It is
estimated that 1.6 million youth are
homeless each year in the United States.
Some may stay away from home for only
one or two nights while others have
been living on the street for years.
Approximately 200,000 youth each year
live permanently on the street –
a life that is extremely difficult,
often dangerous, and associated with
multiple health problems. Sadly, 5,000
teenagers are buried each year in unmarked
graves either because they are unidentified
or unclaimed.
Homeless youth have been identified
by several different designations in
the literature depending on the circumstances
causing their homelessness. Runaway
youth have been defined by the U. S.
Department of Health and Human Services
as “a person under 18 years old
who absents himself or herself from
home or place of legal residence…at
least overnight…without the permission
of parents or legal guardians. “Throwaways”
are youth who have been thrown out of
the house by parents or guardians. The
reasons cited by adolescents for being
thrown out of their homes include drug
use, pregnancy, and gender identification
conflicts. The term “street youth”
is used to indicate youth who have been
living on the street for some time and
do not tend to use shelters or other
traditional services. Unless otherwise
specified, this paper will discuss homeless
youth (ages 12-21), including runaways,
throwaways and street youth, who do
not live with parents or guardians.
Youth who are homeless and living with
their parents face some of the same
issues as youth without parents or guardians,
but are not the focus of this discussion.
Many of the health issues faced by
homeless youth are similar to those
faced by anyone experiencing homelessness.
However, as adolescents, homeless youth
are still developing psychologically,
cognitively and physically and may make
choices that are not in the best interest
of their health. Before becoming homeless,
these youth may have endured a chaotic
and often violent home life and they
may be distrustful of authority and
adults. For these reasons, homeless
youth can benefit from services that
are specific to their needs rather than
incorporated into services for the adult
homeless population. This paper will
discuss the health and social service
needs of homeless youth and provide
information about models of health care
delivery.
Health Care
Homeless adolescents often have
a greater number of physical and mental
health problems than their housed counterparts.
They are more likely to engage in high-risk
behaviors such as unprotected sex with
multiple partners, drug use, and exposure
to and participation in violence. In
addition to health risks, homeless youth
face a number of barriers in accessing
health care. These include lack of insurance,
a need for parental consent, difficulty
navigating the health system, and the
attitude of health staff.5 These issues
will be explored in greater depth below.
Intensive Case Management
In order to provide a continuum of care
from outreach efforts to the delivery
of services, intensive case management
is needed. These young people need extra
help navigating a health care system
that is often confusing even to homeless
adults.6 Case management services must
be comprehensive and address not only
physical health needs, but also mental
health and social service needs.6 For
example, it may be beneficial for homeless
youth to obtain early emancipation.
(Emancipation may not be automatic just
by living away from one’s family.)
The benefits of early emancipation must
be weighed against the loss of certain
protections afforded a minor such as
the parents’ responsibility to
support their child. Because of the
complexity of addressing the many issues
with which homeless youth present, it
is reasonable to limit the number of
youth assigned to each case manager.
Housing
As with all homeless people, stable
housing is an important component to
improving the health status of homeless
youth. Currently, communities provide
varying levels of accommodations specifically
for homeless youth, ranging from emergency
shelters to transitional housing that
prepares young adults to live on their
own. Many communities have a shortage
of shelter space available for homeless
youth. Some communities attempt to reunite
the youth with his or her family. If
this is not possible, either because
the youth is unwilling or the family
situation is unsafe, foster care is
an option. Unfortunately, foster care
is also a source of homelessness for
youth. Some teenagers will run away
from foster homes while others “age
out” of foster care without the
skills needed to live on their own and
they may subsequently become homeless.1
7 Transitional Living Programs (TLP)
for homeless youth are useful for addressing
the latter. The TLPs differ by community,
but have the basic mission of assisting
troubled youth through their transition
to adulthood. Housing and related services
are provided for up to 18 months for
youth ages 16-21 who are unable to return
to their homes.8 Often, the space available
in such programs is limited. The Administration
for Children and Families through the
Family and Youth Services Bureau (FYSB)
also funds youth shelters that provide
emergency shelter, food, clothing, outreach
services, and crisis intervention for
runaway and homeless youth.8Additional
FYSB programs include grants to organizations
serving runaway, homeless, and street
youth to provide street-based outreach
and education to prevent the sexual
abuse and exploitation of these young
people.
Education
Homeless youth often have troubled schooling
histories including having to repeat
grades. In addition, homeless, unaccompanied
youth face several barriers to obtaining
an education. They are often prevented
from enrolling in school because of
liability concerns, legal guardianship
requirements and curfew laws.9 In 1987,
the Stewart B. McKinney Act established
the Education of Homeless Children and
Youth Program. Unfortunately, the program
has not yet received the full funding
authorized in 1987. Only 3 percent of
local education agencies receive funding.10
The link between a lack of education,
unemployment and poverty is obvious.
In addition to needing to complete high
school successfully, homeless youth
need job training skills to be successful
in the job market. In some communities,
the lack of appropriate employment opportunities
is seen as contributing to the incidence
of street crime by at risk and homeless
youth.
The health issues discussed below were
developed from a review of several studies
available in the literature and may not
necessarily reflect homeless youth in
a specific geographic area. Since the
demographics and services offered to homeless
youth vary by region, State, city and
neighborhood, these differences need to
be considered when developing or offering
services.
Barriers to Care
The barriers homeless youth face in
accessing health care services are similar
to those faced by homeless adults. Examples
include lack of transportation, address
requirements and lengthy bureaucratic
processing, lack of financial resources
or health insurance, and lack of awareness
of services. However, because of their
age and lack of experience, homeless
youth are less able than their adult
counterparts to overcome these barriers.
The barriers to care for homeless youth
include confidentiality issues, need
for parental consent, distrust of adults
and professional agencies, denial on
the part of the youth of a need for
care, and lack of coordinated services
and outreach for homeless youth. In
addition, for many of these young people,
health care may not be a priority over
day-to-day survival issues. A study
in Minneapolis of runaway youth looked
at barriers perceived by street youth
being served by community-based agencies.
The most common
When designing a health system for homeless
youth, both real and perceived barriers
to care should be addressed. Having
services that are convenient, low or
no cost and specific to meet the needs
of homeless youth may help to overcome
these barriers.
Substance Abuse
It is not clear to what extent
substance use by adolescents leads to
homelessness. Many homeless youth report
using alcohol and other drugs prior
to and since becoming homeless. In one
study, street youth reported the highest
rate of substance use, followed by sheltered
youth, runaways and housed youth.1 In
another study, 48 percent of homeless
youth report significant alcohol use,
compared to 19 percent of housed youth.
26 percent of homeless youth report
using injection drugs. Most (74 percent)
used illicit drugs before leaving home
and about one-fifth reported that drug
use contributed to their leaving home.
Parental substance use is common among
homeless youth. In one study, one quarter
of homeless youth report that they ran
away from home because of arguments
or physical violence brought on by parental
alcohol use. In another study, 44 percent
of homeless youth reported that at least
one parent had received treatment for
alcohol, drug or psychological problems.
Mental Health
Rates of serious mental illness
among homeless adolescents, as reported
in the literature, range from 19 to
50 percent. This figure contrasts with
4 to 9 percent of community and school
samples of adolescents. The most common
serious mental illness is major depression.
As with the adult homeless population,
co-occurrence of substance abuse disorders
and serious mental illness is not uncommon.
Rates of suicide attempts are much
higher among homeless adolescents than
their housed counterparts. One study
of street youth in Hollywood reported
that up to 48 percent of homeless youth
have attempted suicide with many making
repeated attempts.
Many homeless youth have been exposed
to both domestic and street violence.
A recent study of youth in a shelter
in north central Florida revealed that
66 percent of the youth had experienced
some type of abuse.4 The most common
form of abuse reported was physical
abuse (46.5 percent), but these youth
also reported sexual abuse (23.3 percent),
emotional abuse (2.3 percent) and a
combination of the above (27.9 percent).4Running-away
behavior by youth has been identified
as a method of coping with such abuse.
Either as witnesses or victims, youth
are also exposed to violence on the
street. In a study of homeless youth
in Baltimore, 75 percent of the homeless
youth reported that they had witnessed
a shooting or stabbing. A study of homeless
and runaway youth in Hollywood found
high rates of witnessing violence and
being a victim of violence. These episodes
occurred prior to and since living on
the street: 85 percent had seen someone
being physically attacked, 44 percent
had seen a dead person somewhere in
the community, 31 percent had seen someone
being killed and 24 percent had seen
someone being sexually assaulted.14
As victims, 70 percent reported having
been punched, hit, burned, or beaten
up; 14 percent reported having been
shot at and hit by gunfire; and 32 percent
reported having been sexually assaulted,
with females being more likely than
males.
Because of the high rate of exposure
to violence as spectators and victims,
homeless youth are at an increased risk
of post-traumatic stress disorder (PTSD).1
According to one study of homeless youth
in Hollywood, 46 percent of homeless
youth had symptoms consistent with PTSD.
They are at increased risk of learning
to use violence as a means of resolving
conflicts, although the Hollywood study
found that few youth resort to lethal
forms of violence.
Pregnancy
44 Gary F, Moorhead J,
and
In recent studies, the lifetime pregnancy
rate for homeless adolescent girls ranged
from 27 to 44 percent.1 This compares
to 8.5 percent in a national survey
of the adolescent female general population
in 1997. From 6 to 22 percent of ever
pregnant homeless girls reported having
given birth.1 Because homeless teenage
girls are less likely to get prenatal
care and may have an inadequate diet,
they may be at risk for low-birthweight
babies and high infant mortality.
Sexually Transmitted Diseases
The lifestyle of a homeless adolescent
places him or her at a great risk of
acquiring a sexually transmitted disease
(STD). This is especially true if the
youth is well entrenched into the street
culture, where they may trade sex for
money, drugs, food, or a warm place
to stay. A study of street youth in
Hollywood found that 29 percent of males
and 33.5 percent of females had a history
of STDs. Risk factors for STDs include
beginning sexual activity at an earlier
age, having multiple partners, having
sex with high-risk partners, and sexual
abuse. Studies show that 62 to 93 percent
of homeless youth are sexually active
compared to 48 percent of all United
States adolescents. 15 Homeless adolescents
initiate sexual activity up to 2 years
earlier than housed adolescents. Often,
youth do not practice safe sex techniques.
Only one-third to one-half report using
condoms regularly.1 The low rate of
condom use places the youth at high
risk for STDs. Attempts to practice
safe sex may be hampered by engaging
in sexual activity while under the influence
of drugs or alcohol. Being forced to
have sex also may make it less likely
that an adolescent will be able to use
safe sex techniques. In one study comparing
homeless youth to youth seen in a school-based
clinic in Baltimore, 26 percent of homeless
youth had been forced to have sex compared
with 8.5 percent in the school-based
clinic.
HIV/AIDS
Homeless youth are at high risk
for HIV infection. The national estimate
of seropositivity among homeless youth
is 5 percent, but one study reported
a rate as high as 17 percent among street
youth in San Francisco.18 By comparison,
studies on more general adolescent populations
such as military recruits or Job Corps
entrants report seropositivity rates
of 0.2 to 0.4 percent.18 Several factors
place homeless youth at risk for HIV,
especially those well-entrenched in
the street culture. These risk factors
include survival sex (trading sex for
basic needs), having multiple sexual
partners, boys engaging in homosexual/bisexual
activity, low frequency of condom use,
and injection drug use.1 18 The frequency
of survival sex has been reported as
high as 43 percent in one study of street
youth in Los Angeles.18 The early start
of sexual activity and the large number
of sexual partners also place some homeless
youth at risk for HIV infection. In
one study of New York City street youth,
21 percent of males and 24 percent of
females reported having had more than
100 lifetime partners.18 As mentioned
above, 26 percent of homeless youth
report injection drug use placing them
at high risk for HIV infection.
Oral Health
As with homeless adults, oral health
is an often-neglected area of health
by homeless youth.6 19 Very little formal
research exists looking at oral health
and access to dental care among homeless
youth. Poor oral health affects not
only the health of the individual, but
also can hinder a youth’s attempts
to improve his or her life circumstances.
Decayed or missing teeth can lower an
individual’s self-esteem and have
an impact on social interactions including
attempts to find employment.
There are many factors that lead to
poor oral health among homeless youth.
These include poor nutrition, difficulties
in maintaining regular habits and an
inability to clean their mouths.19 Dental
services, including preventive and restorative
services, must be a part of a comprehensive
primary health care system.
Legal Issues/Consent to Care
The ability to consent to health
care is an important issue for homeless
youth under age 18. Because they may
no longer have a relationship with a
parent, their ability to receive even
basic health care can be hindered by
statutes requiring parental approval
for care. Very few States have laws
specifically dealing with the ability
of homeless and runaway youth to consent
to medical care. In most States, only
laws dealing with minors in general
(homeless or housed) are found, and
they are scattered throughout the State’s
legal code.20While there are some general
issues related to consent to care, it
is important that providers of health
care to homeless youth understand the
laws governing a minor’s consent
to care for individual States.
As a general rule, minors cannot consent
to their own health care. However, over
the past two-to-three decades, all States
have enacted laws that allow minors
to consent to some health care, without
parental consent or notification.20
These laws are usually related to specific
disease States or medical conditions.
For example, all 50 States and the District
of Columbia allow minors to consent
to care for sexually transmitted diseases
including HIV (three States limit HIV
care to testing only).21 Twenty-five
States and the District of Columbia
allow minors to consent to contraceptive
services and 27 States and the District
of Columbia allow minors to consent
to prenatal care.21 The ability to consent
to care for these conditions does not
necessarily mean that a minor can consent
to all health care services. Only 22
States allow minors to consent to general
medical and surgical care. Some States
allow this only under certain circumstances
such as being pregnant, having a child
or having reached a certain age.
Most States allow health care providers
to proceed with emergency services if
delaying treatment awaiting parental
consent would endanger the minor’s
health or well being.20Most States give
minors the authority to consent to drug
and alcohol counseling and treatment.
Only 20 States and the District of Columbia
give minors the authority to consent
to outpatient mental health services.
However, if a State permits a minor
to consent to general medical care,
these laws may be broad enough to cover
mental health and substance abuse treatment
as well.
Needs Assessment
Each community will have its own
needs regarding health care for homeless
youth. In order to understand the needs
of a community, a needs assessment should
be performed. This assessment should
estimate the size of the target population,
identify the geographic area with the
greatest need, identify the health care
needs of the target community and identify
the existing health care resources.
The best understanding of the needs
of the homeless youth within a community
comes from the youth themselves. The
needs assessment should include a survey,
formal or otherwise, in which youth
can help identify the barriers in accessing
care and the gaps in services. Health
care, social services, mental health,
dental care, substance abuse, housing,
and educational needs should be identified.
A firm understanding of the local legal
considerations, especially in the area
of a minor’s ability to consent
to care, is essential.
Financial Support
The needs assessment will help
a program determine the resources needed
to address the gaps identified. The
program should identify potential funding
sources such as Federal, State and local
grants, charitable community organizations,
and foundations. There may be available
services in the community to which a
program can link, and collaborations
with other organizations may provide
“in-kind” support and services.
Identifying these potential partners
can prevent a duplication of services,
thus ensuring that resources are used
wisely.
Choosing a Model of Health Care
Delivery
The needs assessment and projected
funding available will help to determine
the model of care delivery to be used.
Below are examples of models current
programs are using. Possible models
range from having a separate comprehensive
site (with primary care, mental health,
substance abuse, dental, social services
and housing) to linking youth with existing
community services and facilitating
their movement through the system. Depending
on the level of need and available resources,
a separate clinic setting geared exclusively
toward youth may be more acceptable
to homeless youth. Many homeless youth
are distrustful of authority and adult
systems because adults have failed them
in the past. Having a youth-oriented
center and staff who are sensitive to
the unique needs of homeless youth can
increase their acceptance of assistance
and care. If it is not feasible to set
up a separate clinic, setting aside
services within an existing clinic is
a reasonable alternative. This can be
accomplished within a fixed site, at
a shelter or in a mobile van. If little
financial support is available or the
targeted population is small, an alternative
is to provide a linkage to existing
services. In this case, a program may
want to target most of its resources
toward case management in order to help
the youth navigate through an adult
or general adolescent system of care.
Comprehensive Model
Covenant House-Under 21, New York,
New York
Covenant House-Under 21 provides comprehensive
primary health care services to homeless
youth up to the age of 21 and their
children. The program operates a 12-hour
clinic, Monday through Friday, which
includes on-site laboratory and X-ray
facilities. The clinic is housed within
a 24-hour crisis shelter called Crisis
Center. In addition to comprehensive
primary health care services, Covenant
House also provides mental health services
and social services such as eligibility
assistance, substance abuse services,
legal services and outreach services.
More recently, Covenant House has expanded
its services to include street outreach
and satellite sites providing social
services. The street outreach program
operates a nightly van to offer services
to youth who are in need, but are not
ready to come into Covenant House. Covenant
House also operates a transitional living
program called Rights of Passage where,
in addition to housing, youth are provided
with job training and interviewing skills
as well as help with job placement.
All youth staying in Covenant House
are given a thorough health assessment
upon arrival.
Other supportive services offered by
Covenant House include a Mother/Child
Program addressing the needs of young
homeless mothers. The program provides
short-term housing along with classes
in parenting skills, child development
and health care. Covenant House has
a school-based program that is designed
to help needy high school students stay
in school. The program includes counseling,
educational training such as tutoring
and SAT preparation and vocational training
in their Regional Training Center. Each
school-based program runs a youth group
that allows participants to explore
issues of self-esteem, conflict resolution
and violence prevention.
For more information contact Diana Holmes
at (212) 613-0300 or visit the
Covenant
House New York web site.
Fixed-Location Clinic Model
Family Health Centers of San Diego,
San Diego, California
Family Health Centers of San Diego
uses a model that emphasizes intensive
case management. In addition to health
care, case managers in this setting
help with basic services such as linking
youth with social services, housing
services including transitional living
programs, substance abuse detox, emergency
shelters, and transportation for follow-up
appointments. Family Health Centers
of San Diego has a free-standing clinic
exclusively for teens. While the clinic
is not just for homeless youth, it does
serve as an important source for on-going
health care for this population. Teens
help clinic staff and serve as peer
educators. Family Health Centers of
San Diego also has maintained a clinic
in a homeless alternative school for
6 years.
Three years ago, starting with a planning
grant from many contributors, the center
began a mobile medical unit. The Teen
Outreach Mobile Clinic is the result
of collaboration between the health
center and several partners including
private and non-profit foundations,
academic centers, and city, county and
State health departments. The program
has incorporated youth into its advisory
group that assists in the design, implementation
and evaluation of the mobile clinic.
The mobile medical unit is set up to
provide a clinic session on the street
in those areas frequented by homeless
youth. Youth accessing the mobile medical
unit receive direct care, follow up
services, and referrals for medical
and supportive services throughout the
community.
One of the primary goals of the Teen
Outreach Mobile Clinic is to work with
the youth to establish a permanent medical
home. The free-standing Teen Clinic
often serves in this capacity. Initially,
the mobile medical unit operated only
one night per week, but because of an
increase in resources, it soon increased
its operation to three nights per week.
The Mobile Clinic is now able to provide
services in three different locations
around the city on a weekly basis. The
locations were chosen because each has
a high prevalence of homeless and runaway
youth. The unit operates for 4 hours
each evening and provides services to
15 to 35 youths during each clinic session.
By meeting the youths’ health
needs on the street, the goal is to
establish a relationship with the young
people, and ultimately help them integrate
into more traditional health care service
sites.
For more information contact David
Vincent, MSW at (619) 515-2371.
Collaboration Model
City of Manchester Public Health Department,
Manchester, New Hampshire
The City of Manchester Public Health
Department has been able to provide
services to homeless youth through The
Mobile Community Health Team Project/Health
Care for the Homeless (HCH) program
and its collaboration within the community.
The HCH team provides its primary health
care at a large adult shelter in Manchester.
Manchester is an urban center where
youth tend to congregate however, the
homeless youth population in Manchester
is small relative to other large cities
in New Hampshire. Agencies that perform
street outreach bring homeless youth
to the HCH team for basic evaluations
and medical attention. The HCH team
cares for the youth directly and/or
provides linkages to existing services
as indicated. Teens who are 17 or older
and who frequent the adult shelter receive
care from the HCH team at the shelter.
Primary health care includes physical
exams, health maintenance, immunizations,
Tuberculosis and HIV screening, PAP
smears, substance abuse counseling,
health education, dental services and
eye care. Because of the rules of the
shelter, teens under 17 cannot receive
care on a continuing basis. After their
initial visit the younger teens may
be referred to Child Health Service’s
High Risk Pediatric Clinic or their
Teen Health Clinic at the Young Women’s
Christian Association. Both offer settings
sensitive to the needs of homeless youth.
Future plans by the HCH team for youth
programs include fitness activities
and recreation sessions conducted by
the Fitness Specialist and health education
regarding addictions, relationships
and communication skills. These interventions
have proven successful with other homeless
subgroups in Manchester and it is agreed
that they will be beneficial to youth
as well.
The HCH team recognizes the importance
of providing culturally competent care,
so they advocate for homeless patients
and teach non-HCH providers about issues
specific to homeless youth. The HCH
team collaborates with other service
providers on a regular basis. They include
the Academy Parole Program, Our Place
Program for Pregnant Teens, Child and
Family Services Transitional Living
Program, The Merrimack Valley AIDS Project,
The After School Program for Homeless
Youth conducted by the city’s
Board of Education, the Homeless Liaison
counselor at each public school, the
Salvation Army’s Kid’s Café,
The Mental Health Center and the Serenity
Place Sobriety Maintenance/Crisis Shelter.
In addition the HCH substance abuse
counselor serves as a New Futures Community
Leader, in a Statewide effort to prevent
youth substance abuse. Plans are under
way to set up a shelter for homeless
youth that may include Alcoholics Anonymous
meeting opportunities for teens. As
the HCH team collaborates with other
service providers, a comprehensive network
is created to meet the needs of homeless
youth. For many young people who are
homeless, the HCH team is the point
of entry toward recovery.
For more information contact Marianne
S. Feliciano, BSN, Homeless Care Coordinator
at (603) 663-8716 or Frederick Rusczek,
MPH, Executive Director at (603) 624-6466.
Homeless youth are a unique
subset among the larger group of people
experiencing homelessness. Many of their
health concerns are similar to homeless
adults, however, due to their young age,
high-risk behaviors and legal concerns,
homeless youth require specialized services.
Health care and social services geared
exclusively to homeless youth can provide
a place for youth to obtain needed services
without the help of parents, to ensure
successful transitions from childhood
to adulthood, and from homelessness to
being housed.
