & alcohol and psychological problems
Pathway five: Trauma
Peter was a 19-year-old Australian born male. Peter lived with his mother following his father leaving the family when Peter was 2 years old. Peter reported that his mother had a severe problem with alcohol throughout his childhood, which resulted in arguments. Peter began using drugs at 13 and had developed both drug abuse and dependence disorders by 15. Peter continued to satisfy criteria for drug abuse and dependence. Peter also had a moderate major depressive episode at the age of 16 that lasted for 1 year. Peter was admitted to an out-patient unit at a hospital for drug rehabilitation during this time after which he left home and lived with friends and shortly after lived in a refuge. Shortly after becoming homeless, Peter gave up all drug use and was admitted to a hospital for withdrawal. During his admission, he developed a second major depressive episode. Following discharge, Peter resumed
Terry was a 23-year-old Australian born female. Terry predominantly lived with her mother until the age of 16 years; however, her mother made her go to live with her father on weekends after their divorce when Terry was 6 years old. Terry reported a long history of sexual abuse by her father that began when she was five and continued to the age of 14. When Terry was 14, her mother kicked her out of home and she had her first episode of homelessness. Terry reported that her mother asked her to leave because she considered that she was of no use around the home. Terry reported running away for short periods of time to her older brother’s house before 14 because of the experiences of sexual abuse when she was forced to stay with her father on the weekends. Despite Terry’s long history of sexual abuse by her father, she did not meet criteria for any psychological
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disorder at the time she became homeless. Having been asked to leave home at 14, Terry lived with a variety of relatives and moved into a refuge. At 16 years, Terry was assaulted again by her father, and subsequently developed a major depressive episode and attempted suicide. At 19, Terry remained homeless and was raped. She developed PTSD as a result and met criteria for alcohol abuse and dependence. Although her drug and alcohol problems remitted, she continued to meet criteria for PTSD and major depressive disorder and had a further attempt at suicide (Trajectory B).
Discussion The aim of the present study was to explore the life experiences of a group of homeless youth to identify pathways towards homelessness. We aimed to investigate the temporal sequence between those factors previously identified in the literature, namely childhood adversity, trauma, psychiatric disorder, crime and drug and alcohol problems. As is typical in samples of homeless youth, the participants in the current study had high rates of psychopathology and in the majority of cases psychopathology preceded the onset of homelessness. By examining the temporal sequence, pathways to homelessness were suggested by the data. Five pathways to homelessness were identified, accounting for each participant in the sample. Pathways 2 (trauma and psychological problems without drug or alcohol), 3 (drug and alcohol and psychological problems) and 4 (family problems with or without psychological) represented the majority of the sample. Pathway five (trauma alone) accounted for only 6% of the sample. Further analysis of these five different pathways shows that four distinct factors can be distilled from the five pathways, namely drug and alcohol, psychological, trauma and family problems. These findings are consistent with those factors previously identified in the available literature (Kamieniecki, 2001). However, what is highlighted in this current study is the additional importance of early trauma and the resulting psychological difficulties (including drug and alcohol disorders). Although early life experiences and trauma were important in pathways to homelessness, they did not differentiate between youth with different trajectories once homeless. Trauma was still a common experience following homelessness; however, trauma no longer distinguished between the trajectories. This most likely reflects the universality of trauma while on the streets and that traumatic events become so common that they fail to distinguish between the trajectories following homelessness. It seems that whatever way young people come to be homeless, once they are homeless they develop additional psychological or drug problems and
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a sizeable proportion (33%) turn to crime to either support their basic needs or their drug habit. The majority of young people when interviewed reported drug and/or alcohol disorders (70%) and/or psychological disorders (66%) compared to 42% and 44%, respectively, when first homelessness. Our results suggest that if the common factors of trauma, psychological disturbance or drug and alcohol problems remain untreated and the individual continues to live in an impoverished environment that is not conducive to optimal functioning, additional difficulties would be expected to develop. This suggests that the experience of homelessness compounds pre-existing psychological difficulties. Among this sample it was much more common for homeless youth with psychological impairments to use drugs and/or alcohol and to experience a level of criminal activity than to have psychological issues in isolation. Another important finding was that the majority of the sample involved in crime had a range of traumatic experiences, psychological disorders and drug and alcohol problems compared to the smaller number who became involved in crime and/or drugs and alcohol in isolation. Once again, the data show that it is more common for homeless youth to experience a multitude of difficulties rather than simply one problem increasing in severity over time. While studies to date have ventured to establish singular risk or associated factors of homelessness, the present research investigated how a number of factors were temporally linked with the first onset of homelessness. Craig and Hodson (1998) tentatively suggested the existence of ‘‘complex subsidiary pathways’’ (p. 1387) as necessary to explain the development of homelessness. They suggested the necessity of linking factors identified with homelessness and examining their cumulative role in the risk for homelessness. If one can identify complex subsidiary pathways, one may be able to isolate the precipitant factor or cluster of factors that have led to homelessness. This would help explain how and why youth first become homeless. In most cases it is more accurate to identify a pathway, rather than one single factor, that has had direct influence on the adolescent becoming homeless. The conclusions of this research are offered with caution given its limitations. First, the small sample size reduces the potential generalisability of the findings. A larger sample size is needed to determine whether the pathways presented here are exhaustive and generaliseable. A further limitation of this study is the representativeness of the sample. While the sample included youth from four different services around the state, homeless youth currently living ‘on the street’ or not in contact with services were not included. Further, participants were not randomly selected. Therefore the findings reported from this study may not be truly representative of homeless youth throughout Australia.
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Future research would be needed to determine whether street-dwelling youth had similar experiences to those reported here. In addition, the present study relied on retrospective recall in a group of young people with considerable psychopathology. While the investigators attempted to minimise the possibility of recall bias through the use of well-validated diagnostic interviews and the use of a timeline to anchor recall, the reliability of reports remains an issue. Importantly, research has been completed which suggests that young homeless people do report histories of childhood abuse accurately, according to corroboration (where available) and parental reports (Lipschitz, Bernstein, Winegar, & Southwick, 1999). Such results led Urquiza (1991, p. 120) to argue that retrospective research remains ‘‘a consistent, viable and economical source of family violence data’’. Nonetheless, this should be borne in mind when interpreting the data. The above limitations notwithstanding, this research has established a formulation of how young people become homeless. The strength of the present methodology is that it allows examination of the relationships between numerous factors simultaneously. Finally, this research has increased our understanding of the impact of trauma, drugs and alcohol and psychological pathology on youth homelessness. Although preliminary, these results if confirmed have implications for future research in the area of service development for homeless youth. Research in services for this underprivileged group is lacking and the present research suggests a number of areas where such research is warranted: (a) the current management of homeless youth, (b) the prevention of homelessness, (c) prevention of secondary complications and (d) public policy and public perception of homelessness, all of which are important research aims suggested in the literature (Phelan & Link, 1999). Perhaps most importantly the findings outlined in this investigation can be translated into practical suggestions for the development of services in the treatment, rehabilitation and support of homeless youth. In addition to suggestions offered by Buhrich, Hodder, and Teesson (2003), our research indicates the importance of trauma and PTSD. The assessment of homeless youth for a history of trauma and PTSD appears indicated given the high rates of trauma and PTSD in this sample and the high rates of re-victimisation. Secondly, many youth reported family problems as the factor involved in the onset of homelessness, and many of those necessarily came into contact with services through governmental investigations or being taken into care. This would suggest that the assessment of these youth when they first come into contact with services, and provision of appropriate services targeting traumatic experiences, may better help to prevent home-
lessness. Another possible point of early identification may be identifying those youth with drug and alcohol disorders given the high rates in this population found in this study. The identification of these factors may be more difficult given that these youth are not necessarily identified by any service before they become homeless. The majority of the sample (60%) was homeless by the age of 16. It may be that school counsellors could be better educated about the role of drug and alcohol disorders, histories of abuse, psychological difficulties and early trauma in the subsequent risk of youth homelessness. These professionals are amongst the few in an appropriate position to identify students at risk prior to homelessness. Another important implication is the prevention of secondary complications once youth are already homeless. Our data suggests that even only 4 years after the onset of homelessness, considerable increases in drug and alcohol disorders, psychological disorders, traumatic incidents and criminal activity are all common. Hence, early intervention seems warranted. It is also at this point when homeless youth are most likely to take advantage of homeless services to assist them to re-integrate into the community (Auerswald & Eyre, 2002). Another possible point of secondary prevention would be court diversion schemes to deal with the psychopathology that precedes criminal activity amongst homeless youth. For example, those youth who are homeless and become involved in crime to fund drug addictions could be diverted into rehabilitation for assessment and treatment. This may improve drug and alcohol and psychological problems, reduce the need for crime and help to break the cycle of homelessness. The recent introduction of the drug courts in NSW is an example of such a diversion program; however, assessment and treatment focussing on the specific needs of youth who are homeless (such as finding appropriate long-term housing) may increase the benefits for these youth. It is imperative that future research assess the impact of such schemes. Our data also have relevance to the evaluation of service outcomes. The data suggest that once homeless there is a high probability of increasing psychopathology, drug and alcohol problems, criminal involvement and re-victimisation. Based on this finding, existing services for homeless youth that are able to support youth in ways that can prevent the development of additional psychological difficulties should be considered ‘successful’. In the current political and economic climate, the need to justify and evaluate the outcome of services is increasing. The implication of this research is that those services whose clients remain stable, even if function is less than optimal, are in fact producing relative improvements in the outcome for young homeless people.
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The life experiences of the homeless youth interviewed in this study also have important implications for public perception of homelessness, in general, and homeless youth in particular. Homeless people in our community are stigmatised and marginalised. However, understanding the complex set of traumatic experiences that culminate in the psychological difficulties (psychological disorders, PTSD and drug and alcohol problems) can help communities to engender more appropriate attitudes towards homeless young people. In particular, the virtual absence of crime amongst homeless youth prior to homelessness would be an important factor to emphasise in order to encourage the public to have more empathy for young people who find themselves homeless. The present study has identified a number of pathways by which young people become homeless. In particular, the role of childhood adversity, trauma and the presence of psychological disorders, including PTSD, and drug and alcohol problems have been highlighted. Unfortunately, it appears that once young people become homeless, youth develop a broader range of psychological disorders and are commonly revictimised. Further, many young people turn to crime to support their needs once homeless. These results have provided a framework for investigating the pathways to homelessness in larger samples. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revised). Washington, DC: American Psychiatric Association. Auerswald, C. L., & Eyre, S. L. (2002). Youth homelessness in San Francisco: A life cycle approach. Social Science & Medicine, 54, 1497–1512. Buhrich, N., Hodder, R., & Teesson, M. (2000). Lifetime prevalence of trauma among homeless people in Sydney. Australian and New Zealand Journal of Psychiatry, 34, 963–966. Buhrich, N., Hodder, R., & Teesson, M. (2003). Caring for homeless people who have a mental disorder down and out in Sydney, Vol. 2. Sydney, Australia: Research Group in Mental Health and Homelessness. Cauce, A. MN., Paradise, M., Ginzler, J. A., & Embry, L. (2000). The characteristics and mental health of homeless adolescents: Age and gender differences. Journal of Emotional and Behavioural Disorders, 8(4), 230–239. Craig, T., & Hodson, S. (1998). Homeless youth in London: I. Childhood antecedents and psychiatric disorder. Psychological Medicine, 28, 1379–1388. Goering, P., Tomiczenko, G., Sheldon, T., Boydell, K., & Wasylenki, D. (2002). Characteristics of persons who are homeless for the first time. Psychiatric Services, 53, 1472–1474. Herman, D. B., Susser, E. S., Struening, E. L., & Link, B. (1997). Adverse childhood experiences: Are they risk factors for adult homelessness? American Journal of Public Health, 87(2), 249–255.
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House of Representatives Standing Committee on Community Affairs. (1995). Reports on aspects of youth homelessness. Canberra: Australian Government Press Service. Kamieniecki, G. W. (2001). Prevalence of psychological distress and psychiatric disorders among homeless youth in Australia: A comparative review. Australian and New Zealand Journal of Psychiatry, 35, 352–358. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., Williamson, D., & Ryan, N. (1997). Schedule for affective disorders and schizophrenia for school-age children—Present and lifetime version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980–988. Kaufman, J., Birmaher, B, Brent, D., Ryan, N., & Rao, U. (2000). K-SADS-PL. Journal of the American Academy of Child & Adolescent Psychiatry, 39(10), 1208. Lipschitz, D. S., Bernstein, D. P., Winegar, R. K., & Southwick, S. M. (1999). Hospitalised adolescents’ reports of sexual and physical abuse: A comparison of two self-report measures. Journal of Traumatic Stress, 12(4), 641–654. Molnar, B. E., Shade, S. B., Kral, A. H., Booth, R. E., & Watters, J. K. (1998). Suicidal behaviour and sexual/ physical abuse among street youth. Child Abuse & Neglect, 22, 213–222. Noell, J., Rohde, P., Seeley, J., & Ochs, L. (2001). Childhood sexual abuse, adolescent sexual coercion and sexually transmitted infection acquisition among homeless female adolescents. Child Abuse & Neglect, 25, 137–148. North, C. S., Pollio, D. E., Smith, E. M., & Spitznagel, E. L. (1998). Correlates of early onset and chronicity of homelessness in a large urban homeless population. The Journal of Nervous and Mental Diseases, 186(7), 393–400. Phelan, J., & Link, B. G. (1999). Who are ‘the Homeless’? Reconsidering the stability and composition of the homeless population. American Journal of Public Health, 89(9), 1334–1338. Rew, L., Fouladi, R. T., & Yockey, R. D. (2002). Sexual health practices of homeless youth. Journal of Nursing Scholarship, 34(2), 139–145. Ryan, K. D., Kilmer, R. P., Cauce, A. M., Watanabe, H., & Hoyt, D. R. (2000). Psychological consequences of child maltreatment in homeless adolescents: Untangling the unique effects of maltreatment and family environment. Child Abuse & Neglect, 24, 333–352. Stewart, A. J., Steinman, M., Cauce, A. M., Cochran, B., Whitbeck, L., & Hoyt, D. (2004). Victimization and posttraumatic stress disorder among homeless adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 325–331. Urquiza, A. J. (1991). Retrospective methodology in family violence research–our duty to report past abuse. Journal of Interpersonal Violence, 1, 119–126. Wilson, T. D., Houston, C. E., Etling, K. M., & Brekke, N. (1996). A new look at anchoring effects: Basic anchoring and its antecedents. Journal of Experimental Psychology, 125(4), 387–402. Wittchen, H. U. (1994). Reliability and validity of the WHOComposite International Diagnostic Interview (CIDI): A critical review. Journal of Psychiatric Research, 28, 57–84.
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World Health Organisation. (1997). CIDI-Auto, Administrator’s guide. Sydney: World Health Organisation.
Further reading American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: American Psychiatric Association. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Barlow, D. H. (2001). Clinical handbook of psychological disorders (3rd ed.). USA: Guilford Press. Craig, T., & Hodson, S. (2000). Homeless youth in London: II. Accommodation, employment and health outcomes at 1 year. Psychological Medicine, 30(1), 187–194.
Lesieur, H. R., & Blume, S. B. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal of Psychiatry, 144, 1184–1188. Shern, D. L., Tsemberis, S., Anthony, W., Lovell, A. M., Richmond, L., Felton, C. J., Winarski, J., & Cohen, M. (2000). Serving street-dwelling individuals with psychiatric disabilities: Outcomes of a psychiatric rehabilitation clinical trial. American Journal of Public Health, 90(12), 1873–1878. Spielberger, C. D., Gorsuch, R., Lushene, R., Vagg, P., & Jacobs, G. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. Stanley, M. A., Beck, G. J., & Zebb, B. J. (1996). Psychometric properties of four anxiety measures in older adults. Behaviour Research and Therapy, 34(10), 827–838. Stinchfield, R. (2002). Reliability, validity and classification accuracy of the South Oaks Gambling Screen (SOGS). Addictive Behaviours, 27, 1–19.
Social Science & Medicine 62 (2006) 1–12 www.elsevier.com/locate/socscimed
Pathways to youth homelessness Claudine Martijn, Louise Sharpe The Clinical Psychology Unit (F12), School of Psychology, The University of Sydney, Camperdown, NSW 2006, Australia Available online 27 June 2005
Abstract Research documents high levels of psychopathology among homeless youth. Most research, however, has not distinguished between disorders that are present prior to homelessness and those that develop following homelessness. Hence whether psychological disorders are the cause or consequence of homelessness has not been established. The aim of this study is to investigate causal pathways to homelessness amongst currently homeless youth in Australia. The study uses a quasi-qualitative methodology to generate hypotheses for larger-scale research. High rates of psychological disorders were confirmed in the sample 35 homeless youth aged 14–25. The rates of psychological disorders at the point of homelessness were greater than in normative samples, but the rates of clinical disorder increased further once homeless. Further in-depth analyses were conducted to identify the temporal sequence for each individual with a view to establishing a set of causal pathways to homelessness and trajectories following homelessness that characterised the people in the sample. Five pathways to homelessness and five trajectories following homelessness were identified that accounted for the entire sample. Each pathway constituted a series of interactions between different factors similar to that described by Craig and Hodson (1998. Psychological Medicine, 28, 1379–1388) as ‘‘complex subsidiary pathways’’. The major findings were that (1) trauma is a common experience amongst homeless youth prior to homelessness and figured in the causal pathways to homelessness for over half of the sample; (2) once homeless, for the majority of youth there is an increase in the number of psychological diagnoses including drug and alcohol diagnoses; and (3) crime did not precede homelessness for all but one youth; however, following homelessness, involvement in criminal activity was common and became a distinguishing factor amongst youth. The implications of these findings for future research and service development are discussed. r 2005 Elsevier Ltd. All rights reserved. Keywords: Homeless; Youth; Psychological disorders; Pathways; Trauma; Australia
Introduction The prevalence of psychological disorders among homeless adults has consistently found that the vast majority of homeless people experience at least one psychological disorder (Buhrich, Hodder, & Teesson, 2000; Herman, Susser, Struening, & Link, 1997; Kamieniecki, 2001). Consistently, research has found that well in excess of 50% of homeless young people Corresponding author. Tel.: 9351 4558; fax: 9351 7238.
E-mail address: [email protected] (L. Sharpe).
have drug and alcohol problems (e.g. Goering, Tomiczenko, Sheldon, Boydell, & Wasylenki, 2002). Similarly, rates of mood disorders, psychotic disorders and trauma-related disorders have all been found to be over-represented amongst homeless youth (e.g., Cauce, Paradise, Ginzler, & Embry, 2000; Herman et al., 1997; Kamieniecki, 2001). The degree of psychological distress is also indicated by the high rates of suicidal behaviours in this group of disadvantaged youth. Indeed, Molnar, Shade, Kral, Booth, and Watters (1998) found that 48% of homeless young women and 27% of males had attempted suicide, and amongst those with a suicide
0277-9536/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2005.05.007
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attempt, there was an average of 6.2 and 5.1 attempts for women and men, respectively. Moreover, suicide attempts have been found to be independently predicted by a history of childhood trauma (Molnar et al., 1998). Research into the experience of trauma amongst homeless people has found that traumatic events are virtually universal (Buhrich et al., 2000). Many homeless people were the victims of childhood trauma. For example, in one recent study of homeless youth, only 33% of participants did not report a history of either physical or sexual abuse or both (e.g. Ryan, Kilmer, Cauce, Watanabe, & Hoyt, 2000). In addition, research confirms that histories of childhood trauma pre-dispose young homeless people to the risk of future victimisation (Noell, Rohde, Seeley, & Ochs, 2001; Stewart et al., 2004). Despite these findings, few studies have attempted to determine the specific role that trauma and its psychological sequelae have had in promoting the development of homelessness. It is often unclear from research whether traumatic experiences and/or psychological disorders are a cause or a consequence of homelessness. While it is important to know that psychological disorders are common among homeless youth, in order to develop services to meet the needs of this population, such findings do not enable us to identify the pathway(s) by which young people become homeless. That is, we are not able to place events in a temporal sequence to determine likely causal pathways to homelessness. Few investigations have examined the temporal relationship between the experience of trauma, the development of psychological disorders and homelessness. Two studies have investigated the temporal relationship of psychological disorders and other events in relation to the first onset of homelessness, with a view of determining likely causal factors. A UK study with homeless youth by Craig and Hodson (1998) found a significant difference between homeless youth and their control domiciled population in psychiatric disorders and childhood adversity. Craig and Hodson (1998) found that among the homeless subjects, 70% of psychiatric disorders begin prior to homelessness. They went on to develop tentative models that identified risk factors for becoming homeless. They concluded that childhood adversity, educational attainment and the prior existence of psychiatric disorders all independently increased the likelihood of homelessness. Similar results were found, yet significantly different conclusions made, in a study conducted in the USA by North, Pollio, Smith, and Spitznagel (1998) with homeless adults. In keeping with the findings of Craig and Hodson (1998), they found that there was a higher prevalence of psychiatric disorder amongst homeless adults and in most instances the onset of their disorder was prior to homelessness. However, they also compared the age of onset of psychiatric disorders for those
participants in the homeless and control group who had a psychological disorder. The age of onset was similar in the both groups, except for drug and alcohol problems which had their onset earlier in the homeless sample. North et al. (1998) concluded that while the onset of psychiatric disorders preceded homelessness, psychiatric disorders could not be assumed to have a causal role in the onset of homelessness. They argued that the occurrence of psychiatric disorders prior to homelessness is explained ‘‘yby the natural history of the disorders whose onset just happens to occur before a certain age, rather than causally associated with the development of homelessness.’’(p. 398). Their conclusion, while one interpretation of the available data, is open to question. Psychiatric illness should not be excluded as a risk factor for homelessness simply because the timing of the onset of psychiatric disorders was found to be the same between the control and homeless samples. The greater prevalence of psychiatric disorders in the homeless population prior to homelessness suggests that psychiatric illness cannot be excluded as a potential causal factor in youth homelessness. It is clear that further research is needed to establish the temporal relationship between different factors and the onset of homelessness. Notably, neither study assessed for post-traumatic stress disorder (PTSD), despite Craig and Hodson (1998) finding childhood adversity to be an important risk factor for homelessness. Childhood adversity was defined as the experience of neglectful (parental indifference, antipathy, parental control) or abusive (physical and/or sexual) situations in the family of origin. Many of these experiences are traumatic and may result in posttraumatic sequelae, including PTSD. In this context PTSD would seem to be an important disorder to assess. The present study aims to understand the individual transitions of young people, including childhood experiences and psychological disturbance, in relation to the onset of their homelessness. Specifically, the aim of the present study is to determine identifiable ‘pathways’ to homelessness amongst homeless youth and the subsequent trajectories of homeless youth. It is hypothesised that the experience of trauma will be a significant contributory factor in the pathway to homelessness for a large proportion of young people.
Method Participants Participants were recruited from four homeless youth services, run by a charity organisation in New South Wales, Australia. Homeless youth were defined as youth between 14 and 25 years (Kamieniecki, 2001), and either
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(a) living without family assistance; (b) in no accommodation at all; (c) in temporary or emergency accommodation; or (d) in other long-term supported accommodation for homeless people (House of Representatives Standing Committee on Community Affairs, 1995). Each service informed their clients of the study. Three of the services were in the central city area, while the remaining service was a medium-term (6 months) supported accommodation service for homeless youth set within a therapeutic community in a rural area. Forty-one homeless youth were approached to take part in the study and 35 volunteered (85%). Two participants did not complete the interview. Procedure Given the paucity of research in this area, a quasiqualitative methodology was considered both necessary and beneficial to allow the development of testable models. Other studies have employed such methodologies to develop models in under-researched areas, such as the life-cycle of homeless youth (Auerswald & Eyre, 2002) and the sexual health practices of homeless youth (Rew, Fouladi, & Yockey, 2002). Participants were interviewed in-depth about their life experiences for approximately 3 h, with the researcher keeping detailed notes. During this process, they completed a timeline to facilitate accurate recall of the temporal sequence of their life experiences (Wilson, Houston, Etling, & Brekke, 1996). The timeline was presented visually and comprised six dimensions: (a) family, (b) drug and alcohol use, (c) mental health, (d) housing, (e) trauma and (f) other information (e.g. criminal activity). The timeline was presented within a semi-structured interview adapted for youth, based on Buhrich et al. (2000). The interviewer and participant entered significant life events from each dimension at the time of the interview. Further, after the completion of the interview, the researchers used onset and recency data from the structured diagnostic interview to estimate the onset of diagnosable mental disorders. The interview included demographic information, experiences of trauma and childhood parental care, and the CIDI (World Health Organisation (WHO), 1997) or K-SADS (Kaufman, Birmaher, Brent, Ryan, & Rao, 2000) (depending on the age of the youth) to assess mood disorders, drug and alcohol dependence and PTSD. A psychosis screen was also used. As such, the interview consisted of a combination of closed questions and other open-ended questions. All young people were interviewed within a service by the first author who was trained in managing distress. Any participant who remained distressed following the interview or disclosed experiences of abuse which they had not previously disclosed were offered further assistance from staff in each service. Feedback from
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the participants indicated that they valued the opportunity to tell their stories. A number of participants disclosed traumatic experiences for the first time during the interview and in many cases requested that this information be made available to their treating caseworkers so that they could access services to deal with the psychological consequences of the trauma. The University of Sydney Human Research Ethics Committee approved the study and formal approval was granted by the charity. Participants were paid $20 to reimburse them for their time and effort. Measures (i) The Composite International Diagnostic Interview (CIDI) Version 10 (WHO, 1997) is a structured interview that is used to generate psychiatric diagnoses. ICD10 and DSM-IV diagnoses were generated, as were the age of onset of the diagnosis and recency data. The CIDI has been shown to have good interrater reliability and validity (Wittchen, 1994). (ii) The Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version, Version 10 (K-SADS) (Kaufman et al., 2000) was used for those participants under 18 years. This instrument also generates both ICD10 and DSM-IV diagnoses. The relevant sections of the K-SADS were administered to the participant (i.e. depressive disorders, drug and alcohol disorders and PTSD). The K-SADS has been shown to have good reliability and validity (Kaufman et al., 1997). Analysis Criteria (listed as 1–5 below) were developed to determine proximal factors for homelessness and enable the identification of different pathways to the onset of homelessness. Only experiences that had occurred prior to the onset of homelessness were considered. The presence of five main factors was assessed. (1) The first factor was the presence of a psychological disorder. A psychological disorder was considered to have been present if its onset preceded homelessness and it was a diagnosable disorder according to the diagnostic criteria employed. That is, diagnoses of depression and/or PTSD, according to either DSMIV or ICD-10. The diagnosis of psychosis was assumed if the person reported that they had been diagnosed by a psychiatrist with a psychotic illness and scored above the cut-off point on the psychosis screener. Age of onset for psychosis was gauged through self-report. (2) The second factor was ‘trauma’ which was defined by Criteria A of the PTSD diagnostic criteria in
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DSM-IV. Criteria A for PTSD diagnosis is as follows: ‘‘The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, (2) the person’s response involved intense fear, helplessness, or horror.’’ (American Psychiatric Association (APA), 2000). Trauma was identified separately from psychological disorders because the two could occur independently of each other, even though they might clearly be strongly related. (3) The third factor was ‘drug and alcohol problems’. These were categorised separately from psychological disorders due to the high incidence of drug and alcohol problems in this population and the fact that they bring with them a potentially different set of problems other than psychological disorders (e.g. involvement in crime, arguments with family, etc.). Both abuse and dependence were defined according to DSM-IV and/or ICD-10. The use of drugs in the absence of a diagnosis was not included as a factor. Cigarette smoking (i.e. nicotine dependence/abuse) was excluded. (4) The fourth factor was ‘crime’ which was defined as involvement in criminal activity resulting in police involvement and resulting in charges laid. (5) The final factor was ‘family problems’ which was defined as a factor in isolation due to the high rate of family conflict reported by the young people in the sample and its likely relevance (Craig & Hodson, 1998; House of Representatives Standing Committee on Community Affairs, 1995). Incidents such as the family no longer supporting youth by way of money/ shelter/food were considered to be neglect regardless of whether they resulted in state intervention. Specifically, participants were considered to have had ‘family problems’ if they endorsed questions indicating that there was abuse1 or neglect in the family of origin or if they had been taken into care. The incidence of each factor was entered onto each participant’s timeline. The temporal relationship between each factor and the onset of first homelessness was then determined. Those factors that occurred prior to the first episode of homelessness were deemed possible contributors to homelessness. These data were then investigated to determine whether or not the participants’ experiences could be grouped into a meaningful set of pathways that lead to homelessness. The identification of factors and the allocation of participants to pathways was conducted independently by the 1 Abuse, sufficient to meet Criterion A of DSM-IV for PTSD was included under trauma, rather than family problems.
two investigators. Discrepancies were resolved by reaching a consensus. Once a consensus was reached, the data were then re-rated again by the two raters, and then rated a final time by a party independent of the research. The intra-rater reliability was calculated using k coefficients (k ¼ .75). The inter-rater reliability was also good (k ¼ .75).
Results The participants were an average age of 19.9 years (SD ¼ 2.1). On average, participants had been first homeless at the age of 15.8 years (SD ¼ 2.8). Sixty-four percent of the sample was male, 88% single, only 6% had children, 96% were born in Australia or New Zealand, 60% had left school by the age of 16 years and 75% were receiving Youth Allowance (a government source of funding for young people living independently). Ninety percent of the sample had experienced at least one trauma, with an average of 2.2 traumas. Childhood sexual abuse was experienced by 20% of the sample (60% of the young homeless women) and physical abuse was reported by 51.5% of the sample.
Pathways to homelessness Five different pathways were identified. Each pathway is defined by the combination of precipitant factors for homelessness. In describing each pathway, characteristics of the young people in each pathway are described to give a sense of their experiences. Crime, which was initially developed as a separate factor, was removed following analysis of the data. There was only one case in which crime occurred prior to homelessness and it was therefore not considered to significantly represent the pathways identified in the sample. As can be seen in Fig. 1, pathway two (trauma and psychological problems with the absence of drug and alcohol) and pathway three (drug and alcohol) appeared to be the most common pathways to homelessness of the sample. Pathway five (trauma) was the leastcommon pathway and, as can be seen in Fig. 1, accounted for fewer subjects compared with all of the other pathways. The five pathways identified are described in detail below. Pathway one: Drug and alcohol, trauma with or without additional psychological problems Five of the six participants in pathway one were male. All participants in this pathway had experienced a trauma. For half of the participants the trauma preceded any history of drug and/or alcohol abuse/dependence; however, for the other half the trauma occurred
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25
Percentage
20
15
10
5
0 Pathway 1
Pathway 2
Pathway 3
Pathway 4
Pathway 5
Fig. 1. Proportion of subjects in each pathway.
following a history of drug and/or alcohol abuse/ dependence. For the participants where the trauma preceded drug and alcohol abuse/dependence, all three met criteria for cannabis abuse with two of the three also having problems with alcohol abuse/dependence. In contrast, the three young people for whom the drug and/ or alcohol abuse/dependence preceded the trauma all met criteria for multiple drug and/or alcohol abuse/ dependence, including cannabis, hallucinogens, ecstasy, and alcohol. In this pathway, only two of the group met criteria for psychological disorders prior to homelessness. In both cases, the young people met criteria for posttraumatic stress disorder, and in one case there was a co-morbid major depressive disorder. Pathway two: Trauma and psychological problems (the absence of drug and alcohol) Six of the eight participants in pathway two were male. In contrast to pathway one, for all participants in pathway two the trauma preceded any psychological disturbance. The most common psychological disorder was posttraumatic stress disorder, which occurred in six of the eight young people. Of those six, four had a comorbid diagnosis of major depressive disorder. The remaining two participants both met criteria for major depressive disorder.
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the eight cases, participants described their upbringing as neglectful, often reporting spending time living with relatives or friends. One additional participant described emotional abuse as a precursor to drug abuse. The remaining two participants did not report a history of family dysfunction preceding their drug and alcohol use. However, conflict within the family led both of these participants to be ‘thrown out’ of home. Interestingly, both these participants were the only two in this group who met criteria for alcohol dependence and abuse prior to their experience of homelessness. Some participants experienced psychological disorders: three met criteria for major depressive disorder, with two of these diagnoses preceding their drug abuse. One other participant developed schizophrenia, after having met the criteria for cannabis abuse. Pathway four: Family problems Of the seven participants in this pathway to homelessness, four were male. Five of the participants reported a history of neglect necessitating periods of absence from their familial home. In two cases, this resulted in lengthy periods in care during childhood. Of the other two participants, one reported a history of physical abuse, not sufficient to meet Criteria A for PTSD, and witnessing domestic violence in the home. The other participant reported emotional abuse throughout childhood. Surprisingly, of these seven young people, only one met criteria for any psychological disorder prior to homelessness, which was major depressive disorder. Further, none met criteria for drug or alcohol abuse or dependence prior to their first episode of homelessness. Pathway five: Trauma There were only two participants in this pathway, both of whom were female. In both cases, the trauma that they experienced was childhood sexual abuse within the family of origin. Interestingly, in both cases the trauma occurred early in childhood, with both young women reporting the onset of child sexual abuse at the age of 5 years. Neither participant developed any psychological disorder or drug or alcohol abuse or dependence prior to the onset of homelessness.
Pathway three: Drug and alcohol and family problems
Trajectories following first onset of homelessness
Five of the eight participants were male. All participants met criteria for drug abuse or dependence, with the exception of one participant who met criteria for alcohol dependence and abuse. One further participant met criteria for alcohol dependence and abuse in addition to drug dependence and addiction. In five of
The youth represented in each pathway to homelessness were re-visited to determine if the factors that preceded homelessness changed following homelessness. Each subject’s factors were entered on their timeline if the problem developed after they were homeless. The data were analysed in the same way as for pathways to
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homelessness, to determine if there were changes. Analyses were conducted in keeping with the previously developed criteria. Factors that were pre-existing (i.e. featured in the pathways to homelessness for an individual) were not included as factors in the trajectory. That is, a factor was only considered if its onset followed homelessness. There were five identifiable trajectories, as follows (see Fig. 2): Trajectory A: Trajectory B: Trajectory C: Trajectory D: Trajectory E:
Psychological with or without trauma. Psychological with or without trauma, and drug and alcohol. Psychological with or without trauma, drug and alcohol, and crime. Crime and/or drug and alcohol. Stable.
All participants with diagnoses of psychological or addictive disorders prior to homelessness fell into the trajectories A–D. That is, those individuals who at the point of becoming homeless had developed either a psychological disorder or a drug or alcohol problem all developed additional problems once homeless. The four cases that remained stable over time did not satisfy criteria for any psychological or addictive problem at the time of homelessness. Three of these individuals came from pathway four and one from pathway five. That is, these individuals had difficult childhoods, which they negotiated without developing significant psychological difficulties, but nonetheless became homeless. In contrast, the vast majority of the young people in the study (87.5%) deteriorated significantly once homeless (Fig. 3).
40 35 30
Percentage
25 20 15 10 5 0 Pathway A
Pathway B
Pathway C
Pathway D
Pathway E
Fig. 2. Proportion of subjects in each trajectory following the onset of homelessness.
Overall, with the exception of the individuals described above, the trajectories following the onset of homelessness are characterised by four main factors: drug and alcohol, psychological disorders, trauma and crime. The two most prevalent factors were drug and alcohol and psychological factors, the rates of which increased considerably following homelessness. Although crime was less prevalent (33%), given that there was a virtual absence of crime prior to homelessness, the increase once homeless should be highlighted. Interestingly, the two pathways representing the highest proportions of the sample were pathways B and C, both of which share psychological, trauma and drug and alcohol factors and differ only in the factor of crime.
Case examples The findings in this study have generated considerable data providing context to youth homelessness, which is often lost in purely quantitative research. Auerswald and Eyre (2002) argue that contextual and exploratory research is critical for the development of comprehensive understanding of minority populations, in particular. They further argue that qualitative research is descriptive and explanatory and necessary for investigating marginalised populations (Auerswald & Eyre, 2002). The following serves to illustrate the contextual information gathered during interviews, as well as to further contextualise the five pathways identified in this research, and the subsequent trajectories once homeless. All identifying information has been removed or significantly changed to preserve confidentiality. Pathway one: Drug and alcohol, trauma with or without psychological problems Simon was an 18-year-old male born in Tasmania. Simon lived with his mother and father up to the age of 7 years, after which he moved to NSW to live with his Aunt. Simon was moved away from his mother and father due to severe and recurring physical abuse from Simon’s father. The physical abuse began when Simon was five, when he sustained physical injuries requiring hospitalisation on several occasions, and developed PTSD as a result. Simon lived with his Aunt for 10 months after which time he returned to his parents in Tasmania and then shortly thereafter returned to live in NSW with both parents. Simon reported that the physical abuse continued until he was 16, during which time he continued to satisfy criteria for PTSD. Simon reported initial drug use at the age of 13 years and alcohol use at 14. Simon also satisfied criteria for alcohol and drug abuse and dependence at the age of 14, and continued to satisfy criteria for drug dependence at 18. Simon’s alcohol abuse and dependence abated when
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Factor
Pathway
Factor
7
Trajectory
D&A
1
D&A Psych 2
H
A
O
M
3
E Psych L
Trauma B E 4 S
S
Crime
Family 5
C
Fig. 3. Pathways to homelessness and trajectories following the onset of homelessness.
he was 16. However, Simon’s drug and alcohol use remained a source of conflict between him and his father. At the age of 16, his father kicked him out of home due to conflict over his drug and alcohol use. At the time of this argument, his father physically abused him sufficiently severely that his injuries required hospitalisation. After being discharged, Simon had
nowhere to live and moved in with one of his friends for a few days after which time he moved into a refuge for homeless youth. Once homeless, Simon began using speed daily, meeting criteria for an additional drug disorder. By 17, Simon had left school and remained homeless (in a series of refuges and/or on the streets) until the age of 18, when
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he sought services and was admitted to a medium stay residential program for homeless youth. As with many of the young people in pathway one originally, Simon had already developed both drug and alcohol and psychological difficulties before homelessness. However, these problems increased in number following homelessness (Trajectory B). Pathway two: Trauma and psychological problems (the absence of drug and alcohol) John was a 20-year-old Australian born male who lived with his father and mother until he was 16 years when he was kicked out of home. John reported that he had been sexually abused by his father at the age of six and several times thereafter. John satisfied criteria for PTSD from age six and continued to do so. John attempted suicide at the age of 16 years through selfmutilation with a knife. According to diagnostic criteria, John had his first severe major depressive episode at this point in time, which continued at interview. John reported being kicked out of home by his parents because of his aggressive behaviour at home and moved into a refuge for homeless youth when he was 16. Once homeless, John began using drugs including speed, LSD, and ecstasy on a weekly basis. By 17, John fulfilled criteria for alcohol abuse and the abuse of both hallucinogens and cocaine. Although John was intermittently homeless, he did return home for periods of time over the next year. At 18, due to his increasing violence against his mother, an apprehended violence order was taken out against him. By the age of 19, John was admitted to a psychiatric hospital for 4 months with a diagnosis of drug-induced psychosis and was subsequently diagnosed with schizophrenia (Trajectory C).
smoking cannabis daily and became involved with crime to support his drug habit. At 18, he was arrested for breaking and entering and served 6 months in jail. Following his release, he developed a problem with alcohol, and by age 19 met criteria for alcohol dependence and abuse (Trajectory D). Pathway four: Family with or without psychological problems Adam was a 19-year-old Aboriginal male who reported his first period of homelessness at the age of 14 years. Adam lived with his mother until the age of 12. His father left the family when Adam was three. Adam reported that he and his mother continually argued about Adam’s behaviour and did not have a good relationship. When Adam was 12, his mother no longer wanted to care for him, and Adam became a ward of the state. Adam’s grandmother took custody of him 1 month later and Adam lived with her until the age of 14. Adam’s first experience of homelessness was when he moved out of his grandmother’s house reporting that he and his grandmother continually argued. Adam moved into a refuge for 1 month. During his first month in a refuge, Adam was arrested for stealing cars. Over the next 2 years, he was involved with Juvenile Justice on at least four occasions. At 16, Adam developed cannabis abuse and dependence, and continued to have trouble with the law. His offences included car theft and during this time he was involved in a car accident. At 17 years, Adam developed a major depressive episode and shortly thereafter was arrested again for car theft and drunk driving and served 6 months in Juvenile Justice. On his release, he entered a residential program, but continued his drug use and by age 19 also met criteria for alcohol abuse (Trajectory C).
Pathway three: Drug & alcohol and psychological problems
Pathway five: Trauma
Peter was a 19-year-old Australian born male. Peter lived with his mother following his father leaving the family when Peter was 2 years old. Peter reported that his mother had a severe problem with alcohol throughout his childhood, which resulted in arguments. Peter began using drugs at 13 and had developed both drug abuse and dependence disorders by 15. Peter continued to satisfy criteria for drug abuse and dependence. Peter also had a moderate major depressive episode at the age of 16 that lasted for 1 year. Peter was admitted to an out-patient unit at a hospital for drug rehabilitation during this time after which he left home and lived with friends and shortly after lived in a refuge. Shortly after becoming homeless, Peter gave up all drug use and was admitted to a hospital for withdrawal. During his admission, he developed a second major depressive episode. Following discharge, Peter resumed
Terry was a 23-year-old Australian born female. Terry predominantly lived with her mother until the age of 16 years; however, her mother made her go to live with her father on weekends after their divorce when Terry was 6 years old. Terry reported a long history of sexual abuse by her father that began when she was five and continued to the age of 14. When Terry was 14, her mother kicked her out of home and she had her first episode of homelessness. Terry reported that her mother asked her to leave because she considered that she was of no use around the home. Terry reported running away for short periods of time to her older brother’s house before 14 because of the experiences of sexual abuse when she was forced to stay with her father on the weekends. Despite Terry’s long history of sexual abuse by her father, she did not meet criteria for any psychological
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disorder at the time she became homeless. Having been asked to leave home at 14, Terry lived with a variety of relatives and moved into a refuge. At 16 years, Terry was assaulted again by her father, and subsequently developed a major depressive episode and attempted suicide. At 19, Terry remained homeless and was raped. She developed PTSD as a result and met criteria for alcohol abuse and dependence. Although her drug and alcohol problems remitted, she continued to meet criteria for PTSD and major depressive disorder and had a further attempt at suicide (Trajectory B).
Discussion The aim of the present study was to explore the life experiences of a group of homeless youth to identify pathways towards homelessness. We aimed to investigate the temporal sequence between those factors previously identified in the literature, namely childhood adversity, trauma, psychiatric disorder, crime and drug and alcohol problems. As is typical in samples of homeless youth, the participants in the current study had high rates of psychopathology and in the majority of cases psychopathology preceded the onset of homelessness. By examining the temporal sequence, pathways to homelessness were suggested by the data. Five pathways to homelessness were identified, accounting for each participant in the sample. Pathways 2 (trauma and psychological problems without drug or alcohol), 3 (drug and alcohol and psychological problems) and 4 (family problems with or without psychological) represented the majority of the sample. Pathway five (trauma alone) accounted for only 6% of the sample. Further analysis of these five different pathways shows that four distinct factors can be distilled from the five pathways, namely drug and alcohol, psychological, trauma and family problems. These findings are consistent with those factors previously identified in the available literature (Kamieniecki, 2001). However, what is highlighted in this current study is the additional importance of early trauma and the resulting psychological difficulties (including drug and alcohol disorders). Although early life experiences and trauma were important in pathways to homelessness, they did not differentiate between youth with different trajectories once homeless. Trauma was still a common experience following homelessness; however, trauma no longer distinguished between the trajectories. This most likely reflects the universality of trauma while on the streets and that traumatic events become so common that they fail to distinguish between the trajectories following homelessness. It seems that whatever way young people come to be homeless, once they are homeless they develop additional psychological or drug problems and
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a sizeable proportion (33%) turn to crime to either support their basic needs or their drug habit. The majority of young people when interviewed reported drug and/or alcohol disorders (70%) and/or psychological disorders (66%) compared to 42% and 44%, respectively, when first homelessness. Our results suggest that if the common factors of trauma, psychological disturbance or drug and alcohol problems remain untreated and the individual continues to live in an impoverished environment that is not conducive to optimal functioning, additional difficulties would be expected to develop. This suggests that the experience of homelessness compounds pre-existing psychological difficulties. Among this sample it was much more common for homeless youth with psychological impairments to use drugs and/or alcohol and to experience a level of criminal activity than to have psychological issues in isolation. Another important finding was that the majority of the sample involved in crime had a range of traumatic experiences, psychological disorders and drug and alcohol problems compared to the smaller number who became involved in crime and/or drugs and alcohol in isolation. Once again, the data show that it is more common for homeless youth to experience a multitude of difficulties rather than simply one problem increasing in severity over time. While studies to date have ventured to establish singular risk or associated factors of homelessness, the present research investigated how a number of factors were temporally linked with the first onset of homelessness. Craig and Hodson (1998) tentatively suggested the existence of ‘‘complex subsidiary pathways’’ (p. 1387) as necessary to explain the development of homelessness. They suggested the necessity of linking factors identified with homelessness and examining their cumulative role in the risk for homelessness. If one can identify complex subsidiary pathways, one may be able to isolate the precipitant factor or cluster of factors that have led to homelessness. This would help explain how and why youth first become homeless. In most cases it is more accurate to identify a pathway, rather than one single factor, that has had direct influence on the adolescent becoming homeless. The conclusions of this research are offered with caution given its limitations. First, the small sample size reduces the potential generalisability of the findings. A larger sample size is needed to determine whether the pathways presented here are exhaustive and generaliseable. A further limitation of this study is the representativeness of the sample. While the sample included youth from four different services around the state, homeless youth currently living ‘on the street’ or not in contact with services were not included. Further, participants were not randomly selected. Therefore the findings reported from this study may not be truly representative of homeless youth throughout Australia.
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Future research would be needed to determine whether street-dwelling youth had similar experiences to those reported here. In addition, the present study relied on retrospective recall in a group of young people with considerable psychopathology. While the investigators attempted to minimise the possibility of recall bias through the use of well-validated diagnostic interviews and the use of a timeline to anchor recall, the reliability of reports remains an issue. Importantly, research has been completed which suggests that young homeless people do report histories of childhood abuse accurately, according to corroboration (where available) and parental reports (Lipschitz, Bernstein, Winegar, & Southwick, 1999). Such results led Urquiza (1991, p. 120) to argue that retrospective research remains ‘‘a consistent, viable and economical source of family violence data’’. Nonetheless, this should be borne in mind when interpreting the data. The above limitations notwithstanding, this research has established a formulation of how young people become homeless. The strength of the present methodology is that it allows examination of the relationships between numerous factors simultaneously. Finally, this research has increased our understanding of the impact of trauma, drugs and alcohol and psychological pathology on youth homelessness. Although preliminary, these results if confirmed have implications for future research in the area of service development for homeless youth. Research in services for this underprivileged group is lacking and the present research suggests a number of areas where such research is warranted: (a) the current management of homeless youth, (b) the prevention of homelessness, (c) prevention of secondary complications and (d) public policy and public perception of homelessness, all of which are important research aims suggested in the literature (Phelan & Link, 1999). Perhaps most importantly the findings outlined in this investigation can be translated into practical suggestions for the development of services in the treatment, rehabilitation and support of homeless youth. In addition to suggestions offered by Buhrich, Hodder, and Teesson (2003), our research indicates the importance of trauma and PTSD. The assessment of homeless youth for a history of trauma and PTSD appears indicated given the high rates of trauma and PTSD in this sample and the high rates of re-victimisation. Secondly, many youth reported family problems as the factor involved in the onset of homelessness, and many of those necessarily came into contact with services through governmental investigations or being taken into care. This would suggest that the assessment of these youth when they first come into contact with services, and provision of appropriate services targeting traumatic experiences, may better help to prevent home-
lessness. Another possible point of early identification may be identifying those youth with drug and alcohol disorders given the high rates in this population found in this study. The identification of these factors may be more difficult given that these youth are not necessarily identified by any service before they become homeless. The majority of the sample (60%) was homeless by the age of 16. It may be that school counsellors could be better educated about the role of drug and alcohol disorders, histories of abuse, psychological difficulties and early trauma in the subsequent risk of youth homelessness. These professionals are amongst the few in an appropriate position to identify students at risk prior to homelessness. Another important implication is the prevention of secondary complications once youth are already homeless. Our data suggests that even only 4 years after the onset of homelessness, considerable increases in drug and alcohol disorders, psychological disorders, traumatic incidents and criminal activity are all common. Hence, early intervention seems warranted. It is also at this point when homeless youth are most likely to take advantage of homeless services to assist them to re-integrate into the community (Auerswald & Eyre, 2002). Another possible point of secondary prevention would be court diversion schemes to deal with the psychopathology that precedes criminal activity amongst homeless youth. For example, those youth who are homeless and become involved in crime to fund drug addictions could be diverted into rehabilitation for assessment and treatment. This may improve drug and alcohol and psychological problems, reduce the need for crime and help to break the cycle of homelessness. The recent introduction of the drug courts in NSW is an example of such a diversion program; however, assessment and treatment focussing on the specific needs of youth who are homeless (such as finding appropriate long-term housing) may increase the benefits for these youth. It is imperative that future research assess the impact of such schemes. Our data also have relevance to the evaluation of service outcomes. The data suggest that once homeless there is a high probability of increasing psychopathology, drug and alcohol problems, criminal involvement and re-victimisation. Based on this finding, existing services for homeless youth that are able to support youth in ways that can prevent the development of additional psychological difficulties should be considered ‘successful’. In the current political and economic climate, the need to justify and evaluate the outcome of services is increasing. The implication of this research is that those services whose clients remain stable, even if function is less than optimal, are in fact producing relative improvements in the outcome for young homeless people.
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The life experiences of the homeless youth interviewed in this study also have important implications for public perception of homelessness, in general, and homeless youth in particular. Homeless people in our community are stigmatised and marginalised. However, understanding the complex set of traumatic experiences that culminate in the psychological difficulties (psychological disorders, PTSD and drug and alcohol problems) can help communities to engender more appropriate attitudes towards homeless young people. In particular, the virtual absence of crime amongst homeless youth prior to homelessness would be an important factor to emphasise in order to encourage the public to have more empathy for young people who find themselves homeless. The present study has identified a number of pathways by which young people become homeless. In particular, the role of childhood adversity, trauma and the presence of psychological disorders, including PTSD, and drug and alcohol problems have been highlighted. Unfortunately, it appears that once young people become homeless, youth develop a broader range of psychological disorders and are commonly revictimised. Further, many young people turn to crime to support their needs once homeless. These results have provided a framework for investigating the pathways to homelessness in larger samples. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revised). Washington, DC: American Psychiatric Association. Auerswald, C. L., & Eyre, S. L. (2002). Youth homelessness in San Francisco: A life cycle approach. Social Science & Medicine, 54, 1497–1512. Buhrich, N., Hodder, R., & Teesson, M. (2000). Lifetime prevalence of trauma among homeless people in Sydney. Australian and New Zealand Journal of Psychiatry, 34, 963–966. Buhrich, N., Hodder, R., & Teesson, M. (2003). Caring for homeless people who have a mental disorder down and out in Sydney, Vol. 2. Sydney, Australia: Research Group in Mental Health and Homelessness. Cauce, A. MN., Paradise, M., Ginzler, J. A., & Embry, L. (2000). The characteristics and mental health of homeless adolescents: Age and gender differences. Journal of Emotional and Behavioural Disorders, 8(4), 230–239. Craig, T., & Hodson, S. (1998). Homeless youth in London: I. Childhood antecedents and psychiatric disorder. Psychological Medicine, 28, 1379–1388. Goering, P., Tomiczenko, G., Sheldon, T., Boydell, K., & Wasylenki, D. (2002). Characteristics of persons who are homeless for the first time. Psychiatric Services, 53, 1472–1474. Herman, D. B., Susser, E. S., Struening, E. L., & Link, B. (1997). Adverse childhood experiences: Are they risk factors for adult homelessness? American Journal of Public Health, 87(2), 249–255.
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House of Representatives Standing Committee on Community Affairs. (1995). Reports on aspects of youth homelessness. Canberra: Australian Government Press Service. Kamieniecki, G. W. (2001). Prevalence of psychological distress and psychiatric disorders among homeless youth in Australia: A comparative review. Australian and New Zealand Journal of Psychiatry, 35, 352–358. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., Williamson, D., & Ryan, N. (1997). Schedule for affective disorders and schizophrenia for school-age children—Present and lifetime version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980–988. Kaufman, J., Birmaher, B, Brent, D., Ryan, N., & Rao, U. (2000). K-SADS-PL. Journal of the American Academy of Child & Adolescent Psychiatry, 39(10), 1208. Lipschitz, D. S., Bernstein, D. P., Winegar, R. K., & Southwick, S. M. (1999). Hospitalised adolescents’ reports of sexual and physical abuse: A comparison of two self-report measures. Journal of Traumatic Stress, 12(4), 641–654. Molnar, B. E., Shade, S. B., Kral, A. H., Booth, R. E., & Watters, J. K. (1998). Suicidal behaviour and sexual/ physical abuse among street youth. Child Abuse & Neglect, 22, 213–222. Noell, J., Rohde, P., Seeley, J., & Ochs, L. (2001). Childhood sexual abuse, adolescent sexual coercion and sexually transmitted infection acquisition among homeless female adolescents. Child Abuse & Neglect, 25, 137–148. North, C. S., Pollio, D. E., Smith, E. M., & Spitznagel, E. L. (1998). Correlates of early onset and chronicity of homelessness in a large urban homeless population. The Journal of Nervous and Mental Diseases, 186(7), 393–400. Phelan, J., & Link, B. G. (1999). Who are ‘the Homeless’? Reconsidering the stability and composition of the homeless population. American Journal of Public Health, 89(9), 1334–1338. Rew, L., Fouladi, R. T., & Yockey, R. D. (2002). Sexual health practices of homeless youth. Journal of Nursing Scholarship, 34(2), 139–145. Ryan, K. D., Kilmer, R. P., Cauce, A. M., Watanabe, H., & Hoyt, D. R. (2000). Psychological consequences of child maltreatment in homeless adolescents: Untangling the unique effects of maltreatment and family environment. Child Abuse & Neglect, 24, 333–352. Stewart, A. J., Steinman, M., Cauce, A. M., Cochran, B., Whitbeck, L., & Hoyt, D. (2004). Victimization and posttraumatic stress disorder among homeless adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 325–331. Urquiza, A. J. (1991). Retrospective methodology in family violence research–our duty to report past abuse. Journal of Interpersonal Violence, 1, 119–126. Wilson, T. D., Houston, C. E., Etling, K. M., & Brekke, N. (1996). A new look at anchoring effects: Basic anchoring and its antecedents. Journal of Experimental Psychology, 125(4), 387–402. Wittchen, H. U. (1994). Reliability and validity of the WHOComposite International Diagnostic Interview (CIDI): A critical review. Journal of Psychiatric Research, 28, 57–84.
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World Health Organisation. (1997). CIDI-Auto, Administrator’s guide. Sydney: World Health Organisation.
Further reading American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: American Psychiatric Association. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Barlow, D. H. (2001). Clinical handbook of psychological disorders (3rd ed.). USA: Guilford Press. Craig, T., & Hodson, S. (2000). Homeless youth in London: II. Accommodation, employment and health outcomes at 1 year. Psychological Medicine, 30(1), 187–194.
Lesieur, H. R., & Blume, S. B. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal of Psychiatry, 144, 1184–1188. Shern, D. L., Tsemberis, S., Anthony, W., Lovell, A. M., Richmond, L., Felton, C. J., Winarski, J., & Cohen, M. (2000). Serving street-dwelling individuals with psychiatric disabilities: Outcomes of a psychiatric rehabilitation clinical trial. American Journal of Public Health, 90(12), 1873–1878. Spielberger, C. D., Gorsuch, R., Lushene, R., Vagg, P., & Jacobs, G. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. Stanley, M. A., Beck, G. J., & Zebb, B. J. (1996). Psychometric properties of four anxiety measures in older adults. Behaviour Research and Therapy, 34(10), 827–838. Stinchfield, R. (2002). Reliability, validity and classification accuracy of the South Oaks Gambling Screen (SOGS). Addictive Behaviours, 27, 1–19.