1. Dang, Michelle T. PhD, RN, APHN-BC

Article Content

It is estimated that 1.5 to 2.5 million youth in the United States experience homelessness (Congressional Research Reports, 2006). Homeless youth represent one of the most vulnerable and underserved populations and have been referred to as society's forgotten children (Whitbeck & Hoyt, 1999). On the surface, homeless youth appear quite similar to their housed peers and are difficult to distinguish based on appearance or behavior alone; however, a closer examination reveals stark differences between homeless youth and their nonhomeless peers. Homeless youth are more likely than their housed peers to have been abused and victimized, experience higher rates of mental illness and sexually transmitted infections including HIV, and go without food and shelter (Ringwalt, Greene, & Robertson, 1998; Sanchez, Waller, & Greene, 2006; Whitbeck & Hoyt, 1999). Histories of childhood maltreatment including sexual abuse, highly conflicted family relationships, and parental abuse of substances are common among homeless youth and are considered to be the main antecedents to youth leaving home (Brooks, Milburn, Rotheram-Borus, & Witkin, 2004; Hyde, 2005).

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Perhaps one of the most defining characteristic of youth homelessness is the high use of both legal and illegal substances. Cross-sectional and longitudinal studies with homeless youth reveal that substance use and abuse is a significant issue with this population and warrants further investigation for effective interventions from prevention to targeted treatment. In a study comparing drug use among three nationally representative samples of homeless and nonhomeless youth, it was found that the use of marijuana and other hard drugs such as cocaine, heroin, and methamphetamine was across the board substantially higher among homeless youth (Greene, Ennett, & Ringwalt, 1997). Similarly, a study by Johnston, O'Malley, and Bachman (2001) found the prevalence of marijuana use among homeless youth was 95% compared with 37% among high school seniors, and the use of opiates was 54% among homeless youth compared with 6% among nonhomeless youth; higher rates were also noted for all other substances including alcohol. Other studies found high proportions of homeless youth meeting criteria for DSM-IV substance dependence (Baer, Ginzler, & Peterson, 2003; Whitbeck, 2009).


Several factors have been offered as possible explanations for the high rates of substance use among this population. Youth have reported that they often turn to alcohol and drugs to cope with the challenges associated with homelessness such as loneliness, stress, and experiences of victimization (Kidd, 2003). In addition, a significant number of homeless youth have disorders such as attention-deficit/hyperactivity disorder, bipolar disorder, and posttraumatic stress disorder that often go untreated (Busen & Engebretson, 2008); as a result, this subgroup of homeless youth may be using substances as a way to self-medicate. The psychological harm from prior trauma and abuse amplifies when youth leave home and connect with deviant peers and adults on the streets who acculturate them into survival strategies and street economies that often involve criminal activities and drug use (Whitbeck & Hoyt, 1999). Youth who have street peers who use drugs are significantly more likely to use drugs themselves (Whitbeck, 2009). Such street experiences and antisocial connections can further crystallize prior mental illness and substance use and lead to psychopathology and addiction in vulnerable individuals.



Despite the high rates of substance use among homeless youth, studies have found that homeless youth are not receiving the treatment that they need (Smart & Adlaf, 1991), even when the youth themselves recognize the need for addiction treatment. Given the obvious negative developmental trajectory and poor health outcomes as a result of substance use and the barriers that substance use poses to a conventional life such as attending school and being employed, it is critical that services targeting homeless youth address substance use as a key component. Because of the social context of youth homelessness and the unique needs of homeless youth, traditional addiction treatment, often geared for adults, has been challenging with this population (Baer, Peterson, & Wells, 2004). For example, homeless youth is a highly transient and mobile population. High structured interventions that require a youth to keep a consistent schedule or appointment times will most likely be unsuccessful. Furthermore, homeless youth by nature are precociously independent and often resist authority; therefore, programs that compel youth to adhere to strict guidelines including a zero tolerance policy and restrict their autonomy will also likely fail with this population. Because of these aforementioned reasons, interventions specific to homeless youth need to consider both the complex social issues that are unique to youth homelessness and the developmental needs of adolescents. Some promising alternatives to traditional addiction treatment have been explored and warrant further research such as brief motivation interviewing, a harm reduction approach, and structural policies that permit more flexibility such as drop-in appointments and accessibility to all services such as mental health and addiction treatment and other support services in one location or "one stop shopping" (Baer et al., 2004; Christiani, Hudson, Nyamathi, Mutere, & Sweat, 2008). Unfortunately, one of the major barriers to homeless youth seeking treatment is a lack of insurance or money (Whitbeck, 2009). This reflects a need for policies that consider the marginalized and vulnerable position of these youth and the long-term cost to society if they are forced to defer treatment due to structural and financial barriers that they cannot realistically overcome. Homeless youth are unaccompanied adolescents with few means of survival; therefore, expecting youth to pay for treatment is basically shutting the door on any intervention. If substance use among homeless youth was an infectious disease, we can be sure that the public would be highly alarmed and want a quick solution.



Another promising area that warrants research as an intervention for substance use among homeless youth is the concept of social connectedness. Adolescence is a period of dramatic sociobiological changes that bring on exciting new roles and relationships. However, for homeless youth, these changes proffer vulnerabilities because of their social context. Connectedness, a concept grounded in attachment theory, has been used to describe levels of connections and relationships in various contexts related to child and adolescent development (Bernat & Resnick, 2009; McNeely, Nonnemaker, & Blum, 2002; Taylor-Seehafer, Jacobvitz, & Steiker, 2008). Whereas attachment relates to dyadic interactions, connectedness, in contrast, describes a wide spectrum of social elements and experiences that includes quality of relationship, degree of liking, antecedents to behaviors, and states of feelings or attitudes (Barber & Schluterman, 2008). The literature on connectedness has increased over the past decade and reflects a growing recognition for connectedness as an important concept in developmental research. It also underscores the critical role of social experiences from multiple contexts such as schools and neighborhoods as well as the importance of social relationships with nonfamily members such as peers, mentors, and teachers. Among adolescents in general, connectedness has demonstrated powerful results as a protective factor against risky development. On the basis of a nationally representative sample of adolescents from the National Longitudinal Study of Adolescent Health (Add Health), Resnick and colleagues (1997) found that family and school connectedness was protective against numerous behavioral domains including levels of emotional distress, suicidality, violence, substance use, and sexual behaviors, even when controlling for family structure and socioeconomic status. There is no reason to believe that the protective effects of connectedness would not apply to homeless youth. Examples of questions for further exploration are "Is there a relationship between social connectedness (besides antisocial peers) and substance use among homeless youth?" and "Does being socially connected to conventional peers and adults make a difference in substance use and abuse among homeless youth, and if so, what are the mechanisms?"


Despite their transient status, recent research on homeless youth reveals that they have social connections with diverse individuals including prosocial peers and nonparental adults such as relatives and professionals. It was found that homeless youth who were more connected to their home social networks demonstrated less risky sexual behaviors, implying a protective effect from these social ties (Rice, Stein, & Milburn, 2008). The concept of connectedness and its broad application in numerous domains make connectedness a promising concept for intervention on substance use with homeless youth. Homeless youth in general have a mistrust of adults in formal roles and institutions. Capitalizing on the positive connections that are already embedded in their social networks provides a viable option for bridging the youth to services. While homeless youth are likely to leave home due to highly conflicted parental relationships, research also shows that there is rapprochement with parents over time (Whitbeck, 2009). In addition, there is evidence to suggest that homeless youth are connected with caring adults who serve as mentors (Tevendale, Lightfoot, & Slocum, 2009); however, the function of these relationships and the characteristics of these adults are not well known.



While it is clear that substance use among homeless youth is a serious social issue that should garner our attention, it is less evident how we go about curbing this problem and help these young people transition into more positive developmental trajectories. It is unlikely that we can stop youth homelessness anytime soon, but we can certainly create developmentally appropriate, youth-centered, and socially responsive policies that provide meaningful assistance to these youth once they are on the streets. This work cannot be done by any single organization or individual. It will require our collective effort and a comprehensive approach to the complex issue of youth homelessness and substance use.




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