Thinking about homeless youth’s mental health differently: A call for intersectoral prevention

Received: 27-Jan-2018 Accepted Date: Feb 05, 2018; Published: 15-Feb-2018

Citation: MacDonald SA, Roebuck B. Thinking about homeless youth’s mental health differently: A call for intersectoral prevention. J Child Adolesc Psych. 2018;2(1):3-5.

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According to a recent pan-Canadian study on youth homelessness, Without a Home: The National Youth Homelessness Survey [1], the majority of youth experiencing homelessness in Canada face severe mental health challenges, with 85.4% of homeless youth experiencing a mental health crisis, 42% reporting at least one suicide attempt, and 35.2% reporting at least one drug overdose requiring hospitalization [2]. Indigenous, LGBTQ2S (lesbian, gay, bisexual, transgender, queer, questioning and two-spirit), and female homeless youth are disproportionately affected and are at the highest risk of experiencing a mental health crisis, along with youth who become homeless before the age of 16 [2]. Furthermore, they state:

These mental health struggles are the culmination of challenges faced by these youth in their homes, schools, and communities before becoming homeless, combined with exposure to violence and stigmatization once on the streets. The gravity of this situation is highlighted by the fact that suicide and drug overdose are the leading causes of death for Canadian homeless youth [2].

Homeless youth consistently report being physically and sexually assaulted, robbed, threatened with a weapon, chased, shot at, stabbed, beaten up, and exploited at rates greater than the general population [3-6]. Research on youth homelessness highlights that young people may experience high rates of victimization both prior to becoming homeless and once they are living on the streets or in shelters [5,7-13], and victimization is likely to increase with the length of time spent homeless [14] worsening health outcomes [15,16]. Not only are the streets defined as dangerous or “risky”, but the activities associated with street life appear to increase youth’s chances of becoming victims of violence Hoyt et al. Ironically, these youth are the least likely to seek help [15,17,18], specifically mental health services [19], adding another layer to their vulnerability. Young people who are homeless are five times as likely to be victims of assault than domiciled youth, five times more likely to be victims of theft, and ten times more likely to be robbed by force and be victims of sexual assault [17]. These experiences are not without consequence. According to Kidd et al., “rates of psychiatric symptoms and general distress among youth who are homeless are at a level that is commonly seen among youth in outpatient and inpatient psychiatric care settings” (2018: V). This discrepancy between homeless and domiciled youth’s experiences of victimization and their mental health is nothing short of disgraceful, begging the question why these systemic issues have not galvanized national attention and initiatives to address these inequities.

Gender and Victimization

Gender also influences adversity on the street. Homeless women in general are more likely to have been sexually abused, raped, and physically assaulted than the general population or than homeless men [12,20-22]. Sexual assaults against homeless women are reported as being more violent and are often perpetrated by strangers in public places [23]. Among a sample of people who were homeless in Ottawa, 16% of female young people reported that they had experienced a miscarriage resulting from a physical assault [24]. Also found that victimization is not evenly distributed, and young women were more likely to experience victimization than males on the street with minority and queer female youth experiencing the highest rates of victimization [25]. Age was also a significant predictor of victimization, with those who left home at an earlier age being more likely to experience victimization on the streets. Youth who identify as LGBTQ2S frequently leave home because of conflict over their sexual identity or the fear that they will not be accepted if they come out to their parents [26,27]. They report higher rates of abuse in their family home and of victimization on the street than other young people who are homeless [18,26-29].

At-Risk and Risky Homeless Youth

Research on young people who are homeless reveals that most they have experienced childhoods rife with abuse, neglect, and abandonment which set them on a negative developmental course pushing and pulling them to the streets [3,6,8,15,17,30-34]. Poor parent-child relationships and parenting practices [5,35-37] along with family breakdown, instability, and recomposition [38-41] place these youth at increased risk for homelessness, further victimization, mental health problems [20,42] and engagement in criminalized activities [5,43,44].

Many youth arrive on the streets from the child welfare system [16,45] or are released from detention centers and have nowhere else to go [31], revealing a systemic and structural dimension to the problem of youth homelessness. Some researchers have gone one step further arguing that youth exiting the foster care system through emancipation are at an increased risk for homelessness [46]. Significant gaps that contribute to youth homelessness have been identified in Ontario’s child welfare and protection services, especially for sixteen and seventeen-year-olds [16,47]. Structural constraints abound for this population; inadequate social assistance and supportive housing systems, failing health and educational systems and transitioning services to adulthood, and the changing labor market make it difficult for this age group to gain access to scarce resources and to eke out a living in socially legitimate ways [46,48].

While on the street, youth also are known to engage in activities that increase their chances of becoming victims of violence, such as prostitution or selling and using drugs [49]. Many researchers have noted a rise in criminal involvement among youth who do not have access to legitimate means of self-support, without which a significant number are drawn into illegal activities as a method of survival on the streets [8,43,50]. Experience with deviant behaviors increases the likelihood of victimization [5,16- 18,50] and the likelihood of further involvement with deviance and crime [50,51]. Homelessness disrupts important social bonds and impairs personal networking that could be instrumental to getting off the street, and many individuals become trapped in an environment where they will be further victimized [21]. Victimization on the street is psychologically distressing and can lead to depression and low self-esteem, which in turn contributes to apathy and feelings of futility, making it more difficult to escape further abuse [21,52]. Young people experiencing homelessness have much higher levels of mortality through violence and disease than the general population; rates are estimated to be 8 to 11 times higher than similarly aged youth who are not homeless [53]. Young people on the streets who feel “trapped, hopeless, worthless and alone” are also at a higher risk of suicide and suicide attempts [37].

All of the aforementioned factors combine to create a daunting and debilitating picture of homeless youth, however, little is known about how youth perceive such challenges, and how they survive in the face of so many challenges. And although youths’ own voices on their individual efforts to confront, engage with, and negotiate the various risks associated with street life are starting to receive more attention in research, it is clear that much of their energy, strength, creativity and problem-solving are invested in trying to find adequate shelter, food, and resources rather than focusing on education, career, health or relationship goals typical of their peers with access to housing [54]. Given the poor outcomes associated with youth homelessness in the areas of mortality, mental health, substance abuse, victimization, criminal offending, and the disproportionate impacts on youth leaving care, girls, LGBTQ2S and indigenous youth, there is a critical need for multi-sectoral engagement in the prevention and elimination of youth homelessness. Currently, the normalization of youth homelessness and its generalized acceptance or apathy in society act as barriers to stakeholders recognizing the role they could play to ensure that all youth have access to safe housing and perhaps that if we acted in a coordinated effort homelessness could even be prevented. Furthermore, gaps in service delivery and the ways that social services, housing and health agencies compete for funding and clients within their siloed mandates create a climate where young people fall through the cracks [55]. We argue that it is important to think about these problems differently, from a bottom-up approach that recognizes all the systemic factors that create homelessness and subsequently impact, trigger or worsen mental health. We wonder, what if schools, mental health programs, hospitals, criminal justice interventions, child protection agencies, and all levels of governments worked together to ensure that every youth has access to housing and appropriate services? Coordinated prevention has the capacity to interrupt a downward spiral of negative outcomes associated with life on the street and to generate significant social and financial benefits. It is time to work together to end youth homelessness and recognize the interlocking factors that impact mental health.

REFERENCES

1. Gaetz S, O’Grady B, Kidd S, et al. Without a Home: The National Youth Homelessness Survey. Toronto: Canadian Observatory on Homelessness Press; 2016.
2. Schwan K, Kidd S, Gaetz S, et al. Mental Health Care for Homeless Youth: A Proposal for Federal, Provincial and Territorial Leadership, Coordination, and Targeted Investment. Toronto: Canadian Observatory on Homelessness Press; 2017.
3. Janus MD, Archambault FX, Brown SW, et al. Physical abuse in Canadian runaway adolescents. Child Abuse & Neglect. 1995;19(4):433-47.
4. Sleegers J, Spijker J, van Limbeck J, et al. Mental Health Problems Among Homeless Adolescents. Acta Psychiatr Scand. 1998:97:253-259.
5. Whitbeck LB, Hoyt DR, Ackley KA. Abusive Family Backgrounds and Later Victimization Among Runaway and Homeless Adolescents. J Res Adolesc. 1997;7(4):375-392.
6. Whitbeck LB, Simons RL. Life on the Streets: The Victimization of Runaway and Homeless Adolescents. Youth & Society. 1990;22(1):108-125.
7. Roebuck B. Homelessness, Victimization and Crime: Knowledge and Actionable Recommendations. Ottawa, ON: University of Ottawa: Institute for the Prevention of Crime. 2008.
8. Baron SW. Street Youth Violence and Victimization. Trauma, Violence & Abuse. 2003;4(1):22-44.
9. Bassuk EL, Perloff JN, Dawson R. Multiply homeless families: The insidious impact of violence. Hous Policy Debate. 2001;12:299-320.
10. Herman DB, Susser ES, Struening EL, et al. Adverse childhood experiences: Are they risk factors for adult homelessness? Am J Public Health. 1997;87:249-255.
11. Mental Illness and Pathways into Homelessness: Proceedings and Recommendations. Toronto: Mental Health Policy Research Group; 1998.
12. Novac S, Paradis E, Brown J, et al. A Visceral Grief: Young Homeless Mothers and Loss of Child Custody. Centre for Urban and Community Studies. 2006;(34):1-7.
13. Tanner J, Wortley S. The Toronto youth crime and victimization study: Overview report. Centre for Criminology, University of Toronto; 2002.
14. Boivin JF, Roy E, Haley N, et al. The Health of Street Youth: A Canadian Perspective. Canadian J Public Health. 2005;96(6):432-7.
15. Karabanow J. Being Young and Homeless: Understanding How Youth Enter and Exit Street Life. New York, NY: Peter Lang; 2004.
16. Kraus D, Eberle M, Serge L. Environmental Scan on Youth Homelessness: Final Report. Ottawa, ON: Canada Mortgage and Housing Corporation; 2001.
17. Gaetz S. Safe Streets for Whom? Homeless Youth, Social Exclusion, and Criminal Victimization. Can J Criminol Crim Justice. 2004;46(4):423-455.
18. Gaetz S. Whose safety counts? Street youth, social exclusion, and criminal victimization. Finding Home: Policy Options for Addressing Homelessness in Canada. Toronto: Cities Centre, University of Toronto; 2009.
19. McCay E, Langley J, Beanlands H, et al. Mental health challenges and strengths of street-involved youth: The need for a multi-determined approach. Can J Nurs Res. 2010;42(3):30-49.
20. Kidd SA. Mental Health and Youth Homelessness: A Critical Review. In Gaetz S, O’Grady B, Buccieri K, et al. (Eds.), Youth Homelessness in Canada: Implications for Policy and Practice. Toronto: Canadian Homelessness Research Network Press; 2013.
21. D’Ercole A, Struening E. Victimization among homeless women: Implications for service delivery. J Community Psychol. 1990;18:141-151.
22. Jasinski JL, Wesely JK, Wright JD, et al. Hard lives, mean streets: Violence in the lives of homeless women. Boston: Northeastern University Press; 2010.
23. Stermac L, Paradis E. Homeless Women and Victimization: Abuse and Mental Health History Among Homeless Rape Survivors; 2001.
24. Hagan J, McCarthy B. Streetlife and Delinquency. Br J Sociol. 1992;43(4):533-561.
25. Gaetz S, O’Grady B, Buccieri K. Surviving crime and violence: Street youth and victimization in Toronto. Toronto: JFCY & Homeless Hub; 2010.
26. Cochran B, Stewart A, Ginzler J, et al. Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual and transgender homeless adolescents with their heterosexual counterparts. Am J Public Health. 2002;92(5):773-7.
27. Gattis M. Psychosocial problems associated with homelessness in sexual minority youths. J Hum Behav Soc Environ. 2009;19(8):1066-1094.
28. Abramovich A, Shelton J. Where Am I Going to Go? Intersectional Approaches to Ending LGBTQ2S Youth Homelessness in Canada & the U.S. Toronto: Canadian Observatory on Homelessness Press; 2017.
29. Fournier M, Austin S, Samples C, et al. A comparison of weight-related behaviours among high school students who are homeless and non-homeless. J Sch Health. 2009;79(10):466-473.
30. Hoyt DR, Ryan K, Cauce AM. Personal Victimization in a High-Risk Environment: Homeless and Runaway Adolescents. J Res Crime Delinq. 1999;36(4):371-392.
31. Gaetz S, O’Grady B. Making Money: Exploring the Economy of Young Homeless Workers. Work, Employment and Society. 2002;16(3):433-456.
32. Kurtz P, Kurtz G, Jarvis S. Problems of Maltreated Runaway Youth. Adolescence. 1991;26:544-555.
33. Karabanow J, Clement P, Carson A, et al. Community Action on Homelessness Research Committee Advisory Group. Getting Off the Street: Exploring Strategies Used by Canadian Youth to Exit Street Life; 2005.
34. Mounier C, Andujo E. Defensive Functioning of Homeless Youth in Relation to Experiences of Child Maltreatment and Cumulative Victimization. Child Abuse & Neglect. 2003;27(10):1187-1204.
35. DiPaolo M. The Impact of Multiple Childhood Trauma on Homeless Runaway Adolescents. New York, NY: Garland; 1999.
36. Stefanidis N, Pennbridge J, MacKenzie RG, et al. Runaway and Homeless Youth: The Effects of Attachment History on Stabilization. Am J Orthopsychiatry. 1992;62(3):442-446.
37. Kidd S. The walls were closing in, and we were trapped: A qualitative analysis of street youth suicide. Youth & Society. 2004;36(1):30-55.
38. Bearsley-Smith CA, Bond LM, Littlefield L, et al. The psychosocial profile of adolescent risk of homelessness. Eur Child Adolesc Psych. 2008;17(4):226-234.
39. Caputo T, Weiler R, Anderson J. The Street Lifestyle Study. Ottawa, ON: Health Canada, Office of Alcohol, Drugs and Dependency Issues; 1997.
40. Jones G. Youth Homelessness and the “Underclass”. In R. MacDonald (ed.) Youth, the “Underclass” and Social Exclusion. London, UK: Routledge; 1997.
41. Laird G. Homelessness in a Growth economy: Canada’s 21st Century Paradox (Report for the Sheldon Chumir Foundation for Ethics in Leadership). Calgary, AB: Sheldon Chumir Foundations for Ethics in Leadership; 2007.
42. Brown SM, Begun S, Bender K, et al. An Exploratory Factor Analysis of Coping Styles and Relationship to Depression Among a Sample of Homeless Youth.” Community Ment Health J. 2015;51(7):818-27.
43. Baron SW, Forde DR, Kennedy LW. Disputatiousness, Aggressiveness, and Victimization Among Street Youths. Youth Violence Juv Justice. 2007;5(4):411-25.
44. Kidd S, Slesnick N, Frederick T, et al. Mental Health and Addiction Interventions for Youth Experiencing Homelessness: Practical Strategies for Front-Line Providers. Toronto: Canadian Observatory on Homelessness Press; 2018.
45. Novac S, Hermer J, Paradis E, et al. Justice and Injustice: Homelessness, Crime, Victimization, and the Criminal Justice System. Toronto: Centre for Urban and Community Studies, University of Toronto, and the John Howard Society of Toronto; 2006.
46. Bender K, Yang J, Ferguson K, et al. Experiences and Needs of Homeless Youth with a History of Foster Care. Child Youth Serv Rev. 2015;55:222-231.
47. Street Youth in Canada: Findings From Enhanced Surveillance of Canadian Street Youth. Public Health Agency of Canada; 2006:1999-2003.
48. Bessant J. From Sociology of Deviance to Sociology of Risk: Youth Homelessness and the Problem of Empiricism. J Crim Justice. 2001;29:31-43.
49. Heerde JA, Hemphill SA. Sexual Risk Behaviors, Sexual Offenses, and Sexual Victimization Among Homeless Youth: A Systematic Review of Associations with Substance Use. Trauma, Violence & Abuse; 2015:1-22.
50. Hagan J, McCarthy B. Mean Streets: Youth Crime and Homelessness. Cambridge, UK: Cambridge University Press; 1997.
51. Hagan J, McCarthy B. Homeless youth and the perilous passage to adulthood. In Osgood W, Foster E.M, Flanagan C, et al. (eds.), On your own without a net: The transition to adulthood for vulnerable populations. Chicago: University of Chicago Press; 2005:178-201.
52. Simons RL, Whitbeck LB, Bales A. Life on the streets: Victimization and psychological distress among the adult homeless. J Interpers Violence. 1989;4:482-501.
53. Roy E, Haley N, Leclerc P, et al. Mortality in a cohort of street youth in Montreal. J Am Med Assoc. 2004;292 (5):569-574.
54. Roebuck B, Roebuck M. The strengths of young people who are homeless, Can J Community Mental Health. 2016;35(2):43-54.
55. Nichols N. Youth Work: An institutional ethnography of youth homelessness. University of Toronto Press; 2014.