Epidemiology assignment due on 2/14/15

Homeless Youth: Causes, Consequences and the Role

of Occupational Therapy

Ann M. Aviles, MS, OTR/L Christine A. Helfrich, PhD, OTR/L

SUMMARY. This paper reviews the current literature on youth homeless- ness in the United States and the role of occupational therapy with this population. Youth homelessness is increasing with many youths becoming homeless due to a myriad of causes such as abusive situations in their homes and decreases in affordable housing. Definitions, causes, physical and men- tal health consequences and the impact of homelessness on youths’ de- velopment into adult roles are discussed. The role of occupational therapy is described with a focus on useful assessments and intervention principles. Fi- nally, a case study is presented to illustrate the use of these assessments and occupational therapy intervention with a female youth living in an emergency shelter. doi:10.1300/J003v20n03_07 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rights reserved.]

Ann M. Aviles is Assistant Professor, Research Specialist in Health Sciences, De- partment of Psychiatry, University of Illinois at Chicago, 1747 W. Roosevelt Road, MC 747, RM 155, Chicago, IL 60608. Christine A. Helfrich is Assistant Professor, De- partment of Occupational Therapy, University of Illinois at Chicago, M/C 811, 1919 West Taylor Street, Chicago, IL 60612-7250.

This study was supported by grants from the Great Cities Faculty Seed Fund and the Campus Research Board at the University of Illinois at Chicago.

[Haworth co-indexing entry note]: “Homeless Youth: Causes, Consequences and the Role of Occupa- tional Therapy.” Aviles, Ann M., and Christine A. Helfrich. Co-published simultaneously in Occupational Therapy in Health Care (The Haworth Press, Inc.) Vol. 20, No. 3/4, 2006, pp. 99-114; and: Homelessness in America: Perspectives, Characterizations, and Considerations for Occupational Therapy (ed: Kathleen Swenson Miller, Georgiana L. Herzberg, and Sharon A. Ray) The Haworth Press, Inc., 2006, pp. 99-114. Sin- gle or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

Available online at http://othc.haworthpress.com © 2006 by The Haworth Press, Inc. All rights reserved.

doi:10.1300/J003v20n03_07 99

KEYWORDS. Youth homelessness, youth development, life skills

INTRODUCTION

The number of homeless children has been increasing steadily, which can be explained, in part, by the shrinking labor market and decreases in affordable housing (www.nationalhomeless.org). Homelessness is asso- ciated with a myriad of problems for children and youth, one very impor- tant one being lack of life-skill development (Ensign, 2004). The aim of this paper is to review the current literature on youth homelessness and to describe occupational therapy’s role in assessment and intervention with the homeless youth population. This paper will review the physical and mental health consequences faced by homeless youths, and the manner in which these factors impact their ability to complete daily life skills. A case study will be presented to illustrate occupational therapy’s capacity to work with homeless youth on life-skill development.

BACKGROUND INFORMATION

The US Department of Justice estimated that in 1999, nearly 1.7 mil- lion youths had runaway/throwaway episodes that led to homelessness. Additionally, 25% of former foster care youths were homeless at least one night (Hammer, Finkelhor & Sedlak, 2002). These estimates may not truly reflect the number of homeless youths due to their transience and re- luctance to seek out emergency shelter for fear of being returned to home, foster care, juvenile detention centers and psychiatric hospitalization (Greenblatt & Robertson, 1993; Kidd & Scrimenti, 2004). Despite the common belief that homeless youth are “out of control” youths who don’t want to live by parental rules, this is far from the reality; instead, youths are often leaving situations of deprivation and abuse (Wrate & Blair, 1999). Research indicates that many homeless youth report abusive home environments (MacLean, Embry & Cauce, 1999). Additionally, youths experience family conflict over issues such as sexual activity, sexual ori- entation, pregnancy, school problems, and alcohol and drug use, resulting in additional youths who leave home and become homeless (Illinois Pov- erty Summit, 2004; Paradise & Cauce, 2002; Reeg, 2003). The complex- ity of factors contributing to homelessness among youths highlight some of the difficulties in studying this population. In examining the factors

100 HOMELESSNESS IN AMERICA

that contribute to homelessness among youth we must remember that there is a dynamic relationship that exists between adolescent develop- ment and the context(s) they inhabit. Adolescent development is best viewed within the context of family and social systems, as these are the primary systems they have contact with. Youths who are provided with support, guidance and a sense of connectedness to their world, in all con- texts, will have better chances of reaching their full potential.

Homeless Youth Defined

Homeless youth are defined as individuals “not more than 21 years of age . . . for whom it is not possible to live in a safe environment with a rela- tive and who has no other safe alternative living arrangement” (Reeg, 2003, p. 55). There are distinctions made within the category of homeless youth consisting of runaways (youths who have left home voluntarily), throwaways (youths told to leave home), street youth (youths living on the street) and systems youth (wards of the state) (Aviles & Helfrich, 2004). These categories of homeless youth are not mutually exclusive; rather, youths often move in and out of these categories dependent upon their particular situation. Additionally, the definition of “home” is not limited to traditional nuclear families, but also includes foster care, shel- ters, group homes and residential treatment facilities (Schaffner, 1998). It is also suggested that runaway youths leave home of their own will; how- ever, it is often a response to familial conflict and/or abuse occurring in the home environment. Sixty to 80% of youths residing in homeless shelters and transitional living facilities report physical or sexual abuse by their parents or guardians prior to “running” away from home (Illinois Poverty Summit, 2004; Reeg, 2003).

Causes of Homelessness

Much of the literature on homeless youth focuses on youths who have runaway or those asked to leave home. However, the majority of home- less youth come from families that are suffering from instability (Chicago Coalition for the Homeless, 2001; Paradise & Cauce, 2002). More re- cently, emphasis has been placed on former foster care youths, estimating that 25-40% of former foster care youths become homeless (Illinois Pov- erty Summit, 2004). The parallels that exist between foster care youth and non-foster care youth point to the need to address the underlying issues that cause homelessness, specifically home environments plagued with

Ann M. Aviles and Christine A. Helfrich 101

abuse and neglect. Causes of homelessness among youth also consist of serious emotional disturbances, lack of affordable housing and an inabil- ity to secure affordable housing, lack of education and job skills, long-term family economic problems, violence in the home, absence of a parent and/or substance abuse by a parent (Chicago Coalition for the Homeless, 2001; Kidd & Scrimenti, 2004; www.endhomelessness.org). Additionally, youths embedded in families experiencing homelessness are often separated from them due to shelters that only allow young chil- dren to stay with their mothers, forcing older youths to care for them- selves. It is important to note that pregnant and parenting teens, and youths who identify themselves as lesbian, gay, bisexual, transgendered or questioning (LGBTQ) are disproportionately represented among homeless youth (Chicago Coalition for the Homeless, 2001). The grow- ing shortage of affordable housing and increases in poverty also contrib- ute to homelessness (www.nationalhomeless.org).

Youths experiencing homelessness do so at different levels. Some youths may experience homelessness once or twice and may be reunited with their family, enter foster care or independent living. However, there are other youths who experience “chronic” homelessness, meaning that they continually experience homelessness. Youths who have chronic experiences with homelessness have a difficult time meeting basic needs such as acquiring food and shelter. Additionally, because they are on the street more, they are at greater risk for victimization, and physical and men- tal health problems (Lindsey, Kurtz, Jarvis, Williams & Nackerud, 2000).

Due to the varying causes and levels of homelessness experienced by youth it is important to note that homeless youth are not a homogenous group and therefore we must not make assumptions regarding their devel- opment of basic life skills. Youths’ acquirement of life skills is dependent upon such factors as the age they became homeless, and the treatment they received (e.g., respect from adults, responsibilities given) while living in their homes (this includes “traditional” home environment, group home, foster home, etc.).

HEALTH CONSEQUENCES OF HOMELESSNESS

Physical Health

Homeless youth are a medically underserved population in the U.S. (Ensign, 2004). Homeless youth are at great risk for injuries, physical abuse, suicide, and homicide; approximately 5,000 per year die from as-

102 HOMELESSNESS IN AMERICA

sault, illness and suicide (Klein, Woods, Wilson, Prospero, Greene & Ringwalt, 2000). Some of the most common health problems identified by homeless youth consist of sexually transmitted diseases (STDs), Hu- man Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syn- drome (AIDS), pregnancy, dermatologic problems, malnutrition and injuries (Ensign & Gittelson, 1998). Despite youth being at greater risk for illness, they have significantly greater obstacles blocking their access to health-care than all other age groups (Klein et al., 2000). Youths who are able to access health-care consistently are often not provided with the opportunity to speak with their health-care provider privately to discuss sensitive issues such as pregnancy, HIV/AIDS and STDs (Ensign & Gittelson, 1998). Youths also lack the knowledge needed to access regu- lar health-care, often relying on emergency rooms for their health-care needs. The emergency room is often their only access to care due to lack of insurance, confidentiality and embarrassment of their status as homeless youth (Klein et al., 2000; American Academy of Pediatrics [AAP], 1996). Despite youths’ increased risk for injury and illness, they are less likely to seek out care due to their mistrust of adults (Klein et al., 2000)

Additionally, youths are viewed as minors by health-care providers; therefore, they often require parental consent, interfering with their abil- ity to access health care. This is a clear indication of the misunderstanding health-care providers have of unaccompanied homeless youth seeking out health-care services. Youths who are not provided with the necessary services in emergency situations are often less likely to seek out preventa- tive health care in non-emergency situations. As youths are attempting to secure basic needs such as food and shelter, health care becomes less of a priority (AAP, 1996). Many youths leave their communities when they become homeless and may not be familiar with the health services in a new community. Providers working with homeless youth should be aware of the health-care issues homeless youth face in addition to the bar- riers they encounter when attempting to seek out services in order to provide the appropriate resources youth need to access regular health care.

Mental Health

In addition to homeless youths’ physical health needs, research also suggests homeless youth are more likely to demonstrate high rates of mental health problems (e.g., behavioral problems, depression, anxiety and self-harm) (Vostanis, Grattan, & Cumella, 1998). Mental health problems can be defined as behavioral and emotional difficulties causing

Ann M. Aviles and Christine A. Helfrich 103

concern or distress. The rates of mental health problems among homeless children/youth in the US are estimated to be 38% (Vostanis, 1999). Many of the risk factors that lead to homelessness have also been identified as risk factors for mental health problems such as violence in the home and mental illness among parents (Vostanis, 1999). Information regarding homeless youth indicates high rates of substance abuse, depression, men- tal illness and suicide attempts (Ensign & Gittelson, 1998; American Academy of Pediatrics, 1996). Unlike the perception of the seriousness of physical health, mental health is often not viewed as a “serious” problem. Many of the complex issues homeless youth face (e.g., abuse, involve- ment in the child welfare system) are related to underlying psychosocial factors (Vostanis et al., 1998). Furthermore, mental health problems have a negative stigma attached to them, making homeless youths even less likely to seek out services (Reid, 1999). Rather than seeking out mental health services, youths often self-medicate with street drugs (Reid, 1999).

A mental health problem common among homeless youth is post- traumatic stress disorder (PTSD) (Stewart, Steinman, Cauce, Cochran, Whitbeck & Hoyt, 2004). PTSD as defined by the Diagnostic and Statisti- cal Manual of Mental Disorders (DSM-IV) (1994) is “the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves ac- tual or threatened death or serious injury, or a threat to one’s physical in- tegrity” (p. 424). Many youths have experienced traumatic events in their homes that lead to their homeless situations, and are at-risk for victimiza- tion while homeless (Stewart et al., 2004), maintaining their vulnerability to PTSD and other mental health problems. PTSD symptoms such as avoidance, numbing and reexperiencing lead to self-injurious behaviors in homeless youth such as drug use, sexual promiscuity and gang involve- ment (Greenblatt & Robertson, 1993; Paradise & Cauce, 2002). Stewart et al. (2004) found that males are often victim to physical threats and as- saults, and females to sexual exploitation and rape. The above study rec- ognized the difficulty homeless youths face in securing basic needs such as food and shelter when they must also worry about being victimized.

Impact of Homelessness on Youth Development

The adolescent years are a critical time as youths are making their tran- sition to adulthood. During this stage in life significant physical and emo- tional changes occur, making this a difficult time in life. An adolescent’s access to resources that will support him/her in a successful transition to

104 HOMELESSNESS IN AMERICA

adulthood is essential to development. Adolescents require a stable foun- dation that consists of adults they can trust, and a safe, nurturing home en- vironment. Unfortunately many adolescents have not had the privilege of being exposed to healthy environments, making adolescence an even more difficult stage of life.

The experiences homeless youth face exacerbate mental health prob- lems such as aggression, depression, suicide, alcohol and drug use, and sexually transmitted diseases (Vostanis, Grattan, Cumella & Winchester, 1997). Mental health problems often lead to difficulties in social relation- ships and basic skills needed to negotiate various environments such as school and the workplace. Often youths rely on “survival” behaviors such as stealing, destruction of property, carrying a weapon for protection, panhandling, selling drugs or sex (survival sex), and forming gangs (Par- adise & Cauce, 2002). Additionally, Greenblatt and Robertson (1993) recognize that homeless youths often surrender key relationships with adults, fail to develop work skills, rebel against formal institutions and abandon normative values after becoming homeless. Although these be- haviors may be viewed as delinquent by authority figures (e.g., police, teachers, parents, etc.), oftentimes these behaviors are a sign of the strength of youths in their ability to survive their homeless experience.

The loss of “normative” experiences leads to poor or inappropriate de- velopment of basic life skills needed to successfully negotiate social insti- tutions such as the workplace and school. Life skills are fundamental in supporting youth in becoming self-sufficient adults (Gourley, 2000). Life skills are often considered the domain of occupational therapy and lend themselves to an occupational therapy approach. Life skills con- sist of activities of daily living (bathing, dressing, grooming, eating) and instrumental activities of daily living (meal preparation, clothing care, cleaning, household maintenance, money management), and community skills (accessing transportation, time management, social interaction, community safety) (Okkema, 1993). When homeless youths experience a loss of traditional roles such as family member, student, worker, and friend they are often ill equipped to develop into healthy adults. Roth and Brooks-Gunn (2000) note “The numerous changes during adolescence appear to be overwhelming only for some adolescents–those with less op- timal peer and family relationships, poorer coping skills . . . thus, circum- stances from different environments–the family, peers, school–impact adolescents’ preparation for, and success at navigating the transitions in- herent in their development” (p. 4). Therefore, it is within the contexts of home and school that youths develop basic living skills, and for homeless youths this lack of contact with such environments often results in diffi- culties developing during adolescence and with their transition into adult-

Ann M. Aviles and Christine A. Helfrich 105

hood. When youths are not afforded the opportunity to develop “traditional” adolescent roles, they instead develop “survival” roles (e.g., selling drugs). Forcing youths into adult roles without the appropriate preparation and support limits their ability to take on “normative” behav- iors, which may lead to continued engagement of unhealthy behaviors as adults.

As discussed previously, the adversity homeless youth experience of- ten leads to poor mental health, including their self-esteem. Self-esteem is defined as “the person’s evaluation about self that expresses an attitude of approval or disapproval and indicates the extent to which the individual believes him or herself to be capable, significant, successful, and worthy” (Anderson & Olnhausen, 1999, p. 62). Youths who do not view them- selves as “significant” or “worthy” due to their experiences of abuse and/ or victimization may be less likely to care for themselves. Therefore, homeless youth may lack the “willingness to look at themselves and ac- cept themselves as self-care agents and do not accept themselves as in need of or having the ability to perform particular self-care measures” (Anderson & Olnhausen, 1999, p. 63). Shelters provide housing, meals and referrals for various social and medical services; however, many times they do not teach youths the skills needed to access housing, food and other services on their own (Reid, 1999).

In order to better understand an individual’s willingness and capability to perform the necessary life-skills needed to care for oneself, an investi- gation of multiple aspects of homeless youths’ lives needs to be per- formed, including (but not limited to) how they became homeless, age they became homeless, physical and mental health and basic life skills, in order to provide services that will assist with their individual needs.

ASSESSMENT AND TREATMENT APPROACHES WITH HOMELESS YOUTH

Assessment

As discussed previously, youths’ acquirement of life skills often de- pends on factors such as the age they became homeless, the treatment they received while living in their homes, as well as the length of time they have spent living in shelters and/or on the street. There are two assess- ments we have found useful with homeless youth, The Ansell-Casey Life Skill Assessment (ACLSA) and the Occupational Self-Assessment (OSA). Both of these assessments require input from the youths them-

106 HOMELESSNESS IN AMERICA

selves and both acknowledge that youths have areas of strength that should be relied upon to address areas of concern.

The ACLSA is an evaluation of youth independent living skills. It assesses daily living tasks, housing and community resources, money management, self-care, social development (communication, relation- ships, community values), work and study habits (career planning, decision-making, study skills) (www.caseylifeskills.org/index.htm, accessed 1/15/05). The ACLSA has four versions which are age specific: ACLSA-I for ages 8-9 (37 questions), ACLSA-II for ages 10-12 (56 ques- tions), ACLSA-III for ages 13-15 (81 questions), ACLSA-IV for ages 16-and-up (118 questions); also ACLSA short form for ages 11-18 (18 questions) (Casey Family Programs, 2005). Each version of the ACLSA recognizes youth within a developmental context, identifying the differ- ent skills attained as they negotiate adolescence. For example, at age 11 a youth would not be expected to have work skills, but one might expect those skills to be present by the age of 19; the different versions of the ACLSA account for such differentiation. The ACLSA demonstrates in- ternal consistency, reliability, content validity, construct validity and test-retest reliability (Nollan, Horn, Downs & Pecora, 2002). Adminis- tration of the ACLSA takes approximately 30-45 minutes. The full- length assessments (ACLSA-I, ACLSA-II, ACLSA-III, ACLSA-IV) provide an overview of youth life-skills abilities. The ACLSA is useful for goal setting, program planning, and for measuring progress on life- skills acquisition. The short form assessment (ages 11-18) provides a brief summary of youth abilities. It is useful for evaluating programs and for getting a quick assessment of ability. There is also a Homeless Youth Assessment Supplement that assesses specific areas of concern to home- less youth.

The OSA assesses a person’s occupational functioning and environ- ment, measuring a youth’s life-skills competence and the impact of the environment on his/her ability to adapt (Baron, Kielhofner, Goldhammer & Wolenski, 1999). This assessment allows youths to self-identify their areas of strength and weakness in regard to life skills, while simulta- neously measuring how the environment(s) they function in support or in- hibit their life-skill abilities. It also allows youths to identify areas of value, meaning that they categorize the skills that are most important to them in negotiating the different environments they encounter. When completing the OSA, youths rank how they are able to complete life skills through the following categories: “problem,” “I do this all right,” or “I do this well.” Once they identify their ability to complete a task they rank how important it is to them, using a Likert format: “This is not so impor-

Ann M. Aviles and Christine A. Helfrich 107

tant to me,” “This is important to me,” or “This is extremely important to me.” After completing the rankings for each item, the youth then identifies four items that s/he would like to change.

Both of these assessments rely on the youths’ knowledge of their skills and abilities. Staff should have a well-established relationship with each individual so s/he will feel comfortable exploring and sharing skills that are not well-developed. The goal is for youths to recognize and under- stand that it is okay not to know and/or have specific skills. However, in order for them to be independent and negotiate multiple environments (e.g., workplace) acquisition of life skills is a necessity. Therefore, when as- sessing youths’ skills we need to identify their existing strengths as well as identifying areas of need. Recognition of a youth’s strengths can also help build a relationship between the youth and provider, as many home- less youths most often receive negative attention from adults. As provid- ers we need to work with youths on seeing themselves as positive individuals capable of being self-sufficient adults. A study found that as youths begin to understand their experiences and themselves, they will gradually accept and value themselves in new ways, develop more self-confidence, take better care of themselves, take responsibility for their actions and trust potential helpers (Lindsey et al., 2000).

Treatment Principles

It is important for persons working with homeless youth to recognize and understand the barriers they encounter when attempting to access ba- sic services. It is equally important to approach youths in a caring and re- spectful manner. Roth and Brooks-Gunn (2000) identify parental caring, connectedness and involvement with adolescents as of fundamental im- portance, being associated with better grades and educational expecta- tions rather than delinquency and substance abuse. Therefore, youths who are not developing in supportive environments require programs that will provide a safe, “family like” environment, where caring adults will support and facilitate the development of life skills (Roth & Brooks- Gunn, 2000). Youths who are able to create strong relationships with adults (e.g., teachers, counselors) are less likely to engage in delinquent behaviors (Resnick, Bearman, Blum, Bauman, Harris, Jones, Tabor, Beuhring, Sieving, Shew, Ireland, Bearinger & Udry, 1997). Further- more, creating trusting, caring relationships is necessary for a youth to feel comfortable and confident in asking adults for assistance in obtaining life-skill training. A study conducted by Kurtz et al. (2000) found that the quality most needed by homeless youths when interacting with providers

108 HOMELESSNESS IN AMERICA

was trust. The family context many homeless youths have fled from often prevents them from being able to trust others. Therefore, many youths find it difficult to confide in adults and ask for assistance. Many homeless youth have developed effective ways of keeping their distance from oth- ers in order to survive on the street. This may result in homeless adoles- cents struggling to adapt to a new environment, especially when leaving the streets and attempting to transition into a shelter or transitional hous- ing facility (Levy, 1998). As providers we should be aware of the survival mechanisms youths have developed and be understanding of their reluctance to trust adults.

Providers need to recognize and emphasize youths’ strengths and per- sonal resources when working with them on their transition into adult- hood, and hopefully out of homelessness. A study by Lindsey et al. (2000) identified two major criteria for homeless youths’ successful navigation into adulthood: (1) personal strengths and resources; and (2) help re- ceived from others. This study highlights the importance of identifying the strengths homeless youth bring with them and the need to provide as- sistance in an effort to facilitate their ability to become successful adults. It is important to note that “success” should be defined by the youths themselves, rather than pressuring them to conform to societal norms. Al- though it is important for youths to recognize behaviors that interfere with their ability to be successful, youths that are able to come to such conclu- sions on their own often are motivated by their own desire to do well, rather than feeling obligated to do something based on the directions given by an adult. This is a hard balance to strike, as one needs to be help- ful, supportive and firm but not overbearing or forceful. As many youths transition into adulthood they strive for autonomy and respect from adults, but they also continue to require advice and support from adults. This does not mean that a youth will follow the advice provided, and this may become very frustrating to providers working with homeless youth. As many of us progressed through adolescence we were given support and advice from parents, teachers, etc.; however, we often did not learn our lesson until we experienced the feeling of failure, disappointment, excitement, or happiness ourselves.

Providers must also understand the complexity of emotions youth are experiencing. Although youths are homeless due to family conflict, abuse, etc., many youths continue to have contact with their families. They may identify their families as the cause for becoming homeless, yet they continue to have relationships with them and often want to maintain these relationships despite the stress and strain it causes them. “Profes- sionals who work with runaway and homeless youth need to recognize the

Ann M. Aviles and Christine A. Helfrich 109

importance of helping youth consider the possibility of reestablishing connections with family and friends who might be supportive and even engage in family counseling as appropriate to help resolve differences that keep youth and families apart” (Kurtz et al., 2000, p. 401).

The following case study illustrates the use of the assessments de- scribed previously and how occupational therapists can use the informa- tion obtained to plan an intervention.

Case Study

Angela is a 17-year-old female residing at an emergency youth shelter. Angela came to the shelter three years after being removed from her par- ent’s home. Her parents were both addicted to drugs and often left her home alone to care for her younger siblings. She was removed from their home, due to neglect, at the age of 14 by child welfare services. Since that time Angela has lived with different relatives and in various shelters. She gave birth to a son at age 15. Shortly after his birth, she tried to commit sui- cide and was hospitalized for three months. Angela initially received psy- chiatric services and medication, but was unable to maintain these services when she became homeless. Her two-year-old son is develop- mentally delayed and received physical therapy services until they be- came homeless. She has been unable to manage health care for either of them due to their frequent mobility. Angela did not complete high school, but would like to obtain her GED and become employed. Angela ex- presses the importance of obtaining her education in order to “do some- thing with my life.” Angela has never been employed and would like to begin working, but does not have child care for her son. Angela has also stopped attending church, as she feels embarrassed because she does not have “appropriate” clothing to attend church.

Angela was able to identify areas of strength as well as areas of weakness on the Occupational Self Assessment (OSA). Angela’s strengths include: (1) taking care of others for whom I am responsible (her son); (2) getting along with others; (3) expressing myself to others; and (4) tak- ing care of myself. Areas Angela identified as problems include: (1) man- aging my basic needs (food, medicine); and (2) having a place where I can be productive (work, study, volunteer). Angela identified the follow- ing as areas she would like to improve: (1) working towards my goals; (2) handling my responsibilities; (3) identifying and solving problems; and (4) managing my finances. Information obtained from the ACLSA demonstrates Angela’s lack of knowledge in daily living tasks, money management, and her work and study habits (career planning, deci- sion-making, study skills). Her areas of strength include self-care and so-

110 HOMELESSNESS IN AMERICA

cial development (communication, relationships, community values) and her ability to seek out housing and community resources.

One can see from these assessment results that each tool provided the occupational therapist with different, but complementary information about Angela. Angela demonstrated insight as she expressed to the occu- pational therapist that her current situation living in a homeless shelter and her unemployment status are limiting her ability to care for herself and her child. She is motivated to change her current situation but is not able to identify the steps needed to improve her situation.

The occupational therapist working with Angela was able to recognize her strengths. Angela is motivated, goal-oriented, able to self-evaluate, able to ask for assistance, and seeks out resources (sought out shelter and services within it). The shelter is providing her with temporary housing but she recognizes that she has a limited amount of time (120 days) until she will be responsible for herself and her child. Angela is receiving assis- tance with obtaining developmental services and child care for her son and mental health services for herself; however, she also expresses a need for assistance with identifying an approach that will allow her to work towards her goals, handle her responsibilities and successfully identify and solve problems she encounters in the process. While Angela identifies that she requires services to meet her basic needs, it is apparent that in order for her to sustain herself once she leaves the shelter she will need: (1) a provider that will work with her on identifying the actual steps needed to meet her goals; (2) brainstorm alternative situations; and (3) so- lutions that may arise as she works towards meeting her goals. In this pro- cess, it is vitally important that the provider emphasize Angela’s strengths and use them as the vehicle for improvement.

The therapist and Angela engaged in activities such as role playing, to problem solve managing her basic needs (finances, working towards goals) in a safe environment with feedback from an adult. This provided her with opportunities to develop and practice life skills as well as the con- fidence to complete them successfully, contributing to the development of her self-confidence. Once Angela was able to work through problems via role playing, she and the therapist implemented these skills in the real world. Angela and the therapist visited the local bank, opened a savings account and worked on creating a budget; engaged in basic IADLs (laun- dry, simple meal prep); worked on filling out resumes, and engaged in mock interviews. Lastly Angela and the therapist sought out GED pro- grams in the area. The therapist also met with Angela’s case manager to discuss her mental health, resulting in a referral to the community mental health clinic in the shelter area. Angela’s demonstration of life-skill de- velopment made her eligible for an independent living program for home-

Ann M. Aviles and Christine A. Helfrich 111

less teens with children where she will be able to continue to expand and hone her skills.

CONCLUSION

Homeless youth encounter many barriers limiting their ability to ex- pand the life skills needed to engage in traditional roles of student, worker and family member. The reality of family conflict, lack of stable housing and victimization while living on the streets, negatively impact youths’ physical and mental health. Youths’ frequent lack of connection to caring and supportive adults hampers opportunities to cultivate strong, nurtur- ing relationships that facilitate healthy adolescent development and suc- cessful transitions into adulthood. When youths become homeless, they may be unable to build and/or maintain routines and habits that afford them the opportunity to discover and expand life skills. As occupational therapists we are uniquely prepared to assess and identify a person’s strengths and limitations. We are able to work with youth on creating and implementing an individual plan, fostering the skills needed to become a fully functional member of society. Collaborating with homeless youth in identifying life-skill needs and facilitating their development is a necessary component in occupational therapy treatment with the home- less youth population.

REFERENCES

American Academy of Pediatrics (1996). Health Needs of Homeless Children and Families. Pediatrics, 98(4), 789-791.

Anderson, J. & Olnhausen, K. (1999). Adolescent Self-Esteem: A Foundational Dispo- sition. Nursing Science Quarterly, 12(1), 62-67.

Aviles, A. & Helfrich, C.H. (2004). Life Skill Service Needs: Perspectives of Home- less Youth. Journal of Youth and Adolescence, 33: 331-338.

Baron, K., Kielhofner, G., Goldhammer, V., & Wolenski, J. (1999). A User’s Manual for the Occupational Self-Assessment (OSA) (Version 1.0). The Model of Human Occupation Clearinghouse, Department of Occupational Therapy, University of Il- linois at Chicago.

Chicago Coalition for the Homeless. History of Accomplishments. www.chicagohomeless. org/accomplishments.htm, Accessed March 1, 2005.

Chicago Coalition for the Homeless (2001). Youth on the Streets and on Their Own: Youth Homelessness in Illinois. A Report by the Chicago Coalition for the Home- less.

112 HOMELESSNESS IN AMERICA

Ensign, J. (2004). Quality of Health Care: The Views of Homeless Youth. Health Ser- vices Research, 39(4): 695-707.

Ensign, J. & Gittelson, J. (1998). Health and Access to Care: Perspectives of Homeless Youth in Baltimore City, U.S.A. Social Science Medicine, 47: 2087-2099.

Gourley, M. (2000). High-Risk Youths Receive OT Intervention. OT Practice, May, 9-10.

Greenblatt, M. & Robertson, M. (1993). Life-styles, Adaptive Strategies and Sexual Behavior of Homeless Adolescents. Hospital, Community Psychiatry, 44: 1177- 1180.

Hammer, H., Finkelhor, D. & Sedlak, A. (2002). Runaway/Throwaway Children: Na- tional Estimates and Characteristics. National Incidence Studies of Missing, Abduc- ted, Runaway, and Throwaway Children. US Department of Justice. Office of Justice Programs. Office of Juvenile Justice and Delinquency Prevention.

Illinois Poverty Summit. (2004). 2004 Report on Illinois Poverty: Breaking the Cycle of Poverty for Illinois Teens.

Kidd, S. & Scrimenti, K. (2004). Evaluating Child and Youth Homelessness: The Ex- ample of New Haven, Connecticut. Evaluation Review, 28(4): 325-341.

Klein, J., Woods, A., Wilson, K., Prospero, M., Green, J. & Ringwalt, C. (2000). Homeless and Runaway Youth’s Access to Health Care. Journal of Adolescent Health, 27(5): 331-339.

Kurtz, P., Lindsey, E., Jarvis, S. & Nackerud, L. (2000). How Runaway and Homeless Youth Navigate Troubled Waters: The Role of Formal and Informal Helpers. Child and Adolescent Social Work Journal, 17(5): 381-402.

Levy, J.S. (1998). Homeless Outreach: A Developmental Model. Psychiatric Rehabili- tation Journal, 22(2):123-131.

Lindsey, E., Kurtz, P., Jarvis, S., Williams, N. & Nackerud, L. (2000). How Runaway and Homeless Youth Navigate Troubled Waters: Personal Strengths and Resources. Child and Adolescent Social Work Journal, 17(2): 115-140.

MacLean, M., Embry, L. & Cauce, A. (1999). Homeless Adolescents’ Paths to Separa- tion from Family: Comparison of Family Characteristics, Psychological Adjust- ment and Victimization. Journal of Community Psychology (1999) 27: 179-187.

National Alliance to End Homelessness, Ending Homeless Youth, www.endhome lessness.org/youth/, accessed 08/05/05.

National Alliance to End Homelessness, Youth Homelessness, www.endhomeless ness.org/back/YouthFacts.pdf, accessed 1/25/06.

National Coalition for the Homeless, www.nationalhomeless.org, accessed 08/12/05. Nollan, K.A., Horn, M., Downs, C.A. & Pecora, P.J. (2002). Ansell-Casey Life Skills

Assessment (ACLSA) and Life Skills Guidebook Manual. Casey Family Programs. Seattle, WA.

Okkema, K. (1993). Cognition and Perception in the Stroke Patient. Gaithersburg, MD: Aspen Publication Inc.

Paradise, M. & Cauce, A.M. (2002). Home Street Home: The Interpersonal Dimen- sions of Adolescent Homelessness. Analysis of Social Issues and Public Policy, 2(1): 223-238.

Reeg, B. (2003). The Runaway and Homeless Youth Act and Disconnected Youth, Leave No Youth Behind: Opportunities for Congress to Reach Disconnected

Ann M. Aviles and Christine A. Helfrich 113

Youth. In Levin-Epstein, J. & Greenburg, M. (Eds.). Center for Law and Social Pol- icy.

Reid, P. (1999). Young Homeless People and Service Provision. Health & Social Care in the Community, 7(1): 17-24.

Resnick, M.D., Bearman, P.S., Blum, R.W., Bauman, K.E., Harris, K.M., Jones, J., Ta- bor, J., Beuhring, T., Seiving, R.E., Shew, M., Ireland, M., Bearinger, L.H. & Udry, J.R. (1997). Protecting Adolescents from Harm: Findings from the National Longi- tudinal Study on Adolescent Health. Journal of the American Medical Association, 278(10): 823-832.

Roth, J. & Brooks-Gunn, J. (2000). What Do Adolescents Need for Healthy Develop- ment? Implications for Youth Policy. Social Policy Report, Giving Child and Youth Development Knowledge Away, 14(1), 3-19.

Schaffner, L. (1998). Searching for Connection: A New Look at Teenaged Runaways. Adolescence, 33: 619-628.

Stewart, A., Steinman, M., Cauce, A., Cochran, B., Whitbeck, L. & Hoyt, D. (2004). Victimization and Posttraumatic Stress Disorder Among Homeless Adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 43(3): 325-331.

Vostanis, P. (1999). Child Mental Health Problems. In Homeless Children: Problems and Needs.Vostanis, P. & Cumella, S. (Eds.). London: Kingley Publishers.

Vostanis, P., Grattan, E. & Cumella, S. (1998). Mental Health Problems of Homeless Children and Families: Longitudinal Study. British Medical Journal, 316: 899-902.

Vostanis, P., Grattan, E., Cumella, S., & Winchester, C. (1997). Psychosocial Func- tioning of Homeless Children. Journal of the American Academy of Child & Ado- lescent Psychiatry, 36(7): 881-889.

Wrate, R. & Blair, C. (1999). Homeless Adolescents. In Homeless Children: Problems and Needs. Vostanis, P. & Cumella, S. (Eds.). London: Kingley Publishers.

doi:10.1300/J003v20n03_07

114 HOMELESSNESS IN AMERICA