Cultural.

ORIGINAL PAPER

Conduct disorder behaviors, childhood family instability, and childhood abuse as predictors of severity of adult homelessness among American veterans

Jack Tsai • Robert A. Rosenheck

Received: 16 February 2012 / Accepted: 26 June 2012 / Published online: 15 July 2012

� Springer-Verlag (outside the USA) 2012

Abstract

Purpose Despite US federal efforts to end and prevent

homelessness among veterans, there has been limited

examination of pre-military factors like childhood prob-

lems, associated with adult homelessness. This study

examined childhood problems among homeless veterans

and its relation to severity of homelessness and outcomes

in supported housing.

Methods Using data from 1,161 homeless veterans at 19

sites enrolled in the Housing and Urban Development-

Veterans Affairs Supportive Housing (HUD-VASH) pro-

gram, three types of childhood problems were examined:

conduct disorder behaviors, family instability, and child-

hood abuse. Multiple regressions were conducted to

examine the association between childhood problems and

severity of homelessness before supported housing, and

childhood problems and outcomes after supported housing.

Results About one-third reported conduct disorder

behaviors, over half reported family instability, and 40 %

reported childhood abuse. Greater childhood problems

were found in this sample compared to published samples

of non-homeless veterans. Conduct disorder behaviors,

family instability, and childhood abuse were each weakly

associated with lifetime homeless episodes. One year after

enrollment in the HUD-VASH program, past conduct dis-

order behaviors and family instability were not predictive

of outcomes, except childhood abuse was related to less

social support and lower quality of life.

Conclusions These findings demonstrate not only the

potential impact of childhood abuse on social relationships

and quality of life in adulthood, but also the resilience of

homeless veterans from adverse childhoods to be suc-

cessfully housed in a supported housing program.

Keywords Childhood � Conduct disorder � Homelessness � Supported housing � Veterans

Introduction

There is major interest in ending and preventing home-

lessness among veterans of the US military [1, 2]. Research

on preventing homelessness among veterans has examined

various adult risk factors [3], but there has been little

examination of the childhood experiences of homeless

veterans. Although childhood factors may be viewed as

distal variables when examining adult outcomes, study of

these factors may nevertheless contribute to our under-

standing of risk factors and theories related to pathways by

which veterans become homeless. Examination of how

childhood factors may affect treatment may also inform

clinical care. Despite the common assumption that military

experience is the cause of veteran homelessness, studies

suggest some of the problems veterans experience after the

military actually stem from pre-military factors [4–6],

although risk factors as early as childhood have not been

examined among veterans.

J. Tsai (&) � R. A. Rosenheck VA New England Mental Illness Research, Education,

and Clinical Center, 950 Campbell Ave., 151D,

West Haven, CT 06516, USA

e-mail: [email protected]

J. Tsai � R. A. Rosenheck Department of Psychiatry, Yale University,

New Haven, CT, USA

R. A. Rosenheck

School of Epidemiology and Public Health, Yale University,

New Haven, CT, USA

123

Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486

DOI 10.1007/s00127-012-0551-4

The few studies on childhood experiences of homeless

veterans have found that childhood physical or sexual

abuse, placement in foster care, and other childhood

hardships increase vulnerability for homelessness [6, 7].

While some data on childhood problems among non-

homeless veterans exist [8–10], there have been no pub-

lished comparisons using these data to compare with

homeless veterans. Furthermore no study found has

examined, whether conduct disorder behaviors during

childhood are associated with adult homelessness among

veterans, although important linkages have been found

between criminal justice involvement and homelessness in

veterans [11, 12].

More importantly, to our knowledge, no study has

examined the association of childhood problems and out-

comes among veterans enrolled in supported housing.

Supported housings broadly defined as subsidized housing

with case management support, has become a main service

model for homeless veterans. As the Department of Vet-

erans Affairs (VA) is scaling up supported housing pro-

grams to address veteran homelessness, examination of

childhood problems that may affect the success of veterans

in supported housing may be informative for service pro-

viders and program administrators. Childhood problems

are known to negatively affect various clinical outcomes in

adulthood [13, 14], and the question remains whether

childhood problems hinder veterans’ abilities to derive

treatment gains from supported housing.

A sizable literature exists on the childhood experiences of

other homeless populations besides veterans. While homeless

veterans may differ from non-veterans in their life experi-

ences and pathways to homelessness [15], findings from the

general homeless literature may provide some insight that

may be relatable to homeless veterans. Other homeless

populations that have been studied in terms of childhood

problems include general homeless adults, homeless adults

with mental illness, and chronically homeless adults.

Studies on general homeless adults have found that

homeless adults experience more adverse childhood events

such as out-of-home placement, physical and sexual abuse,

lack of parental care, and unstable housing situations than

non-homeless adults [16–19]. High rates of conduct dis-

order have been found among runaway and homeless youth

in the general populace, which presumably can predispose

them to homelessness in adulthood although the direc-

tionality of the relation between conduct disorder and

homelessness is not well established [20, 21].

Homeless adults with mental illness appear to have had

even more childhood problems than homeless adults with

no mental illness. In fact, they appear to be doubly disad-

vantaged as homeless adults with mental illness report

more family and home instability during childhood than

non-mentally ill homeless adults and also report more

poverty in childhood than mentally ill housed adults [22].

Adults who became homeless before becoming mentally ill

had the highest levels of disadvantage and social disrup-

tion, while those who became homeless after becoming

mentally ill had an especially high prevalence of alcohol

dependence.

Chronically homeless adults, who are often distin-

guished from other homeless adults by their extensive

histories of homelessness are estimated to comprise 23 %

of all homeless adults [23]. One study found that among

chronically homeless adults, childhood problems were

associated with an earlier age of homelessness and more

severe drug problems [24]. However, the study also found

that once enrolled in supported housing, chronically

homeless adults who reported many childhood problems

were not at increased risk for further homelessness com-

pared to those who reported fewer or no childhood prob-

lems. One caveat of the study was that measurement of

childhood problems did not separate family instability from

conduct disorder behaviors, which may have affected the

results as different types of childhood problems may dif-

ferentially affect outcomes.

The literature on childhood predictors of adult home-

lessness remains incomplete. There has been limited

research on the childhood problems of the homeless vet-

eran population and no comparison to non-homeless vet-

erans. It is unknown how problems veterans experience

during childhood may lead to homelessness in adulthood or

how childhood problems may affect the ability of veterans

to benefit from housing services. Based on the extant lit-

erature, we hypothesized that homeless veterans would

have more childhood problems than non-homeless veterans

and that these problems would be associated with more

severe homelessness before supported housing and less

successful outcomes in supported housing. Using measures

to examine three types of childhood problems, conduct

disorder behaviors, family instability, and childhood abuse

(physical, sexual or emotional), we aimed to (1) describe

the reported childhood problems of homeless veterans in a

nationwide supported housing program and compare them

to published samples of non-homeless veterans, (2)

examine whether problems experienced during childhood

are associated with greater adult homelessness, and (3)

observe whether childhood problems are associated with

poorer outcomes in supported housing.

Methods

Program description

Data were based on a combined national observational

dataset and an experimental dataset of a total of 1,161

478 Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486

123

participants who entered the Housing and Urban Devel-

opment-Veterans affairs Supportive Housing (HUD-

VASH) program across 19 sites between 1992 and 2003.

Eligibility criteria for HUD-VASH during this time inclu-

ded being eligible for VA services, living in a shelter or on

the street for at least 30 days, and having a psychiatric and/

or substance use disorder at the time of initial contact.

Veterans were referred to HUD-VASH by clinicians

working in specialized VA homeless services programs and

once admitted into HUD-VASH, they were assigned a

HUD-VASH case manager. Case managers assisted clients

in obtaining their housing voucher, locating and moving

into an apartment and providing intensive case manage-

ment support. Interviews with clients were conducted by

clinical staff at baseline and every 3 months. This study

focused on clients at baseline before entry into HUD-

VASH and at 1-year follow-up after entering HUD-VASH.

Measures

Sociodemographic characteristics and mental health diag-

noses of clients were obtained by clinical staff through

interviews and reviews of existing medical records. All

participants provided informed consent and the procedures

were approved by the institutional review boards at each

site.

Childhood problems

Conduct disorder behaviors before the age of 15 were

assessed at baseline with nine items from a previously

developed scale [25, 26] that asked participants to respond

dichotomously to questions about academic school per-

formance, fights, lying, stealing, damaging property, and

being arrested during their childhood. This measure is not

used to diagnose conduct disorder, but captures conduct

disorder-type behaviors. Items were summed for a total

scores ranging from 0 to 9 with higher scores reflecting

more conduct disorder behaviors during childhood. In this

study, there was adequate internal consistency with Cron-

bach’s a = 77. Family instability before the age of 18 was assessed at

baseline with the 11-item Family Instability Scale [27, 28],

which asked participants to respond dichotomously to

questions about their parents missing, their parents

divorcing, having to live in institutions, moving often,

getting into trouble, poverty, having friends who got into

trouble, and playing hooky. Items were summed for a total

score ranging from 0 to 11 with higher scores reflecting

more family instability during childhood. In this study, the

internal consistency was minimally acceptable [29] with

a = 67.

Childhood abuse was assessed with a dichotomous item

that asked participants whether they experienced any

physical, sexual or emotional abuse before the age of 18.

These measures of childhood problems were selected to

reduce participant burden, allow for comparisons with

previously published studies, and for their face validity.

Employment and income

At baseline, participants were asked about the duration of

their longest full-time job and their employment pattern in

the past 3 years. At baseline and 1-year follow-up, partic-

ipants were asked the number of days they worked in the

past month, and the amount of money they received from

employment, pension/disability, welfare, and relationships

(i.e., mate, family or friends) in the past month. Total

income was the sum of these three income sources.

Homelessness and psychiatric hospitalization

At baseline, participants were asked the total number of

years they had been homeless, the number of times they

had been homeless, and the number of psychiatric hospi-

talizations they have had in their lifetime. At baseline and

1-year follow-up, participants were asked the number of

nights they were housed (i.e., own apartment, room, or

house, or somebody else’s place, hotel or boarding home),

in a hospital, and homeless (i.e., shelter, outdoors, auto-

mobile) in the past 3 months.

Social relationships

At baseline and 1-year follow-up, participants were asked

to report how many people they felt close to out of a list of

ten relationship categories including parents, grandparents,

brothers/sisters, spouse/significant other, children, other

family, other veterans, friends (other than veterans), co-

workers (other than veterans or friends), and health care

providers. Participants could report up to eight people in

each category and the number in each category was sum-

med for a total score. Participants were also asked to rate

how often they had seen people in each category in the past

3 months from 0 (never) to 6 (lives with me). Scores were

summed for a total score indicating the number of close

relationship contacts clients had.

Social support was assessed at baseline and 1-year fol-

low-up by asking participants the number of types of per-

sons who they could ‘‘have counted on’’ in the past

3 months for: a short-term loan of $100, a ride to an

appointment or assistance if they felt suicidal [30]. The

total mean number of types of persons was calculated for a

total score ranging from 0 to 10.

Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486 479

123

Quality of life

At baseline and 1-year follow up, quality of life was

evaluated using eight scales from the Lehman Quality of

Life Interview [31]: living situation (11 items), family (five

items), finances (four items), health (six items), leisure (six

items), life satisfaction (one item), safety (seven items),

and friends (six items). For each subscale, participants

were asked to rate items on a scale from 1 (terrible) to 7

(delighted) and mean scores were calculated for each

subscale.

Data analysis

Analyses proceeded in four steps. First, participant soci-

odemographics, mental health diagnoses, reported child-

hood problems, employment and income, homelessness

and psychiatric hospitalization history, social relationships,

and quality of life at baseline were summarized with fre-

quency analyses and descriptive statistics. To examine the

association between different childhood problems, Pearson

correlations were conducted between conduct disorder

behavior scores, family instability scores, and reports of

childhood abuse.

Second, conduct disorder behavior scores and family

instability scores in this sample of homeless veterans were

compared to scores of other published samples of veterans

that used the same measures. Effect sizes were calculated

as Cohen’s d.

Third, multiple regression analyses were conducted to

identify the independent association of conduct disorder

behavior scores, family instability scores, and reports of

childhood abuse with baseline employment, homelessness

and psychiatric hospitalization history, social relationships,

and quality of life before entry into the HUD-VASH pro-

gram. Participant sociodemographics and mental health

diagnoses were controlled for by entering them into the

first block of the regression before conduct disorder

behavior scores, family instability scores, and reports of

childhood abuse were entered into the second block of

predictors.

Fourth, a final set of multiple regression analyses were

conducted to examine childhood problems as predictors of

outcome 1 year after entry into the HUD-VASH program

net of potentially confounding baseline factors. Again,

participant sociodemographics and mental health diagnoses

were entered into the first block of measures, and conduct

disorder behavior scores, family instability scores, and

reports of childhood abuse were entered into the second

block as predictors of employment and income, home-

lessness severity and psychiatric hospitalizations, social

relationships, and quality of life 1 year after entry into

HUD-VASH. To reduce type I error with the number of

analyses conducted, the significance level was set at 0.01

for all statistical tests.

Results

Table 1 shows the majority of participants were male in

their 40s either black or white had a high school education,

were not married, from the Vietnam War era, and had an

alcohol abuse/dependency disorder. The most common

conduct disorder behaviors participants reported during

childhood were that they lied a lot (33.51 %), drank or used

drugs often (28.25 %), and ran away from home (23.08 %)

before the age of 15. The most common family instability

issues participants reported were that they had friends who

got into trouble with the law or school authorities

(61.33 %), they had one or both parents missing from

the home (57.11 %) or their parents separated/divorced/

died before the age of 18 (56.59 %). A high proportion

(40.31 %) of participants reported experiencing physical,

sexual or emotional abuse before the age of 18. There were

significant inter-correlations between childhood problems,

i.e., between conduct disorder behavior scores and family

instability scores (r = 0.47, p \ 0.001), between conduct disorder behavior scores and childhood abuse (r = 0.34,

p \ 0.001), and between family instability scores and childhood abuse was (r = 0.30, p \ 0.001).

Most participants had a past history of employment and

had been employed full-time or part-time during most of

the past 3 years (61.59 %). However, most had not worked

more than 5 of the past 30 days and the largest source of

income was pension and disability benefits. As expected,

participants had extensive histories of homelessness. On

average, participants reported being homeless for more

than 3 years in their lives had been homeless more than

two times in their lifetimes, and were homeless for more

than 30 of the past 90 days.

Participants reported having a mean of 11 close rela-

tionships and having some contact in these relationships in

the past 3 months, although they only had a mean score of

2.59 out of 10 on the social support scale. On average,

participants scored in the ‘‘mostly dissatisfied’’ to ‘‘mixed’’

range on the quality of life scales with the highest score on

the family subscale and the lowest on the finances subscale.

Table 2 shows conduct disorder behavior scores, family

instability scores, and reports of childhood abuse in the

HUD-VASH sample as compared to other published sam-

ples of veterans. Compared to a sample of Vietnam vet-

erans seeking VA outpatient mental health care [8], there

was a small to medium effect size difference in conduct

disorder behavior scores, a medium effect size difference in

family instability scores, and a conservatively estimated

small effect size difference in childhood abuse. Compared

480 Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486

123

Table 1 Summary of baseline participant characteristics and child- hood problems

Sociodemographics Participants

(n = 1,107–1,161)

Age 42.97 (7.99)

Gender-male 1,102 (94.92 %)

Race/ethnicity

White 517 (44.53 %)

Black 552 (47.55 %)

Hispanic 59 (5.08 %)

Asian/Indian/Alaskan 21 (1.81 %)

Other/missing 12 (1.03 %)

Education (years) 12.50 (1.80)

Married 53 (4.57 %)

Service era

Before Vietnam War 138 (12.51 %)

Vietnam War 657 (59.56 %)

Post-Vietnam era 290 (26.29 %)

Persian Gulf 18 (1.63 %)

Mental health diagnosis

Psychotic disorder 149 (12.83 %)

Mood disorder 373 (32.13 %)

Personality disorder 175 (15.07 %)

Posttraumatic stress disorder 172 (14.81 %)

Adjustment disorder/other 265 (22.83 %)

Alcohol abuse/dependency 733 (63.14 %)

Drug abuse/dependency 569 (49.01 %)

Other disorder 122 (10.51 %)

Dual diagnosis 403 (34.71 %)

Childhood problems

Conduct disorder behaviors before age 15

Poor or below average academic

performance

210 (18.09 %)

Expelled or suspended from school 258 (22.22 %)

Arrested or sent to juvenile court 240 (20.67 %)

Ran away from home 268 (23.08 %)

Lied a lot 389 (33.51 %)

Drank or used drugs often 328 (28.25 %)

Stole things often 237 (20.41 %)

Deliberately damaged things that weren’t

yours

141 (12.14 %)

Started fist fights often 235 (20.24 %)

Conduct disorder behavior score 1.99 (2.18)

Family instability before age 18

One or both parents missing from home 663 (57.11 %)

Parents separated/divorced/died 657 (56.59 %)

Lived in a foster home/residential

treatment/orphanage any time

131 (11.28 %)

Family moved more than twice while

in high school

311 (26.79)

Table 1 continued

Sociodemographics Participants

(n = 1,107–1,161)

Seven or more children living in home 276 (23.77)

Father out of work more than half the time 211 (18.17)

Family income too low to meet expenses 430 (37.04 %)

Did not complete high school before

military

471 (40.57 %)

Had friends who got into trouble with law

or school authorities

712 (61.33 %)

Got into trouble with law or school

authorities

449 (38.67 %)

Played hooky frequently 444 (38.24 %)

Family instability score 4.08 (2.42)

Any childhood abuse (physical, sexual,

or emotional)

468 (40.31 %)

Employment and income

Longest full-time job (months) 64.51 (58.04)

Employment pattern in past 3 years

Full-time 407 (35.06 %)

Part-time 308 (26.53 %)

Student/service/volunteer 17 (1.46 %)

Retired/disabled 116 (9.99 %)

Unemployed/institution 310 (26.70 %)

Days worked, past month 4.45 (7.82)

Money from employment, past month 129.88 (284.63)

Money from pension/disability, past month 149.63 (305.19)

Money from welfare, past month 29.01 (87.27)

Money from relationships, past month 11.46 (79.43)

Homeless and psychiatric hospitalization history

Lifetime homelessness (years) 3.53 (4.06)

No of times homeless in lifetime 2.43 (1.27)

No of times hospitalized in lifetime 1.84 (4.59)

Nights housed, past 3 months 6.41 (17.11)

Nights in hospital, past 3 months 6.23 (14.80)

Nights homeless, past 3 months 31.27 (34.08)

Social relationships

No of close relationships 11.36 (9.72)

No of close relationship contacts, past

3 months

11.66 (7.70)

Social Support score 2.59 (1.82)

Quality of life

Family scale 4.32 (1.50)

Finances scale 2.61 (1.32)

Health scale 4.16 (1.32)

Leisure scale 3.42 (1.34)

Life satisfaction scale 4.17 (1.46)

Living situation scale 3.45 (1.24)

Safety scale 3.52 (1.53)

Social scale 3.94 (1.25)

Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486 481

123

to a national community sample of male Vietnam theatre

veterans from the National Vietnam Veterans Readjust-

ment Study (NVVRS) [10], there was a small effect size

difference in conduct disorder behavior scores, a medium

to large effect size difference in family instability scores,

and a conservatively estimated small to medium effect size

difference in childhood abuse. Compared to a national

community sample of female Vietnam theatre veterans [9],

there was a large effect size difference in conduct disorder

behavior scores, large effect size difference in family

instability scores, and large percentage difference in

childhood abuse.

Table 3 shows the association between participants’

reported childhood problems and their unemployment,

homelessness, and psychiatric hospitalization in adulthood

at baseline before entry into the HUD-VASH program.

After controlling for sociodemographics and mental health

diagnoses, family instability scores were significantly

associated with number of lifetime homeless episodes

(b = 0.12), number of contacts with close relationships in the past 3 months (b = -0.11), social support scores (b = -0.09), and quality of life scores on the family scale (b = -0.09) and finance scale (b = -0.11), but not with duration of lifetime homelessness, housing in the past

month, employment or social support.

Childhood abuse was significantly associated with the

number of lifetime homeless episodes (b = 0.10), number of close relationships (b = -0.08), social support scores (b = -0.14), and four of the eight quality of life scales related to family, health, life satisfaction, and social life

(b = -0.11 to -0.23). Participants who reported physical, sexual or emotional abuse before the age of 18 had been

homeless more times had less social support, and lower

quality of life in many areas (Table 3).

Conduct disorder behavior scores were not significantly

associated with any baseline variables, except for the

number of lifetime homeless episodes (b = -0.11). Together with family instability scores and reports of

childhood abuse, childhood problems explained a small,

but notably significant proportion of the variance in quality

of life related to family (9 %), number of lifetime home-

less episodes (5 %), social support (3 %), duration of

lifetime homelessness (2 %), the number of close rela-

tionship contacts (2 %), and quality of life related to health

(2 %) and life satisfaction (2 %).

One year after enrollment in the HUD-VASH program,

after controlling for sociodemographics and mental health

diagnoses, childhood conduct disorder behavior scores and

family instability scores were not significantly associated

with any outcome measures related to employment,

homelessness, psychiatric hospitalization, social relation-

ships or quality of life, except for one positive association

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482 Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486

123

(Table 4). Childhood abuse remained significantly and

negatively associated with social support scores (b = -0.18), and four of the eight quality of life scales related to

family (b = -0.23), leisure (b = -0.13), life satisfaction (b = -0.15), and social life (b = -0.15). Together, con- duct disorder behavior scores, family instability scores, and

reports of childhood abuse explained very little variance in

outcomes (0–3 %) related to employment, homelessness

and psychiatric hospitalization, and social relationships.

The most variance explained by childhood problems was in

quality of life related to family (5 %).

Discussion

This study describes the reported childhood problems of

homeless veterans entering the HUD-VASH program and

examines their relation to adult homelessness, and outcomes

in housing, employment, social relationships, and quality of

life in supported housing. The first notable finding is that

family instability and childhood abuse is common among

homeless veterans, which suggests behavioral and emotional

problems began early for this population. More than half of

the participants reported they had a parent missing in their

household and nearly 40 % reported some childhood phys-

ical, sexual or emotional abuse. Somewhat less common,

though still relatively frequently were conduct disorder

behaviors, about a third reported they lied a lot during

childhood and more than a quarter reported drinking or

using drugs often during childhood.

The second main finding was that homeless veterans

reported more family instability, conduct disorder behav-

iors, and childhood abuse than previous samples of non-

homeless veterans seeking outpatient mental health care

and general samples of Vietnam veterans. The largest

differences were in family instability and childhood abuse,

suggesting these are important factors in differentiating

homeless veterans from the rest of the veteran population.

However, direct comparisons were not made and different

characteristics of the samples may explain some or all of

Table 3 Regression coefficients with childhood problems as pre- dictors of unemployment, homelessness, and psychiatric hospitaliza-

tion in adulthood before enrollment in supported housing

Conduct

disorder

behavior

score

Family

instability

score

Any

childhood

abuse

Incremental

R2

Employment

Longest full-time

job (months)

-0.02 -0.04 -0.05 0.01

Days worked, past

month

-0.04 -0.01 -0.02 0.00

Money from

employment,

past month

-0.02 -0.06 0.01 0.00

Money from

pension/

disability, past

month

-0.01 -0.04 -0.01 0.00

Money from

welfare, past

month

-0.02 0.04 0.05 0.00

Money from

relationships,

past month

0.01 0.01 0.02 0.00

Homeless and psychiatric hospitalization history

Lifetime

homelessness

(years)

0.09 0.06 0.04 0.02**

No of times

homeless in

lifetime

0.11* 0.12* 0.10* 0.05***

No of times

hospitalized in

lifetime

0.06 -0.02 -0.02 0.00

Nights housed,

past month

-0.04 0.05 0.05 0.01

Nights in hospital,

past month

0.01 -0.02 -0.04 0.00

Nights homeless,

past month

-0.02 -0.00 -0.03 0.00

Social relationships

No of close

relationships

-0.02 -0.06 -0.06 0.01

No of close

relationships

contacts, past

3 months

0.04 -0.11* -0.07 0.02*

Social support

score

0.05 -0.09* -0.14** 0.03**

Quality of life

Family scale -0.08 -0.09* -0.23** 0.09**

Finances scale 0.01 -0.11* -0.02 0.01*

Health scale -0.03 -0.03 -0.11* 0.02**

Leisure scale -0.01 -0.03 -0.07 0.01

Life satisfaction

scale

-0.05 -0.01 -0.12** 0.02**

Table 3 continued

Conduct

disorder

behavior

score

Family

instability

score

Any

childhood

abuse

Incremental

R2

Living situation

scale

0.02 -0.04 -0.02 0.00

Safety scale 0.07 -0.07 -0.08 0.01

Social scale -0.03 0.00 -0.11* 0.01*

Controlling for sociodemographics and mental health diagnoses

* p \ 0.01, ** p \ 0.001

Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486 483

123

the differences found. Even though this study provided

some comparability between homeless veterans and other

veterans by examining scores on similar measures of

childhood problems, further study is needed to carefully

delineate these differences.

The third finding was all measures of childhood prob-

lems were weakly associated with more episodes of life-

time homelessness. Family instability was associated with

more lifetime episodes of homelessness among veterans,

which extends previous studies on the general homeless

population [16–19], chronically homeless adults [24], and a

previous study on homeless veterans [6]. These findings are

also consistent with a large literature that has shown

adverse childhood experiences are associated with various

emotional and behavioral problems in adulthood [32, 33].

Childhood abuse and conduct disorders behaviors were

also associated with more lifetime episodes of homeless-

ness. While both childhood abuse and conduct disorder

behaviors have not been examined among homeless vet-

erans before, the findings are consistent with the literature

documenting the negative effects of childhood abuse on

adult development and social functioning [34–37] and the

link between criminal justice involvement and homeless-

ness among veterans [11, 12]. However, it is worth noting

that these associations were relatively small, suggesting

childhood problems are distal, weak predictors on adult

homelessness and other factors may need to be considered.

Both family instability and childhood abuse were also

associated with other domains of functioning, including

less perceived social support and lower quality of life

before supported housing. It is well documented that adults

with severe mental illness who are homeless often lack

social support [38–40], but it appears adverse childhood

experiences may result in even less social support. Family

instability and childhood abuse may result in mental health

problems which ultimately lead to low social support; but

family instability and childhood abuse were also found to

be independently associated with lower social support after

controlling for mental health problems. These findings

demonstrate the often complex pathway by which some

veterans become homeless which include problems during

childhood, more homeless episodes, less social support,

and lower quality of life. As others have urged [17], health

and social policies focused on helping children have

healthy childhood will improve their lives as adults, and

reduce their risk for homelessness.

The fourth finding was that 1 year after veterans enrol-

led in the HUD-VASH programs conduct disorder behav-

iors and family instability during childhood were not

predictive of housing, employment, social or quality of life

outcomes. In other words, veterans who experienced family

instability or engaged in conduct disorder behaviors during

childhood benefitted equally from supported housing

compared to veterans who had fewer of these problems.

This may be due to the case management supports provided

in the HUD-VASH program, which may provide emotional

Table 4 Regression coefficients with childhood problems as pre- dictors of employment, housing, social relationship, and quality of life

outcomes 1 year after enrollment in supported housing

Conduct

disorder

behavior

score

Family

instability

score

Any

childhood

abuse

Incremental

R2

Employment and income

Days worked,

past month

-0.03 0.02 -0.02 0.00

Money from

employment,

past month

-0.01 -0.05 -0.04 0.01

Money from

pension/disability,

past month

0.06 0.02 -0.04 0.00

Money from

welfare, past

month

0.01 -0.01 0.07 0.01

Money from

relationships,

past month

0.14* -0.08 0.04 0.02

Homelessness and psychiatric hospitalization

Nights housed, past

month

0.00 0.09 -0.06 0.01

Nights in hospital,

past month

0.02 -0.07 -0.04 0.01

Nights homeless,

past month

0.00 -0.06 0.07 0.01

Social relationships

No of close

relationships

0.00 0.01 -0.10 0.01

No of contacts with

close

relationships,

past 3 months

0.05 -0.01 -0.12 0.01

Social support

score

0.07 -0.04 -0.18** 0.03*

Quality of life

Family scale -0.07 0.05 -0.23** 0.05**

Finances scale -0.02 -0.03 -0.09 0.01

Health scale 0.04 0.05 -0.11 0.01

Leisure scale 0.07 0.08 -0.13* 0.02

Life satisfaction

scale

0.03 0.03 -0.15* 0.02

Living situation

scale

0.01 0.10 -0.10 0.01

Safety scale 0.07 0.06 -0.12 0.01

Social scale 0.02 0.10 -0.15* 0.02*

Controlling for sociodemographics and mental health diagnoses

* p \ 0.01, ** p \ 0.001

484 Soc Psychiatry Psychiatr Epidemiol (2013) 48:477–486

123

and instrumental resources not previously available to cli-

ents. This finding extends previous findings on chronically

homeless adults [24] to the homeless veteran population

and demonstrates the potentially beneficial effects of

supported housing despite childhood adversities.

However, childhood abuse did appear to negatively

affect social support and quality of life in supported

housing. Veterans in supported housing who reported

childhood abuse reported less social support and lower

quality of life, compared to other veterans in supported

housing who reported no childhood abuse. Thus the neg-

ative effect of childhood abuse on the social life of veterans

was not only evident before supported housing services,

but persisted once veterans had obtained housing. This

finding may have clinical implications as supported hous-

ing services often have little effect on social adjustment

[41, 42]. As the VA seeks to end homelessness among

veterans, services that improve their social quality of life

after they are housed needs to be considered, especially

among those who experienced abuse during childhood.

In summary this study found that childhood problems,

particularly family instability and childhood abuse were

common among homeless veterans. Family instability

during childhood, conduct disorders, and childhood abuse

were marginally related to more lifetime homeless epi-

sodes; childhood abuse seemed to be particularly related to

less social support and lower quality of life while conduct

disorder behaviors did not appear to be adversely associ-

ated with any life domains before entry into HUD-VASH.

Importantly once veterans were engaged in supported

housing, none of the childhood problems measured were

associated with a greater risk for homelessness, although

childhood abuse did appear to be negatively associated

with social support and quality of life.

These findings demonstrate the resilience of homeless

veterans who come from adverse family environments

once they are engaged in treatment and show the robust

effectiveness of supported housing programs like HUD-

VASH. But they also suggest the potential impact of

childhood abuse on social and other aspects of veterans’

lives. Because childhood problems only explained a small

amount of variance in homeless indicators, the results

suggest that other, more proximal, factors are likely to be

more important risk factors for homelessness. As efforts to

end and prevent homelessness among veterans continue

[1, 2], identification of other events that occur after child-

hood need to be considered for prevention.

Limitations of this study are that assessment of child-

hood problems were based on retrospective self-report,

long after events of childhood had occurred. Childhood

abuse was only assessed with one item, and older measures

of conduct disorder behaviors and family instability were

used instead of more recent, psychometrically validated

measures so these results may need to be replicated with

more recent measures. No diagnostic measures were used for

childhood problems, but it is notable that the diagnostic cri-

teria for conduct disorder has changed slightly from DSM-III

[43] to DSM-IV [44], including a few items dropped

(e.g., early substance abuse) and added (e.g., bullying).

Conduct disorder behaviors, family instability, and

childhood abuse were treated as separate constructs,

although they were shown to be interrelated. However, we

found differential associations between these constructs

and various outcomes, lending more credibility to our

findings suggesting distinct impacts. The data were pri-

marily based on the HUD-VASH program in the 1990s,

and characteristics of the program and clients may have

changed over time. However it is not clear exactly how the

program has changed as this has not been empirically

evaluated, but the findings may not be generalizable to

more recent HUD-VASH clients, as well as other homeless

veterans who were not eligible for HUD-VASH (ineligible

for VA services, homeless less than 1 month or did not

have a mental illness). There were not enough women in

the sample (n = 56) for statistical power to conduct anal-

yses separately by gender, so further study is needed to

examine whether there are differences by gender.

Strengths of this study were the large sample size, sta-

tistical adjustment for sociodemographics and mental

health diagnoses in the analyses, and assessment of mul-

tiple dimensions of functioning. This is also one of the few

studies that have examined pre-military experiences among

homeless veterans and specifically the link between con-

duct problems, family instability, and abuse during child-

hood to severity of homelessness in adulthood and

functioning after receiving supported housing services.

Acknowledgments There was no specific funding for this study. This material was based upon work supported by the Department of

Veterans Affairs, Veterans Health Administration, Office of Research

and Development. The views presented here are those of the authors

alone, and do not represent the position of any federal agency or of

the United States Government.

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