- Email: [email protected]
Characteristics and health care needs of homeless adolescents
Nurs Clin N Am 37 (2002) 423–431
Characteristics and health care needs of homeless adolescents Lynn Rew, EdD, RNC, HNC, FAAN School of Nursing, The University of Texas at Austin, 1700 Red River, Austin, TX 78701, USA
The exact number of homeless adolescents in the United States is unknown. Estimates ranging between 1 and 2 million youths include those who are homeless with their families (about 500,000), those who have been thrown away by their families (another 500,000), and those who have simply run away from home (1,000,000) [1]. Although an accurate estimate of the number of homeless adolescents is unknown, there is an expanding literature indicating that these youths are present in communities from coast to coast and from north to south. Moreover, their need for health care and social services is largely unmet. The purpose of this article is to describe the characteristics of adolescents who are homeless, reasons they give for their homeless condition, characteristics of the culture they share living on the streets of America, their health status and needs, and types of intervention programs that have been developed in response to their needs for health care and social services. The focus is on adolescents who are homeless without their families.
Homeless adolescents in the United States Adolescents who are homeless in the United States come from every socioeconomic stratum in urban, suburban, and rural areas. Homeless youth are both males and females of every racial/ethnic identity. Those who are homeless with their families are more likely to come from conditions of poverty whereas runaways come from families with variable economic resources [1]. Some homeless youth reside in shelters from time to time while others avoid contact with shelters unless their situations become extreme [2]. Many homeless teens make their beds under bridges, on informal E-mail address: [email protected] (L. Rew). 0029-6465/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 2 9 - 6 4 6 5 ( 0 2 ) 0 0 0 0 9 - 9
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campgrounds, and in abandoned buildings. A few find shelter with friends who have apartments. Characteristics of homeless adolescents There are many definitions of homeless youths. The National Coalition for the Homeless identifies homeless youths as those under 18 years of age who lack parental, foster, or institutional care [3]. The National Adolescent Health Information Center classifies youths as ‘‘runaways’’ when they leave home without parental permission, ‘‘thrownaways’’ when they are forced to leave home by their parents or guardians, and ‘‘street youth’’ when they have no home to return to and spend most of their time with peers on the street [4]. Another classification system identifies three types of runaway youth: (1) ‘‘running-to youths’’ who leave home in search of adventure, (2) ‘‘running-from youths’’ who make a rational decision to leave a dysfunctional family situation, and (3) ‘‘thrown-out youths’’ who are alienated from their families and there is mutual motivation from the teen and parents that the child not return home [5]. Youths who live at home with their parents or guardians, in contrast, are referred to as ‘‘household youths.’’ Reasons for adolescent homelessness There are many reasons why youth are homeless in the United States. Many who are known as ‘‘system kids’’ end up on the streets after multiple placements in foster homes, psychiatric hospitals, juvenile detention centers, residential schools, and shelters [6]. System kids are removed from their families by authorities who deem the home to be unsafe because of neglect or abuse, or because of death or incarceration of the caretakers [7]. Some youths drift into street life because they seek work on the streets to supplement their family’s income [8]. Others leave home to escape neglect and abuse related to their parents’ alcohol or other drug abuse [9]. And many more run away in response to physical, emotional, or sexual abuse [10]. In a recent study of 414 homeless youths in Texas, Rew, Fouladi, and Yockey [11] found that nearly 1 in 5 reported leaving home because of conflict with their parents over sexual orientation. Other participants reported leaving home because of emotional, physical, and/or sexual abuse. Alcohol and other drug (AOD) use are frequently cited as a factor that both contributes to adolescent homelessness [6] and is a consequence of coping with homelessness [12]. While homeless, many youth become disconnected from important relationships and adopt non-normative social values such as AOD use [12]. In a study of 929 homeless and runaway youths in New York City, Clatts et al found that more than half (53%) had used cocaine and over one third had used crack (36%) and heroin (38%) [13]. In sum, homeless adolescents arise from every geographic area and socioeconomic status in the United States. Their numbers are growing in
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response to continuing problems of parental neglect and abuse, family conflict and dysfunction, and inadequacies in the foster care and juvenile detention centers of this country. Health status and needs of homeless adolescents The major morbidities and mortalities of adolescents are primarily preventable and related to health-risk behaviors. Unlike infectious diseases of the early twentieth century, major morbidities of youths today are related to learned social behaviors such as using motor vehicles, experimenting with alcohol and other drugs, and engaging in unprotected sexual activities [6]. Moreover, most adolescents view themselves as healthy [8]. From a convenience sample of 96 homeless adolescents, Rew [14] found that the respondents’ perceived well-being was positively related to feeling socially connected to others who cared about them and inversely related to a history of sexual abuse and feelings of loneliness. About one third (38%) of the participants in the study stated they thought their health status was better than when they were living at home because they did more walking and had given up drugs and alcohol. Fewer (16%) stated they felt worse since they left home. Homeless adolescents must learn to survive in environments that are highly stressful and filled with greater health risks than those encountered by household youths. Although many have fled from homes that were chaotic, all of them find that having no permanent place for food, shelter, or social support creates a formidable challenge to healthy growth and development. These youths must also overcome multiple barriers to obtain comprehensive health care services including cost, distrust of care providers, transportation, fearing a diagnosis, not knowing where to go, and feeling embarrassed to ask for help [15]. Most homeless youths lack health insurance and rely on commonsense remedies for many of their health problems. Sexual abuse has been identified as a reason why many adolescents run away from home [16]. Both male and female runaways report having been sexually abused, although the rates are higher among females [16,17]. Adolescents who are sexually abused tend to run away from home earlier than other homeless teens and to trade sex for survival needs. For females, in particular, street life increases the chances that these homeless youths will be further victimized because they have low self-esteem and increased exposure to offenders [18]. In addition, homeless youths with abuse histories are more likely than those who were not abused to use alcohol and other drugs, have more sexual partners, and have a higher incidence of unprotected sexual activity [10]. In general, homeless people are at high risk for respiratory diseases including tuberculosis, dermatologic and vascular disorders, drug abuse, mental illness, and sexually transmitted infections (STIs) because they live in crowded conditions, have few vocational skills, and have poor access to health care [19]. Homeless adolescents lack not only the protection of
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parents and a stable home, but they also lack economic, social, and emotional resources for coping with their stage of development [9]. Respiratory and other infections Crowding, inadequate nutrition, and poor hygiene have been identified as factors that contribute to increased rates of respiratory infections and other communicable diseases, including tuberculosis, in homeless adolescents [20]. In a study of 50 adolescents in a runaway shelter, Bradford found that the most frequent health concern reported was asthma [21]. Other respiratory problems reported in the study were bronchitis, colds, hoarse and sore throats, lung collapse, and postnasal drip. Respiratory infections have also been associated with exposure to inclement weather, often with inadequate clothing, and reluctance to seek health care early [14,21]. Another factor that increases the risk for respiratory infections is the high prevalence of cigarette and marijuana use by both street youths and those in shelters [17].
Sexual health Homeless adolescents are at very high risk for STIs, including human immunodeficiency virus (HIV)/AIDS, because they engage in many highrisk sexual behaviors [10]. Compared with household youths, homeless youths have higher rates of STI. In a convenience sample of homeless and runaway youths in Hollywood, California, 11.5% tested positively for HIV infection [22]. Many of these youths initiate sexual behaviors at early ages [12,23], engage in sexual activities with multiple partners [12,23], use or have sexual partners who use injection drugs, and report inconsistent condom use [24]. Often, homeless youths engage in ‘‘survival sex,’’ trading sex for drugs, money, food, or shelter [25]. Because they have few material resources or job skills, these adolescents have only their bodies to barter for meeting basic survival needs. A high percentage of homeless adolescents report gay/lesbian/bisexual (GLB) sexual orientation. Many of these youths have been forced to leave their families because of conflict about their sexual orientation [11]. In a cross-sectional study of 334 runaway youths in San Francisco, Moon et al found that 27% of males and 17% of females reported GLB orientation [26]. When compared with heterosexual respondents, the GLB youths reported having run away from home at an earlier age, earlier initiation of sexual activity, and earlier onset of heroin use. Homeless youths travel frequently and are prone to engage in sexual activity with multiple partners. In a study of runaways, those who had been sexually abused were more likely than those who were not abused to have more sexual partners, use drugs, and have unprotected sexual intercourse [10]. Engaging in sexual activity with multiple partners along with the use
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of alcohol and other drugs increases the chances that a homeless youth will develop a STI. Under these conditions, consistent use of condoms for protection is usually not practical. Substance abuse AOD is a significant health problem for homeless adolescents. The prevalence of AOD among homeless youth in three locations (San Francisco, New York City, and Denver) is reported at 97% with the prevalence of injectable drug use as high as 21% [27]. AOD use is highly associated with health-related outcomes of hepatitis, sexually transmitted disease (STD), HIV/AIDS, depression, suicide, and violence in homeless youth [28]. As the amount of time adolescents are homeless or on the streets increases, the greater is the likelihood that they will adopt street values. Such values encourage health-risk behaviors such as prostitution and/or drug and alcohol use as means of survival. When compared with youth in shelters, runaway/homeless youths who live on the streets have higher rates of using tobacco, marijuana, alcohol, crack cocaine, hallucinogens, and intravenous drugs, which are readily available in this environment. In a study of 96 homeless youths, Rew et al found that the majority were under 13 years of age when they first tried alcohol (72.6%), marijuana (64.6%), and cocaine (58.9%) [17]. Over half (56.3%) of the respondents in the sample reported using injectable drugs. Mental health problems Homelessness in adolescents is often the outcome of the youth’s coping with abusive and dysfunctional families. Mental health problems such as depression, self-harm, and suicide are prevalent among homeless adolescents and are strongly associated with histories of abuse [29]. In a study of 329 homeless adolescents in Seattle, Washington, researchers found that youth who experienced both physical and sexual abuse were more likely than those with no abuse backgrounds to meet criteria for depression, to have fathers with alcohol problems, and to report more lifetime suicide attempts [28]. In a study of 188 homeless adolescents who were compared with a matched sample of 118 household youth, researchers found that the homeless had more disruptive behavior disorders and alcohol use and dependence than household youth [30]. Further, in this sample, homeless youth had significantly more symptoms of depression, anxiety, phobic anxiety, hostility, paranoid ideation, and other psychoses. Males in this sample showed more disruptive behavior disorders than girls, and those who had been maltreated at home showed both more alcohol dependence and disruptive behavior disorders than those not maltreated [30]. In a longitudinal study of 219 runaway and homeless adolescents, researchers found that 50% of the males and 60% of the females in the
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sample were diagnosed with conduct disorder [31]. Conduct disorder was defined as a persistent pattern of antisocial behavior including stealing, forced sex, and confrontation. In this sample, conduct disorder was the strongest predictor of engaging in survival sex, having multiple sex partners, and using cocaine or heroin. The researchers who conducted this study noted that these findings have major implications for developing interventions for this segment of society. Homeless adolescents in the Seattle, Washington, area were recruited for a study of psychological adjustment related to running away, being kicked out of the home, or being removed by the authorities [7]. There were no statistically significant differences among the three groups on psychological symptoms, but those who had been removed from their homes by the authorities had the most disruptive family histories and those who had runaway had the least. In this sample, girls were more likely to run away from home than boys, and boys were more likely to be kicked out of the home than girls. These researchers concluded that the experience of homelessness itself is traumatic and may supersede the differences in pathways to homelessness among youth in explaining psychological adjustment. Suicide is more prevalent among homeless than among household youths. In one study of street youth in three major cities, 58% had suicidal thoughts and 34% had attempted suicide [32]. Similarly, another study of homeless teens found that 35% had seriously considered suicide in the preceding 12 months [17]. In a study of 576 mostly black or Hispanic runaways in New York City, Rotheram-Borus found that 46% had attempted suicide at least once and a full 37% had attempted it one or more times [33]. Most of those who had attempted suicide were alone at the time. Most (62%) attempted suicide by ingesting drugs, whereas fewer jumped (16%), cut their wrists (11%), or used guns or hanging (5% each). In summary, the usual morbidities and mortalities of adolescents are compounded among the homeless. Compared with household youths, homeless youths are at higher risk for communicable diseases, including HIV/AIDS, substance abuse, and mental health problems. More homeless than household youths have been the victims of childhood abuse and more have attempted suicide. Their need for health and social services is enormous.
Health and social service interventions It is clear that homeless youths, including those in shelters and those striving to survive on the streets, need a variety of programs and services to meet their unique developmental and health needs. Federal, state, and local organizations provide a variety of programs and services for homeless families and youth. The Stewart B. McKinney Homeless Assistance Act, Public Law 100-77, mandates that states provide access to free public education to homeless children and provide other services such as emergency
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shelter, food, and housing. The Interagency Council on the Homeless, reports that 85% of all assistance programs for the homeless are provided by nonprofit agencies, whereas the government operates only 14% of them; the majority of those provided by the government are health programs. Approximately half of all homeless assistance programs are offered in major cities, whereas about one third are offered in rural areas and only one fifth in suburban areas [34]. The Runaway and Homeless Youth Act (RHYA) of 1977 was originally part of the Juvenile Justice and Delinquency Prevention Act (JJDPA) administered by the Department of Justice. However, in an attempt to decriminalize the status offenses of runaway youth and treat them more sympathetically, the RHYA split off and became part of the Administration for Children, Youth, and Families in 1988. Services provided by the RHYA include short-term shelter, food, clothing, crisis counseling, education, and programs for dealing with substance abuse, mental health problems, pregnancy, and sexual abuse. Programs and services for homeless teens, however, are largely uncoordinated, and there is currently no national policy that assures them of programs to promote their education and health [1]. Van der Ploeg and Scholte noted that social services for homeless youths lack communication and mutual trust, particularly between police and social workers [2]. Thus, many youth fail to receive appropriate services for their health and developmental needs. Analysis of comprehensive programs resulted in identification of 5 steps needed to coordinate the private and public services needed by homeless adolescents: 1. Construction of an interdisciplinary, case management service network that includes drop-in shelters. 2. Establishing and maintaining contact with youths through outreach that provides basic needs such as medical assistance. 3. Assessment of psychosocial needs and planning comprehensive care with goals of self-empowerment, independent living, work and education, and a stable supportive social network. 4. Coordinating and monitoring care provided. 5. Providing follow-up care to prevent backsliding [21]. Little research has been done to show what effects comprehensive services and specialized programs have on the healthy growth and development of homeless teens. Many of the health-risk behaviors noted above (ie, risky sexual activity, AOD) tend to cluster together in this population, and it is difficult to keep these youths in intervention programs that can significantly alter attitudes and behaviors. One study of 244 street youths who were recruited from a community drop-in center was designed to offer a peerbased training program to help these youths reduce drug- and sex-related health-risk behaviors [31]. Findings were that, although those who received the intervention increased their knowledge about HIV/AIDS and increased their perceived risk of HIV infection, they continued to engage in high-risk
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behaviors. The researchers concluded that these adolescents need other alternatives to such high-risk health behaviors. Summary There is a significant and growing number of adolescents who separate early from their families and become homeless. These youths are heterogeneous in terms of gender, race, ethnicity, and socioeconomic status, but the majority come from families that have been disruptive or dysfunctional in some way. Homeless adolescents are vulnerable to a variety of physical and psychologic problems related not only to their family histories but to the stressful environments in which they try to survive. Although numerous federal, state, and local programs have been developed to meet their needs for shelter, health care, and education, much remains to be done to ensure their healthy development and to prepare them for responsible life in the larger society. References [1] Shane PG. What about America’s homeless children? Thousand Oaks, CA: Sage Publications; 1996. [2] Van der Ploeg J, Scholte E. Homeless youth. Thousand Oaks, CA: Sage Publications; 1997. [3] National Coalition for the Homeless. Homeless youth: NICH fact sheet 11 (April 1999) Available at: http:www.nationalhomeless.org/youth.html. Accessed July 8, 2002. [4] National Adolescent Health Information Center [NAHIC]. Fact sheet: out-of-home youth—foster care, incarcerated, homeless/runaway adolescents. San Francisco: University of California, San Francisco; 1996. [5] Zide MR, Cherry AL. A typology of runaway youths: an empirically based definition. Child and Adolescent Social Work Journal 1992;9:155–68. [6] Athey JL. HIV infection and homeless adolescents. Child Welfare League of America 70(5):517–28. [7] MacLean MG, Embry LE, Cauce AM. Homeless adolescents’ paths to separation from family: comparison of family characteristics, psychological adjustment, and victimization. J Community Psychol 1999;27:179–87. [8] Bond LS, Mazin R, Jiminez MV. Street youth and AIDS. AIDS Education and Prevention, 1992;4(Suppl):14–23. [9] Bassuk EL, Buckner JC, Weinreb LF, Browne A, Bassuk SS, Dawson R, Perloff JN. Homelessness in female-headed families: childhood and adult risk and protective factors. American Journal of Public Health 1997;87(2):241–8. [10] Rotheram-Borus MJ, Mahler KA, Koopman C, Langabeer K. Sexual abuse history and associated multiple risk behavior in adolescent runaways. Am J Orthopsychiatry 1996;66:390–400. [11] Rew L, Fouladi RT, Yockey RD. Sexual health practices of homeless adolescents. J Nurs Scholarsh 2002;34(2):139–45. [12] Greenblatt M, Robertson MJ. Life-styles, adaptive strategies, and sexual behaviors of homeless adolescents. Hosp Community Psychiatry 1993;44(12):1177–80. [13] Clatts MC, Davis WR, Sotheran JL, Atillasoy A. Correlates and distribution of HIV risk behaviors among homeless youths in New York City: implications for prevention and policy. Child Welfare 1998;77(2):195–207.
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[14] Rew L. Relationships of sexual abuse; connectedness, and loneliness in homeless youth. J for Specialists in Pediatr Nurs 2002;7(2):51–63. [15] Geber GM. Barriers to health care for street youth. J Adolesc Health 1997;21:287–90. [16] Burgess AW. Youth at risk: understanding runaway and exploited youth. Washington, DC: National Center for Missing & Exploited Children; 1986. [17] Rew L, Taylor-Seehafer M, Fitzgerald ML. Sexual abuse, alcohol and other drug use, and suicidal behaviors in homeless adolescents. Issues Compr Pediatr Nurs 2001;24:225–40. [18] Tyler KA, Hoyt DR, Whitbeck LB. The effects of early sexual abuse on later sexual victimization among female homeless and runaway adolescents. Journal of Interpersonal Violence 2000;15:235–50. [19] Breakey WR. Editorial: it’s time for the public health community to declare war on homelessness. American Journal of Public Health 1997;87:153–5. [20] Rew L. Health risks of homeless adolescents. Implications for holistic nursing. J Holist Nurs 1996;14:348–59. [21] Bradford MS. Health concerns and prevalence of abuse and sexual activity in adolescents at a runaway shelter. Appl Nurs Res 1995;8(4):187–90. [22] Pfeifer RW, Oliver J. A study of HIV seroprevalence in a group of homeless youth in Hollywood, California. J Adolesc Health 1997;20:339–42. [23] Cohen E, MacKenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health 1991;12:539–44. [24] Clements K, Gleghorn A, Garcia D, Katz M, Marx R. A risk profile of street youth in Northern California: implications for gender-specific human immunodeficiency virus prevention. J Adolesc Health 1991;20:343–53. [25] Rotheram-Borus MJ, Meyer-Bahlburg HFL, Rosario M, Koopman C, Haignere CS, Exner TM, Matthieu M, Gruen RS. Lifetime sexual behaviors among predominantly minority male runaways and gay/bisexual adolescents in New York City. AIDS Education and Prevention. 1992;4(Suppl):34–42. [26] Moon MW, McFarland W, Kellogg T, Baxter M, Katz MH, MacKellar D, et al. HIV risk behavior of runaway youth in San Francisco. Youth & Society 2000;32:184–201. [27] Kral AH, Molnar BE, Booth BE, Watter JK. Prevalence of sexual risk behavior and substance use among runaway and homeless adolescents in San Francisco, Denver, and New York City. Int J STD AIDS 1997;8(2):109–17. [28] Ryan KD, Kilmer RP, Cauce AM, Watanabe H, Hoyt DR. Psychological consequences of child maltreatment in homeless adolescents: untangling the unique effects of maltreatment and family environment. Child Abuse Negl 2000;24:333–52. [29] Unger JB, Kipke MD, Simon TR, Montgomery SB, Johnson CJ. Homeless youths and young adults in Los Angeles: prevalence of mental health problems and the relationship between mental health and substance abuse disorders. Am J Community Psychol 1997; 25(3):371–94. [30] McCaskill PA, Toro PA, Wolfe SM. Homeless and matched housed adolescents: a comparative study of psychopathology. J Clin Child Psychol 1998;27:306–19. [31] Booth RE, Zhang Y, Kwiatkowski CE. The challenge of changing drug and sex risk behaviors of runaway and homeless adolescents. Child Abuse Negl 1999;23(12):1295–306. [32] Molnar BE, Shade SB, Kral AH, Booth RE, Watters JK. Suicidal behavior and sexual/ physical abuse among street youth. Child Abuse Negl 1998;22:213–22. [33] Rotheram-Borus MJ. Suicidal behavior and risk factors among runaway youths. Am J Psychiatry 1993;150(1):103–7. [34] Unger JB, Simon TR, Newman TL, Montgomery SB, Kipke MD, Albornoz M. Early adolescent street youth: an overlooked population with unique problems and service needs. Journal of Early Adolescence 1998;18:325–48.
Characteristics and health care needs of homeless adolescents Lynn Rew, EdD, RNC, HNC, FAAN School of Nursing, The University of Texas at Austin, 1700 Red River, Austin, TX 78701, USA
The exact number of homeless adolescents in the United States is unknown. Estimates ranging between 1 and 2 million youths include those who are homeless with their families (about 500,000), those who have been thrown away by their families (another 500,000), and those who have simply run away from home (1,000,000) [1]. Although an accurate estimate of the number of homeless adolescents is unknown, there is an expanding literature indicating that these youths are present in communities from coast to coast and from north to south. Moreover, their need for health care and social services is largely unmet. The purpose of this article is to describe the characteristics of adolescents who are homeless, reasons they give for their homeless condition, characteristics of the culture they share living on the streets of America, their health status and needs, and types of intervention programs that have been developed in response to their needs for health care and social services. The focus is on adolescents who are homeless without their families.
Homeless adolescents in the United States Adolescents who are homeless in the United States come from every socioeconomic stratum in urban, suburban, and rural areas. Homeless youth are both males and females of every racial/ethnic identity. Those who are homeless with their families are more likely to come from conditions of poverty whereas runaways come from families with variable economic resources [1]. Some homeless youth reside in shelters from time to time while others avoid contact with shelters unless their situations become extreme [2]. Many homeless teens make their beds under bridges, on informal E-mail address: [email protected] (L. Rew). 0029-6465/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 2 9 - 6 4 6 5 ( 0 2 ) 0 0 0 0 9 - 9
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campgrounds, and in abandoned buildings. A few find shelter with friends who have apartments. Characteristics of homeless adolescents There are many definitions of homeless youths. The National Coalition for the Homeless identifies homeless youths as those under 18 years of age who lack parental, foster, or institutional care [3]. The National Adolescent Health Information Center classifies youths as ‘‘runaways’’ when they leave home without parental permission, ‘‘thrownaways’’ when they are forced to leave home by their parents or guardians, and ‘‘street youth’’ when they have no home to return to and spend most of their time with peers on the street [4]. Another classification system identifies three types of runaway youth: (1) ‘‘running-to youths’’ who leave home in search of adventure, (2) ‘‘running-from youths’’ who make a rational decision to leave a dysfunctional family situation, and (3) ‘‘thrown-out youths’’ who are alienated from their families and there is mutual motivation from the teen and parents that the child not return home [5]. Youths who live at home with their parents or guardians, in contrast, are referred to as ‘‘household youths.’’ Reasons for adolescent homelessness There are many reasons why youth are homeless in the United States. Many who are known as ‘‘system kids’’ end up on the streets after multiple placements in foster homes, psychiatric hospitals, juvenile detention centers, residential schools, and shelters [6]. System kids are removed from their families by authorities who deem the home to be unsafe because of neglect or abuse, or because of death or incarceration of the caretakers [7]. Some youths drift into street life because they seek work on the streets to supplement their family’s income [8]. Others leave home to escape neglect and abuse related to their parents’ alcohol or other drug abuse [9]. And many more run away in response to physical, emotional, or sexual abuse [10]. In a recent study of 414 homeless youths in Texas, Rew, Fouladi, and Yockey [11] found that nearly 1 in 5 reported leaving home because of conflict with their parents over sexual orientation. Other participants reported leaving home because of emotional, physical, and/or sexual abuse. Alcohol and other drug (AOD) use are frequently cited as a factor that both contributes to adolescent homelessness [6] and is a consequence of coping with homelessness [12]. While homeless, many youth become disconnected from important relationships and adopt non-normative social values such as AOD use [12]. In a study of 929 homeless and runaway youths in New York City, Clatts et al found that more than half (53%) had used cocaine and over one third had used crack (36%) and heroin (38%) [13]. In sum, homeless adolescents arise from every geographic area and socioeconomic status in the United States. Their numbers are growing in
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response to continuing problems of parental neglect and abuse, family conflict and dysfunction, and inadequacies in the foster care and juvenile detention centers of this country. Health status and needs of homeless adolescents The major morbidities and mortalities of adolescents are primarily preventable and related to health-risk behaviors. Unlike infectious diseases of the early twentieth century, major morbidities of youths today are related to learned social behaviors such as using motor vehicles, experimenting with alcohol and other drugs, and engaging in unprotected sexual activities [6]. Moreover, most adolescents view themselves as healthy [8]. From a convenience sample of 96 homeless adolescents, Rew [14] found that the respondents’ perceived well-being was positively related to feeling socially connected to others who cared about them and inversely related to a history of sexual abuse and feelings of loneliness. About one third (38%) of the participants in the study stated they thought their health status was better than when they were living at home because they did more walking and had given up drugs and alcohol. Fewer (16%) stated they felt worse since they left home. Homeless adolescents must learn to survive in environments that are highly stressful and filled with greater health risks than those encountered by household youths. Although many have fled from homes that were chaotic, all of them find that having no permanent place for food, shelter, or social support creates a formidable challenge to healthy growth and development. These youths must also overcome multiple barriers to obtain comprehensive health care services including cost, distrust of care providers, transportation, fearing a diagnosis, not knowing where to go, and feeling embarrassed to ask for help [15]. Most homeless youths lack health insurance and rely on commonsense remedies for many of their health problems. Sexual abuse has been identified as a reason why many adolescents run away from home [16]. Both male and female runaways report having been sexually abused, although the rates are higher among females [16,17]. Adolescents who are sexually abused tend to run away from home earlier than other homeless teens and to trade sex for survival needs. For females, in particular, street life increases the chances that these homeless youths will be further victimized because they have low self-esteem and increased exposure to offenders [18]. In addition, homeless youths with abuse histories are more likely than those who were not abused to use alcohol and other drugs, have more sexual partners, and have a higher incidence of unprotected sexual activity [10]. In general, homeless people are at high risk for respiratory diseases including tuberculosis, dermatologic and vascular disorders, drug abuse, mental illness, and sexually transmitted infections (STIs) because they live in crowded conditions, have few vocational skills, and have poor access to health care [19]. Homeless adolescents lack not only the protection of
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parents and a stable home, but they also lack economic, social, and emotional resources for coping with their stage of development [9]. Respiratory and other infections Crowding, inadequate nutrition, and poor hygiene have been identified as factors that contribute to increased rates of respiratory infections and other communicable diseases, including tuberculosis, in homeless adolescents [20]. In a study of 50 adolescents in a runaway shelter, Bradford found that the most frequent health concern reported was asthma [21]. Other respiratory problems reported in the study were bronchitis, colds, hoarse and sore throats, lung collapse, and postnasal drip. Respiratory infections have also been associated with exposure to inclement weather, often with inadequate clothing, and reluctance to seek health care early [14,21]. Another factor that increases the risk for respiratory infections is the high prevalence of cigarette and marijuana use by both street youths and those in shelters [17].
Sexual health Homeless adolescents are at very high risk for STIs, including human immunodeficiency virus (HIV)/AIDS, because they engage in many highrisk sexual behaviors [10]. Compared with household youths, homeless youths have higher rates of STI. In a convenience sample of homeless and runaway youths in Hollywood, California, 11.5% tested positively for HIV infection [22]. Many of these youths initiate sexual behaviors at early ages [12,23], engage in sexual activities with multiple partners [12,23], use or have sexual partners who use injection drugs, and report inconsistent condom use [24]. Often, homeless youths engage in ‘‘survival sex,’’ trading sex for drugs, money, food, or shelter [25]. Because they have few material resources or job skills, these adolescents have only their bodies to barter for meeting basic survival needs. A high percentage of homeless adolescents report gay/lesbian/bisexual (GLB) sexual orientation. Many of these youths have been forced to leave their families because of conflict about their sexual orientation [11]. In a cross-sectional study of 334 runaway youths in San Francisco, Moon et al found that 27% of males and 17% of females reported GLB orientation [26]. When compared with heterosexual respondents, the GLB youths reported having run away from home at an earlier age, earlier initiation of sexual activity, and earlier onset of heroin use. Homeless youths travel frequently and are prone to engage in sexual activity with multiple partners. In a study of runaways, those who had been sexually abused were more likely than those who were not abused to have more sexual partners, use drugs, and have unprotected sexual intercourse [10]. Engaging in sexual activity with multiple partners along with the use
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of alcohol and other drugs increases the chances that a homeless youth will develop a STI. Under these conditions, consistent use of condoms for protection is usually not practical. Substance abuse AOD is a significant health problem for homeless adolescents. The prevalence of AOD among homeless youth in three locations (San Francisco, New York City, and Denver) is reported at 97% with the prevalence of injectable drug use as high as 21% [27]. AOD use is highly associated with health-related outcomes of hepatitis, sexually transmitted disease (STD), HIV/AIDS, depression, suicide, and violence in homeless youth [28]. As the amount of time adolescents are homeless or on the streets increases, the greater is the likelihood that they will adopt street values. Such values encourage health-risk behaviors such as prostitution and/or drug and alcohol use as means of survival. When compared with youth in shelters, runaway/homeless youths who live on the streets have higher rates of using tobacco, marijuana, alcohol, crack cocaine, hallucinogens, and intravenous drugs, which are readily available in this environment. In a study of 96 homeless youths, Rew et al found that the majority were under 13 years of age when they first tried alcohol (72.6%), marijuana (64.6%), and cocaine (58.9%) [17]. Over half (56.3%) of the respondents in the sample reported using injectable drugs. Mental health problems Homelessness in adolescents is often the outcome of the youth’s coping with abusive and dysfunctional families. Mental health problems such as depression, self-harm, and suicide are prevalent among homeless adolescents and are strongly associated with histories of abuse [29]. In a study of 329 homeless adolescents in Seattle, Washington, researchers found that youth who experienced both physical and sexual abuse were more likely than those with no abuse backgrounds to meet criteria for depression, to have fathers with alcohol problems, and to report more lifetime suicide attempts [28]. In a study of 188 homeless adolescents who were compared with a matched sample of 118 household youth, researchers found that the homeless had more disruptive behavior disorders and alcohol use and dependence than household youth [30]. Further, in this sample, homeless youth had significantly more symptoms of depression, anxiety, phobic anxiety, hostility, paranoid ideation, and other psychoses. Males in this sample showed more disruptive behavior disorders than girls, and those who had been maltreated at home showed both more alcohol dependence and disruptive behavior disorders than those not maltreated [30]. In a longitudinal study of 219 runaway and homeless adolescents, researchers found that 50% of the males and 60% of the females in the
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sample were diagnosed with conduct disorder [31]. Conduct disorder was defined as a persistent pattern of antisocial behavior including stealing, forced sex, and confrontation. In this sample, conduct disorder was the strongest predictor of engaging in survival sex, having multiple sex partners, and using cocaine or heroin. The researchers who conducted this study noted that these findings have major implications for developing interventions for this segment of society. Homeless adolescents in the Seattle, Washington, area were recruited for a study of psychological adjustment related to running away, being kicked out of the home, or being removed by the authorities [7]. There were no statistically significant differences among the three groups on psychological symptoms, but those who had been removed from their homes by the authorities had the most disruptive family histories and those who had runaway had the least. In this sample, girls were more likely to run away from home than boys, and boys were more likely to be kicked out of the home than girls. These researchers concluded that the experience of homelessness itself is traumatic and may supersede the differences in pathways to homelessness among youth in explaining psychological adjustment. Suicide is more prevalent among homeless than among household youths. In one study of street youth in three major cities, 58% had suicidal thoughts and 34% had attempted suicide [32]. Similarly, another study of homeless teens found that 35% had seriously considered suicide in the preceding 12 months [17]. In a study of 576 mostly black or Hispanic runaways in New York City, Rotheram-Borus found that 46% had attempted suicide at least once and a full 37% had attempted it one or more times [33]. Most of those who had attempted suicide were alone at the time. Most (62%) attempted suicide by ingesting drugs, whereas fewer jumped (16%), cut their wrists (11%), or used guns or hanging (5% each). In summary, the usual morbidities and mortalities of adolescents are compounded among the homeless. Compared with household youths, homeless youths are at higher risk for communicable diseases, including HIV/AIDS, substance abuse, and mental health problems. More homeless than household youths have been the victims of childhood abuse and more have attempted suicide. Their need for health and social services is enormous.
Health and social service interventions It is clear that homeless youths, including those in shelters and those striving to survive on the streets, need a variety of programs and services to meet their unique developmental and health needs. Federal, state, and local organizations provide a variety of programs and services for homeless families and youth. The Stewart B. McKinney Homeless Assistance Act, Public Law 100-77, mandates that states provide access to free public education to homeless children and provide other services such as emergency
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shelter, food, and housing. The Interagency Council on the Homeless, reports that 85% of all assistance programs for the homeless are provided by nonprofit agencies, whereas the government operates only 14% of them; the majority of those provided by the government are health programs. Approximately half of all homeless assistance programs are offered in major cities, whereas about one third are offered in rural areas and only one fifth in suburban areas [34]. The Runaway and Homeless Youth Act (RHYA) of 1977 was originally part of the Juvenile Justice and Delinquency Prevention Act (JJDPA) administered by the Department of Justice. However, in an attempt to decriminalize the status offenses of runaway youth and treat them more sympathetically, the RHYA split off and became part of the Administration for Children, Youth, and Families in 1988. Services provided by the RHYA include short-term shelter, food, clothing, crisis counseling, education, and programs for dealing with substance abuse, mental health problems, pregnancy, and sexual abuse. Programs and services for homeless teens, however, are largely uncoordinated, and there is currently no national policy that assures them of programs to promote their education and health [1]. Van der Ploeg and Scholte noted that social services for homeless youths lack communication and mutual trust, particularly between police and social workers [2]. Thus, many youth fail to receive appropriate services for their health and developmental needs. Analysis of comprehensive programs resulted in identification of 5 steps needed to coordinate the private and public services needed by homeless adolescents: 1. Construction of an interdisciplinary, case management service network that includes drop-in shelters. 2. Establishing and maintaining contact with youths through outreach that provides basic needs such as medical assistance. 3. Assessment of psychosocial needs and planning comprehensive care with goals of self-empowerment, independent living, work and education, and a stable supportive social network. 4. Coordinating and monitoring care provided. 5. Providing follow-up care to prevent backsliding [21]. Little research has been done to show what effects comprehensive services and specialized programs have on the healthy growth and development of homeless teens. Many of the health-risk behaviors noted above (ie, risky sexual activity, AOD) tend to cluster together in this population, and it is difficult to keep these youths in intervention programs that can significantly alter attitudes and behaviors. One study of 244 street youths who were recruited from a community drop-in center was designed to offer a peerbased training program to help these youths reduce drug- and sex-related health-risk behaviors [31]. Findings were that, although those who received the intervention increased their knowledge about HIV/AIDS and increased their perceived risk of HIV infection, they continued to engage in high-risk
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behaviors. The researchers concluded that these adolescents need other alternatives to such high-risk health behaviors. Summary There is a significant and growing number of adolescents who separate early from their families and become homeless. These youths are heterogeneous in terms of gender, race, ethnicity, and socioeconomic status, but the majority come from families that have been disruptive or dysfunctional in some way. Homeless adolescents are vulnerable to a variety of physical and psychologic problems related not only to their family histories but to the stressful environments in which they try to survive. Although numerous federal, state, and local programs have been developed to meet their needs for shelter, health care, and education, much remains to be done to ensure their healthy development and to prepare them for responsible life in the larger society. References [1] Shane PG. What about America’s homeless children? Thousand Oaks, CA: Sage Publications; 1996. [2] Van der Ploeg J, Scholte E. Homeless youth. Thousand Oaks, CA: Sage Publications; 1997. [3] National Coalition for the Homeless. Homeless youth: NICH fact sheet 11 (April 1999) Available at: http:www.nationalhomeless.org/youth.html. Accessed July 8, 2002. [4] National Adolescent Health Information Center [NAHIC]. Fact sheet: out-of-home youth—foster care, incarcerated, homeless/runaway adolescents. San Francisco: University of California, San Francisco; 1996. [5] Zide MR, Cherry AL. A typology of runaway youths: an empirically based definition. Child and Adolescent Social Work Journal 1992;9:155–68. [6] Athey JL. HIV infection and homeless adolescents. Child Welfare League of America 70(5):517–28. [7] MacLean MG, Embry LE, Cauce AM. Homeless adolescents’ paths to separation from family: comparison of family characteristics, psychological adjustment, and victimization. J Community Psychol 1999;27:179–87. [8] Bond LS, Mazin R, Jiminez MV. Street youth and AIDS. AIDS Education and Prevention, 1992;4(Suppl):14–23. [9] Bassuk EL, Buckner JC, Weinreb LF, Browne A, Bassuk SS, Dawson R, Perloff JN. Homelessness in female-headed families: childhood and adult risk and protective factors. American Journal of Public Health 1997;87(2):241–8. [10] Rotheram-Borus MJ, Mahler KA, Koopman C, Langabeer K. Sexual abuse history and associated multiple risk behavior in adolescent runaways. Am J Orthopsychiatry 1996;66:390–400. [11] Rew L, Fouladi RT, Yockey RD. Sexual health practices of homeless adolescents. J Nurs Scholarsh 2002;34(2):139–45. [12] Greenblatt M, Robertson MJ. Life-styles, adaptive strategies, and sexual behaviors of homeless adolescents. Hosp Community Psychiatry 1993;44(12):1177–80. [13] Clatts MC, Davis WR, Sotheran JL, Atillasoy A. Correlates and distribution of HIV risk behaviors among homeless youths in New York City: implications for prevention and policy. Child Welfare 1998;77(2):195–207.
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[14] Rew L. Relationships of sexual abuse; connectedness, and loneliness in homeless youth. J for Specialists in Pediatr Nurs 2002;7(2):51–63. [15] Geber GM. Barriers to health care for street youth. J Adolesc Health 1997;21:287–90. [16] Burgess AW. Youth at risk: understanding runaway and exploited youth. Washington, DC: National Center for Missing & Exploited Children; 1986. [17] Rew L, Taylor-Seehafer M, Fitzgerald ML. Sexual abuse, alcohol and other drug use, and suicidal behaviors in homeless adolescents. Issues Compr Pediatr Nurs 2001;24:225–40. [18] Tyler KA, Hoyt DR, Whitbeck LB. The effects of early sexual abuse on later sexual victimization among female homeless and runaway adolescents. Journal of Interpersonal Violence 2000;15:235–50. [19] Breakey WR. Editorial: it’s time for the public health community to declare war on homelessness. American Journal of Public Health 1997;87:153–5. [20] Rew L. Health risks of homeless adolescents. Implications for holistic nursing. J Holist Nurs 1996;14:348–59. [21] Bradford MS. Health concerns and prevalence of abuse and sexual activity in adolescents at a runaway shelter. Appl Nurs Res 1995;8(4):187–90. [22] Pfeifer RW, Oliver J. A study of HIV seroprevalence in a group of homeless youth in Hollywood, California. J Adolesc Health 1997;20:339–42. [23] Cohen E, MacKenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health 1991;12:539–44. [24] Clements K, Gleghorn A, Garcia D, Katz M, Marx R. A risk profile of street youth in Northern California: implications for gender-specific human immunodeficiency virus prevention. J Adolesc Health 1991;20:343–53. [25] Rotheram-Borus MJ, Meyer-Bahlburg HFL, Rosario M, Koopman C, Haignere CS, Exner TM, Matthieu M, Gruen RS. Lifetime sexual behaviors among predominantly minority male runaways and gay/bisexual adolescents in New York City. AIDS Education and Prevention. 1992;4(Suppl):34–42. [26] Moon MW, McFarland W, Kellogg T, Baxter M, Katz MH, MacKellar D, et al. HIV risk behavior of runaway youth in San Francisco. Youth & Society 2000;32:184–201. [27] Kral AH, Molnar BE, Booth BE, Watter JK. Prevalence of sexual risk behavior and substance use among runaway and homeless adolescents in San Francisco, Denver, and New York City. Int J STD AIDS 1997;8(2):109–17. [28] Ryan KD, Kilmer RP, Cauce AM, Watanabe H, Hoyt DR. Psychological consequences of child maltreatment in homeless adolescents: untangling the unique effects of maltreatment and family environment. Child Abuse Negl 2000;24:333–52. [29] Unger JB, Kipke MD, Simon TR, Montgomery SB, Johnson CJ. Homeless youths and young adults in Los Angeles: prevalence of mental health problems and the relationship between mental health and substance abuse disorders. Am J Community Psychol 1997; 25(3):371–94. [30] McCaskill PA, Toro PA, Wolfe SM. Homeless and matched housed adolescents: a comparative study of psychopathology. J Clin Child Psychol 1998;27:306–19. [31] Booth RE, Zhang Y, Kwiatkowski CE. The challenge of changing drug and sex risk behaviors of runaway and homeless adolescents. Child Abuse Negl 1999;23(12):1295–306. [32] Molnar BE, Shade SB, Kral AH, Booth RE, Watters JK. Suicidal behavior and sexual/ physical abuse among street youth. Child Abuse Negl 1998;22:213–22. [33] Rotheram-Borus MJ. Suicidal behavior and risk factors among runaway youths. Am J Psychiatry 1993;150(1):103–7. [34] Unger JB, Simon TR, Newman TL, Montgomery SB, Kipke MD, Albornoz M. Early adolescent street youth: an overlooked population with unique problems and service needs. Journal of Early Adolescence 1998;18:325–48.