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Homeless Women With Children The Role of Alcohol and Other Drug Abuse

Marjorie J. Robertson

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For some women with children, alcohol and other drug use may be an important risk factor for homelessness be- cause it may interfere with a woman's capacity to compete for scarce resources such as housing, employment, or ser- vices. The impact of various policy decisions on homeless women, their dependent children, and the family unit is considered, including women's right to privacy, crim- inalization of drug use, and scarcity of appropriate treat- ment programs for homeless women.

Homeless families are a heterogeneous population, an d the causes o f family homelessness are multiple an d in- teractive (McChesney, in press; Weitzman, K n i c k m a n , & Shinn, 1990; Wood, Schlossman, Hayashi, & Valdez, 1989). T h e most accurate and comprehensive depiction o f homeless women with children and the risk factors for their homelessness is essential for the design o f adequate programs and services to prevent or alleviate homelessness in this population.

Often, descriptions o f the individual characteristics o f homeless persons, such as alcohol- or other drug-related problems, have been inappropriately interpreted as ex- planations o f their homelessness. O n one hand, such sim- plistic explanations t e n d to ignore or m i n i m i z e structural or e n v i r o n m e n t a l factors that influence the extent and course ofhomelessness (Hopper, 1990). Principal a m o n g these are the crisis in affordable housing, r e d u c e d social welfare benefits, and increasing poverty a m o n g single women with children in the U n i t e d States.

O n the other hand, the experience o f homelessness is n o t a r a n d o m event that is i n d e p e n d e n t o f individual characteristics or experiences. In the context o f poverty and high housing costs (Dolbeare, 1989), serious personal and family problems such as alcohol and other drug abuse can m a k e an individual less able to c o m p e t e for scarce resources such as low-cost housing or e m p l o y m e n t (Hop- per, 1990; W o o d et al., 1989). In the words o f on e re- searcher, serious alcohol or other drug abuse represents an additional " b u r d e n o f vulnerability" for homeless an d other p o o r people (Fischer, 1989). Thus, although alcohol or other drug abuse should not be construed as the ex- planation o f family homelessness (Weitzman et al., 1990), it m a y serve as an i m p o r t a n t contributing risk factor for some w o m e n with children.

Alcohol and other d r u g use a m o n g c o n t e m p o r a r y homeless adults is increasingly identified as a serious

Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical Research Institute of San Francisco, Berkeley, CA

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p r o b l e m t h a t is m o r e prevalent a m o n g the homeless t h a n a m o n g the general population (Fischer, 1989; G arrett, 1989; Milburn, 1988). However, almost nothing is known a b o u t the direct c o n t r i b u t i o n o f alcohol an d other drug abuse t o homelessness a m o n g w o m e n with d ep endent children. In this article, I explore critical ways in which alcohol a n d o t h er d ru g use can aggravate, precipitate, or prolong homeless episodes a m o n g homeless w o m e n with d ep en d en t children. Epidemiologic d at a o n the i m p a c t o f alcohol an d o t h er d ru g use on w o m e n and their chil- dren, and o n the stability o f the family unit, are discussed briefly. Policy considerations are introduced, including available t r e a t m e n t an d policy options. Because the lit- erat u re is limited, substantive findings will be integrated into a conceptual i n q u i r y i n t o the ways in which alcohol a n d other d ru g abuse affects homeless w o m e n with chil- dren.

Alcohol and Other Drug Use Among Homeless Women With Children Alcohol-related p ro b l em s have been p r o m i n e n t l y re- p o r t e d in studies o f homeless persons in past decades, an d the c o n t e m p o r a r y generation o f homeless adults is distinguished b y reports o f high rates o f illicit d r u g use, as well (Garrett, 1989). A review o f the empirical literature suggests t h at alcohol an d o t h er d r u g p r o b l e m s are m o r e prevalent a m o n g the homeless population t h a n a m o n g the general population, with estimates o f alcohol problems ranging f r o m 12% t o 68%, an d estimates o f other drug p r o b l e m s ranging f r o m 1% to 48% (Fischer, 1989). In general, alcohol a n d o t h er d ru g p r o b l e m s are reportedly less prevalent a m o n g homeless w o m e n t h a n a m o n g homeless m e n (Fischer).

Homeless w o m e n with d e p e n d e n t children seem to be a distinctive subpopulation a m o n g homeless adults, with lower rates o f substance use and related p roblems than have been reported for homeless m e n o r for homeless w o m en without children (Burr & Cohen, 1989; J o h n s o n

Preparation of this article was supported by National Institute of Mental Health Grant RO1 MH46104.

The author is grateful to Elizabeth A. Smith, Herb Westerfelt, Scott O. Swain, and anonymous reviewers for comments on earlier drafts of this article.

Correspondence concerning this article should be addressed to Marjorie J. Robertson, Alcohol Research Group, Institute for Epide- miology and Behavioral Medicine, 2000 Hearst Avenue, Suite 300, Berkeley, CA 94709.

Vol. 46, No. 11, 1198-1204

& Krueger, 1989; R o b e r t s o n , in press-a). E s t i m a t i n g the prevalence o f alcohol a n d o t h e r d r u g a b u s e in this special p o p u l a t i o n is difficult, however. T h e t a s k o f e s t i m a t i o n is h a m p e r e d b y the p a u c i t y o f e m p i r i c a l w o r k o n homeless families. Also, b e c a u s e o f m a j o r m e t h o d o l o g i c a l limita- tions c o m m o n to studies o f homeless populations, m o s t c u r r e n t findings o n h o m e l e s s w o m e n with children are neither c o m p a r a b l e with o n e a n o t h e r n o r representative o f the p o p u l a t i o n as a whole. Studies o f homeless families v a r y significantly b y focus, design, m e a s u r e m e n t , a n d def- initions o f homelessness a n d family unit. These variations p r o h i b i t meaningful generaliTation or c o m p a r i s o n s across studies. F o r e x a m p l e , studies o f homeless families t e n d t o b e b a s e d exclusively o n families in shelters, leaving u n c e r t a i n h o w these homeless families differ f r o m those t h a t are n o t in shelters (Solarz, in press). Virtually all o f the studies are cross-sectional, overrepresenting persons w h o have b e e n homeless longer a n d likely overrepresent- ing the prevalence o f alcohol- a n d o t h e r drug-related p r o b l e m s , i n a s m u c h as these p r o b l e m s a r e m o r e likely to be associated with longer t e r m homelessness. Moreover, the lack o f rigorous s a m p l i n g m e t h o d s often prevents generalization b e y o n d the homeless f a m i l y m e m b e r s in- terviewed.

W i t h r e g a r d t o i n s t r u m e n t a t i o n , m o s t studies o f homeless families are n o t designed as epidemiologic studies o f s u b s t a n c e abuse. Because studies o f homeless families t e n d n o t to focus o n alcohol a n d d r u g use, sparse findings m u s t be gleaned f r o m studies o f homeless families t h a t have b e e n designed with s o m e o t h e r focus, such as physical o r m e n t a l health. T h i s is a c o m m o n strategy for e x a m i n i n g alcohol a n d o t h e r d r u g use a m o n g homeless persons generally (Fischer, 1989). F u r t h e r m o r e , i f alcohol a n d o t h e r d r u g use are assessed at all, standardized in- s t r u m e n t a t i o n or specific criteria for alcohol o r drug abuse are often lacking. Prevalence rates c a n n o t b e c o m p a r e d across studies b e c a u s e rates v a r y as a function o f instru- m e n t a t i o n a n d w h e t h e r o n e uses lifetime or c u r r e n t rates, clinical o r descriptive definitions o f abuse, o r t r e a t m e n t histories (Fischer). Also, i n f o r m a t i o n a b o u t use o f a spe- cific d r u g is s e l d o m r e p o r t e d , a n d alcohol a n d other d r u g indicators a r e often aggregated into a single rate o f sub- stance use, abyse, o r t r e a t m e n t (Robertson, in press-b).

Although these methodological issues c o n s t r a i n o u r ability t o generalize across s a m p l e s t o the larger p o p u - lation, the available literature suggests a high prevalence o f alcohol a n d other d r u g use a n d related p r o b l e m s a m o n g homeless w o m e n with children c o m p a r e d with other p o o r w o m e n with children. F o r e x a m p l e , in a case-control s t u d y o f poor, f e m a l e - h e a d e d families in Boston, higher alcohol a n d o t h e r d r u g p r o b l e m s were r e p o r t e d for homeless m o t h e r s c o m p a r e d with p o o r - b u t - h o u s e d m o t h e r s (16% c o m p a r e d with 6%, respectively, o n the basis o f s t r u c t u r e d psychiatric interviews a n d a p p l y i n g Diagnostic and Statistical Manual o f Mental Disorders, 3rd edition criteria (Bassuk & Rosenberg, 1988). Simi- larly, in N e w York City, m o r e homeless parents (i.e., those requesting access to city shelters) r e p o r t e d recent, personal s u b s t a n c e - a b u s e p r o b l e m s t h a n did h o u s e d p a r e n t s re-

ceiving public assistance (4.8% vs. 1.1%, respectively; K n i c k m a n & W e i t z m a n , 1989; W e i t z m a n , Shinn, & K n i c k m a n , 1989). I n the s a m e study, detoxification t r e a t m e n t for alcohol o r drugs was a significant p r e d i c t o r o f homelessness in a m u l t i v a r i a t e model. I n L o s Angeles, homeless m o t h e r s r e p o r t e d m o r e alcohol or o t h e r d r u g use t h a n did poor, h o u s e d m o t h e r s (43% vs. 30%; W o o d , Valdez, Hayashi, & Shen, 1990). T h e difference in d r u g use s t e m m e d m a i n l y f r o m a higher prevalence a n d m o r e frequent use o f cocaine, including crack, a m o n g homeless m o t h e r s (25.3% o f homeless m o t h e r s used cocaine c o m - p a r e d with 16.8% o f h o u s e d m o t h e r s , a n d cocaine was frequently used b y 8.7% o f homeless m o t h e r s c o m p a r e d with 3.1% o f h o u s e d m o t h e r s ; personal c o m m u n i c a t i o n , Hayashi, J a n u a r y 18, 1990; W o o d et al., 1989).

I n s u m , there is insufficient e m p i r i c a l evidence o n which to base a reliable prevalence e s t i m a t e f o r alcohol a n d o t h e r d r u g a b u s e a m o n g homeless w o m e n with chil- dren. M o r e g e r m a n e t h a n specific prevalence rates, how- ever, a r e the p a t t e r n e d findings t h a t suggest t h a t homeless w o m e n with children c o n s u m e less alcohol a n d o t h e r drugs t h a n d o either homeless m e n o r homeless w o m e n w i t h o u t children (Robertson, in press-b). However, homeless w o m e n with children have higher rates o f al- cohol a n d o t h e r d r u g use t h a n d o o t h e r p o o r w o m e n with children.

T h e s e findings a r e descriptive a n d n o t explanatory, however, a n d a causal relationship between substance use a n d homelessness c a n n o t b e a s s u m e d . However, r e c e n t literature suggests t h a t alcohol a n d other d r u g a b u s e c a n b e a c o n t r i b u t i n g factor in f a m i l y homelessness (Shedlin, 1989; W e i t z m a n et al., 1989), with a p p a r e n t consequences for the w o m a n , her children, a n d the f a m i l y as a u n i t J

Consequences for the Woman, Her Children, and the Family Unit Alcohol a n d other d r u g a b u s e a m o n g homeless w o m e n represents a personal health risk for the w o m e n , b e y o n d the effects o f d r u g use itself. U s e o f alcohol or o t h e r d r u g s

l Discussion here will focus on alcohol or other drug use by homeless women with dependent children. However, substance abuse by the wom- an's partner may also contribute to family homelessness, especially when alcohol or other drug abuse is combined with domestic violence toward the mother or her children (Somers, in press). Histories of domestic violence are more common among homeless mothers than among other poor but housed mothers with children (Bassuk & Rosenberg, 1988; Weitzman, Shinn, & Knickman, 1989). Some homeless women report that alcohol or drug abuse by their partner may be coupled with domestic violence that precipitated their homelessness (Dail, 1990). For example, in a Massachusetts study, more than 40% of homeless mothers reported that their most recent boyfriend or spouse was a substance abuser, and two thirds reported that battering episodes were most commonly alcohol related. Although 40% of the mothers reported that they had been in an abusive relationship at some time in the past, they seldom identified domestic violence as a precipitant of their current homeless episode (Bassuk, in press). Similarly, compared with housed tingle mothers, more homeless single mothers in Los Angeles reported their most recent male partners to have problems with drug and alcohol use and domestic vi- olence (Wood et al., 1989). Howevea; a connection between the substance use and violence is not specified and in many instances is unclear (Somers, in press).

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m a y result in disinhibition, which m a y in t u r n lead t o sexual risk taking and increased chance o f pregnan cy o r exposure to sexually t r a n s m i t t e d diseases, including hu- m a n i m m u n o d e f i c i e n c y virus (HIV). Cocaine use in par- ticular has been r e p o r t e d to be associated with syphilis a m o n g women, d u e in p a r t to related sexual behaviors such as trading sex for drugs (Rolfs, Goldberg, & Sharrar, 1990; "Sex-for-Drngs Trade," 1990; " S t u d y Points," 1990). Intravenous use o f heroin or cocaine puts o n e at additional risk for exposure to HIV. In order to p r o c u r e drugs, w o m e n who use crack or other illicit drugs m ay participate in criminal behaviors, such as drug dealing (McChesney, in press) or prostitution (Inciardi, 1989; Rolfs et al., 1990), which have a t t e n d a n t risks o f incar- ceration and consequent family and e m p l o y m e n t disrup- tion (Williams, 1991).

T h e impact o f a woman's alcohol and other drug use represents multiple health risks for her children. For ex- ample, any substance ingested by a pregnant woman m ay affect the developing fetus, and the specific detrimental effects o f alcohol and other drugs have been d o c u m e n t e d (McKay, 1983). 2 Intravenous drug use increases the risk o f prenatal H I V exposure and infection ("Study Points," 1990). Furthermore, drug use combined with homelessness may represent a barrier to prenatal health care, inasmuch as substance-abusing women in general (McKay, 1983; U.S. House o f Representatives, 1989) and homeless women in particular (Robertson & Cousineau, 1986; Shedlin, 1989) are less likely to obtain prenatal or other health care t h an are other women. Under the rubric o f child neglect, abuse, and endangerment laws, in m a n y counties, infants with positive toxicology screens o f their urine at birth are re- moved from their mother's custody or placed under su- pervision o f the court or d e p a r t m e n t o f children's services ("Pregnant Addicts," 1990; Shedlin, 1989; U.S. House o f Representatives, 1989; Wilcox, 1990).

O t h e r research indicates that the consequences o f a homeless m o t h e r ' s d r u g use m a y include the neglect, vi- olent t r e a t m e n t , or a b a n d o n m e n t o f her children. Some neglect m a y stem from intoxication that interferes with a w o m a n ' s ability to m o n i t o r and m e e t the needs o f de- p e n d e n t children. It m a y also stem f r o m use o f limited family resources for illicit drug purchase. In addition, neglect and violence are also attributed to the specific e m o t i o n a l a n d behavioral alterations caused b y crack o r other d r u g use (Inciardi, 1989; Shedlin, 1989). For ex- ample, Shedlin r e p o r t e d that drugs that caused violent behavior, extreme m o o d swings, or withdrawal were m o r e likely to be associated with violence and neglect o f chil- dren. In that study, m o r e violence and neglect o f children was r e p o r t e d for homeless crack-addicted mothers t h a n for homeless heroin-addicted mothers. Although p o o r parenting skills, stress, and a history o f family violence also m a y c o n t r i b u t e to neglect and abuse o f children b y homeless mothers, homeless women in one study believed drug use per se was the m a i n reason for the neglect an d abuse o f their children and for similar behavior o f o t h er w o m e n (Shedlin).

Several studies o f homeless children (Bassuk & Ro-

senberg, 1988; Molnar, Rath, & Klein, 1990; W o o d et al., 1989) r e p o r t e d higher rates o f child abuse or neglect o r i n v o l v em en t o f child protective agencies, c o m p a r e d with o t h e r p o o r families. However, it is w o rt h noting that some r e p o r t e d incidents o f child abuse an d neglect o f homeless children m a y to some degree be a p r o d u c t o f their parents' homelessness a n d exaggerated poverty. In addition, b y virtue o f their homelessness, homeless par- ents are subject to m o r e intense scrutiny b y the public, shelter a n d other service providers, an d public welfare staff. Observers rep o rt the same behaviors as m o r e abusive for low-income parents t h a n for m i d d l e - i n c o m e parents (Mo l n ar et al.). Also, homelessness itself is interpreted to be child neglect u n d e r some child p r o t e c t i o n statutes.

W o m en with alcohol- or other drug-related problems m a y experience m o r e difficulty t h a n do other p o o r women in keeping their families together and housed. Such w o m e n face increased difficulty competing in a tight housing market, in which low-income w o m e n with chil- dren, welfare recipients, a n d w o m e n o f color are already at a disadvantage (City o f New York, 1986; Sullivan & D a m r o s c h , 1987). Alcohol o r o t h er d r u g abuse poses an additional obstacle t o finding an d keeping e m p l o y m e n t for w o m en w h o are already at a disadvantage in the j o b m a r k e t because o f educational deficits, lack o f vocational skills, o r limited e m p l o y m e n t histories (Bassuk & Rosen- berg, 1988; M i l b u r n & Booth, 1989-1990; Mills & Ota, 1989; Shedlin, 1989; Sullivan & D a m r o s c h , 1987). Fur- t h e r m o r e , a homeless m o t h e r w h o uses alcohol or drugs risks exclusion o r expulsion o f b o t h herself a n d her chil- d r e n f r o m emergency shelters or transitional housing. Th o se settings are often centers for access t o welfare ad- vocacy, health care, child care, and other essential services. Consequently, w o m en with alcohol- o r drug-use problems m ay be less able to take advantage o f rehabilitation and other services (Sullivan & D am ro sch ), b o t h because o f the w o m a n ' s i m p a i r e d ability t o negotiate bureaucratic barriers (such as keeping a p p o i n t m e n t s ) an d because o f policies o f exclusion f r o m p ro g ram s o n the basis o f her substance use (Robertson, in press-a).

Clearly, alcohol an d other d r u g use m a y i m p a i r a w o m an 's ability t o c o m p e t e for scarce resources, and thereby t h r e a t e n family integrity. Also, d r u g o r alcohol abuse is likely t o place a homeless w o m a n at higher risk o f losing cu st o d y o f her c h i l d r e n ) Separation m a y o c c u r

2 Specific outcomes of prenatal alcohol and other drug exposure include prematurity, low birth weight, hypertonicity, low Apgar scores, and longer hospital stays, often in the intensive care nursery (Petitti & Coleman, 1990; U.S. House of Representatives, 1989). Other risks of prenatal drug exposure include fetal alcohol syndrome or the infant's dependence on cocaine, heroin, or methadone at birth (Bullard, 1983; McKay, 1983). Congenital syphilis is a special risk among infants born to crack users who trade sex for drugs ("Sex-for-Drugs Trade," 1990). Crack cocaine and alcohol are reported to be significant parts of the poly-drug pattern of substance abuse among pregnant women (U.S. House of Representatives, 1989).

3 Many homeless women have already experienced separations from their children. For example, two thirds of women in New York City single-adult shelters had children who were not present (Weitzman, Shinn, & Knickman, 1989).

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w h e n the m o t h e r i n f o r m a l l y places a child with a friend o r r e l a t i v e - - o f t e n the child's g r a n d p a r e n t (Wilcox, 1990). O t h e r separations o c c u r w h e n children are placed in foster care, either v o l u n t a r i l y b y the m o t h e r or as a result o f i n t e r v e n t i o n b y authorities, such as c o u n t y child p r o t e c - tive services ( W o o d et at., 1990). T h e r e m o v a l o f children f r o m their m o t h e r ' s c u s t o d y m a y have several conse- quences for the w o m a n , b e y o n d the psychological i m p a c t o f being i n v o l u n t a r i l y s e p a r a t e d f r o m her children. Loss o f children m a y affect s u p p o r t f r o m the e x t e n d e d family. According t o professional s t a f f i n one N e w York City wel- fare hotel, children were seen t o e n h a n c e a w o m a n ' s kin- ship ties a n d consequent e m o t i o n a l a n d economic s u p p o r t with the c h i l d r e n ' s father's f a m i l y (Shedlin, 1989). O n a m o r e m a t e r i a l level, loss o f c u s t o d y m a y also affect eli- gibility for public housing o r for family benefits t h r o u g h Aid to Families with D e p e n d e n t C h i l d r e n (AFDC). Loss o f benefits f u r t h e r reduces a w o m a n ' s ability to secure or m a i n t a i n stable housing for herself a n d her children. O n c e the child has b e e n p l a c e d in foster care, it m a y b e ex- t r e m e l y difficult t o regain custody, even in cases in which there was n o p r i o r evidence o f p a r e n t a l a b u s e or neglect (Solarz, in press). M a n y agencies will n o t restore c u s t o d y until the m o t h e r d e m o n s t r a t e s t h a t she has a d e q u a t e a n d stable housing a n d i n c o m e ; ironically, she is n o t eligible for A F D C or housing benefits until the children reside with her (Williams, 1991).

I n s u m , a w o m a n ' s alcohol a n d o t h e r d r u g use m a y result in increased residential instability for herself a n d her children, including prolonged or episodic homeless- ness, foster p l a c e m e n t or o t h e r relocation o f the children, r e d u c e d c o n t a c t with e x t e n d e d family m e m b e r s , r e d u c e d access to health care a n d o t h e r social services, a n d risk o f neglect or a b u s e for the children.

Treatment Barriers T h e r e a r e multiple b a r r i e r s for homeless w o m e n with children w h o seek t r e a t m e n t for their alcohol o r other d r u g use. O n e b a r r i e r c o m m o n to all w o m e n is the in- a d e q u a t e n u m b e r o f alcohol- a n d o t h e r d r u g - t r e a t m e n t p r o g r a m s in the U n i t e d States t h a t are geared t o the spe- cial needs o f w o m e n ( C o m f o r t , Shipley, White, Griffith, & Shandler, 1990; Ridlen, A s a m o a h , Edwards, & Z i m m e r , 1990). Also, there are long waiting p e r i o d s for d r u g treat- m e n t , even for p r e g n a n t w o m e n (Robin-Vergeer, 1990; U.S. H o u s e o f Representatives, 1989). For e x a m p l e , o f a n e s t i m a t e d 4 million w o m e n in the U n i t e d States w h o c u r r e n t l y need alcohol or o t h e r d r u g t r e a t m e n t a n d w h o c a n n o t find placements, 250,000 are p r e g n a n t ( " S u r v e y F i n d s , " 1990). Moreover, a recent s u r v e y showed t h a t m o r e t h a n one h a l f o f N e w York City t r e a t m e n t p r o g r a m s refused to enroll p r e g n a n t women, a n d nearly 90% refused p r e g n a n t w o m e n on Medicaid w h o were addicted to crack ( " P r e g n a n t Addicts," 1990).

L a c k o f access to t r e a t m e n t p r o g r a m s creates a n ad- ditional b u r d e n for homeless w o m e n w h o have m i n o r children. Residential t r e a t m e n t p r o g r a m s t e n d to be de- signed for adults only, a n d they only rarely m a k e provi- sions for w o m e n with children. S o m e innovative p r o g r a m s

are designed t o w o r k with p r e g n a n t w o m e n w h o are d r u g users, as a n alternative to the state's taking c u s t o d y o f the n e w b o r n (Wilcox, 1990), b u t even these facilities are n o t designed to a c c o m m o d a t e a w o m a n ' s other children. A n d a l t h o u g h a few counties allow g r a n d p a r e n t s to b e c o m e foster p a r e n t s t o their o w n g r a n d c h i l d r e n (Fagan, 1990), the extended family m o r e often lacks resources to s u p p o r t the children o f p o o r o r homeless w o m e n in t r e a t m e n t . To e n t e r a residential t r e a t m e n t p r o g r a m , a homeless m o t h e r m a y have t o place her children in foster care (Weinreb & Bassuk, 1990), k n o w i n g t h a t she m a y n o t b e able to retrieve t h e m even i f she successfully c o m p l e t e s the t r e a t m e n t p r o g r a m .

Few t r e a t m e n t a n d recovery p r o g r a m s are sensitive t o service needs o f indigent clients ( T h o m a s , Kelly, & Cousineau, 1990). Also, t r e a t m e n t p r o g r a m s usually are n o t p r e p a r e d t o deal with clients w h o have a history o f poly-substance use or c o m o r b i d m e n t a l health a n d sub- stance-use p r o b l e m s , b o t h o f which a p p e a r t o b e m o r e c o m m o n a m o n g homeless w o m e n t h a n a m o n g w o m e n in the general t r e a t m e n t population. H o m e l e s s w o m e n have an additional o b v i o u s b a r r i e r to t r e a t m e n t : the lack o f stable housing t h a t would p e r m i t use o f o u t p a t i e n t t r e a t m e n t a n d aftercare services ( W i t t m a n , 1989).

Policy Considerations Because there is a p a u c i t y o f e m p i r i c a l literature on homeless w o m e n with children, it is difficult t o m a k e c o m p r e h e n s i v e policy r e c o m m e n d a t i o n s . Nevertheless, available literature is sufficient t o identify t h r e e related issues t h a t require choices o n the p a r t o f policymakers. Although these policies are played o u t here in the lives o f homeless w o m e n , t h e y also affect o t h e r p o o r w o m e n a n d w o m e n in the c o m m u n i t y at large.

Women's Versus Children's and Fetal Rights

I n the previous discussion, one t h e m e t h a t emerges is the conflict between a n individual w o m a n ' s right to p r i v a c y a n d a child's right to p r o t e c t i o n b y the state. Child p r o - tection statutes are invoked, p r e s u m a b l y , in the interest o f the child's welfare. However, legal safeguards for the m o t h e r m a y b e seriously curtailed, including her right t o confidential t r e a t m e n t as well as her right to p r i v a c y as guaranteed u n d e r the F o u r t e e n t h A m e n d m e n t to the U.S. Constitution ( " P r e g n a n t Addicts," 1990; Robin-Vergeer, 1990). 4 This conflict is especially a p p a r e n t in the prenatal

4 In the R o e v. W a d e decision in 1973, the Court recognized that one aspect of the "liberty" protected by the due process clause of the Fourteenth Amendment is "a right of personal privacy, or a guarantee of certain areas or zones of privacy." This right of personal privacy includes, "the interest in independence in making certain kinds of im- portant decisions . . . . (1)t is clear that among the decisions that an individual may make without unjustified government interference are personal decisions relating to marriage; procreation; contraception; family relationships; and child rearing and education" (Robin-Vergeer, 1990, p. 785). Also, the Supreme Court has historically recognized that freedom of personal choice in matters of family life is a fundamental liberty interest protected by the Fourteenth Amendment (Robin-Vergeer).

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screening of pregnant women for illicit drug use and the potential removal of newborns from their mothers by the state.

Besides constitutional issues, there are practical consequences of the threat of state intervention in the name of child protection. For example, because their drug use may be detected during prenatal examinations, homeless pregnant women who use street drugs are thought to avoid or delay prenatal care, potentially risking the health of the woman and the developing fetus (McKay, 1983; "Pregnant Addicts," 1990). Also, removal of the newborn child from the woman's custody may affect the family welfare income and further destabilize the family unit and weaken the mother's ability to take care of other children in the family. As a consequence, the mother may lose her welfare support and even her other children.

In addition to constitutional and practical concerns, removing newborns or other dependent children from their mothers has broader social implications. States that have laws placing drug-exposed newborns under state custody often overwhelm the foster care system ("Preg- nant Addicts," 1990; "Public Health Problems," 1990; Robin-Vergeer, 1990; U.S. House of Representatives, 1989). Drug-exposed newborns who have been medically cleared for discharge may remain in the hospital for var- ious reasons, including eventual abandonment by their mothers, the lack of available and appropriate foster care placement, or delayed protective services evaluation, producing "boarder" babies in many hospitals (Robin- Vergeer, 1990; U.S. House of Representatives, 1989). In addition to disrupting the family, this is an inefficient use of state resources. If counties intervene on behalf of all infants with positive toxicological screens, resources will be spread so thinly that, inevitably, those infants whose lives truly need thorough investigation will receive only cursory attention. In short, removing infants from mothers who use drugs results in the "warehousing" of infants to the detriment of both mother and child (Robin- Vergeer).

Criminalization Versus Treatment of Drug Users

There are two competing policy responses to women who use drugs during pregnancy. One is criminalization, in which drug use is seen as willful criminal behavior that prompts criminal prosecution or intervention by a child protection agency. The second response is treatment, in which drug use is seen as an illness or as a problematic hcalth-risk behavior that prompts health intervention ("Pregnant Addicts," 1990). In its popular "war on drugs," the Bush Administration has continued to place massive political and budgetary emphasis on law enforce- ment control of illicit drugs. In contrast, the administra- tion's policy has placed inadequate emphasis on preven- tion of and treatment for drug use. It has also failed to target dangerous legal drugs, including alcohol and to- bacco. Furthermore, the administration has not addressed the social context that helps engender drug problems ("Groups Decry Lack," 1991).

Although the current administration emphasizes le- gal over medical solutions, legal intervention is not uni- form and appears to be applied primarily to poor women and women of color. For example, legal intervention often begins in medical institutions in which prenatal and ob- stetrical care can include tests for drug use. In this context, the threat of criminal prosecution of patients for drug use raises several legal, ethical, and practical questions. Responses to a drug-exposed infant vary within states, and positive toxicological screens are not subject to man- dated reporting. Furthermore, protocols for administering toxicological screens on infants vary among hospitals: Many hospitals do not use them at all, whereas public hospitals that serve large numbers of poor and minority women do tend to screen (Robin-Vergeer, 1990). In hos- pitals that do screen, the screening criteria themselves may contribute to disproportionate screening of poorer women and their children. For example, infants whose mothers have had no prenatal care are typically screened, overrepresenting homeless and other poor women, who are less likely to have received prenatal care (Robin-Ver- geer). Homeless women are at further risk, in that children with positive screens may be immediately removed if child welfare agencies expect difficulty in locating the mother after discharge (Robin-Vergeer). Within hospitals, treating physicians or nurses exercise discretion, potentially re- sulting in discriminatory decisions as to who will be screened (Robin-Vergeer).

Legal reaction to a woman's drug use during preg- nancy is inconsistent within states and includes coercive interventions such as removal of newborns from their mothers; court-ordered detention of pregnant, drug-using women; and in several states, prosecution for injury or death of infants when the mother's drug use during preg- nancy was a contributing factor ("Pregnant Addicts," 1990; Robin-Vergeer, 1990). There is some evidence that women of color and low-income women may be dispro- portionately affected by punitive measures ("Policy Statement 9020," 1991; "Pregnant Addicts," 1990).

As mentioned earlier, one consequence of the use of medical care in the service of drug criminalization is that women who might want medical care for themselves and their babies may not feel free to seek treatment because of the threat of criminal prosecution related to illicit drug use (Robin-Vergeer, 1990). Furthermore, the interven- tionist approach ignores more pervasive problems preg- nant women face, including inadequate access to prenatal care, insufficient and inadequate treatment programs for substance abuse, and the host of socioeconomic condi- tions that make it difficult for poor women to care for themselves and their fetuses during pregnancy (Robin- Vergeer).

When considering criminalization of drug use by pregnant women, policymakers should consider the source of the appeal for this approach. For example, is a woman subject to prosecution because she puts a devel- oping fetus at risk or because she is using drugs, a highly stigmatized behavior? Protecting the fetus seems to be pretext for punishing illicit drug use. For example, preg-

1202 November 1991 • American Psychologist

n a n t w o m e n m a y be prosecuted for use o f illicit drugs b u t n o t for alcohol or cigarette use, b o t h o f which have d e m o n s t r a t e d d e t r i m e n t a l health effects on a developing fetus. Similarly, a w o m a n is n o t prosecuted i f she know- ingly puts the fetus at risk because o f some other behavior, such as n o t eating well or driving a car w i t h o u t using a seat belt. Finally, second parties are n o t prosecut ed for providing illicit drugs, such as cocaine, to preg n an t women.

Several groups have r e c o m m e n d e d decriminalizing d r u g use b y p r e g n a n t women, in favor o f treating the drug problem. In 1990, the governing council o f the A m e r i c a n Public Health Association (APHA) reco m - m e n d e d viewing illicit d r u g use b y pregnant w o m e n as a public health p r o b l e m rather t h a n a criminal justice p r o b l e m ("Policy S t a t e m e n t 9020," 1991). T h e y rec- o m m e n d e d that n o punitive measures be taken against p r e g n a n t w o m e n when n o other illegal acts have been c o m m i t t e d . T h e y f u r t h e r encouraged development o f outreach programs and services to meet specialized needs o f w o m e n and their children, including d r u g t r e a t m e n t facilities and halfway houses to serve w o m e n w h o use illicit drugs, their newborns, and their other d e p e n d e n t children. In 1991, the A P H A called for programs to es- tablish d r u g t r e a t m e n t as an alternative to incarceration.

T r a d i t i o n a l V e r s u s T a i l o r e d T r e a t m e n t P r o g r a m s f o r Homeless Women

A t h i r d policy c o n c e r n is the i n a d e q u a c y o f alcohol or other d r u g t r e a t m e n t p r o g r a m s to m e e t the specific needs o f homeless w o m e n with children. T h o s e interested in providing such t r e a t m e n t m a y need to tailor creative t r e a t m e n t interventions to these w o m e n and to intervene at multiple levels, creating in effect, family-centered d r u g t r e a t m e n t ("Policy S t a t e m e n t 9020," 1991; Weinreb & Bassuk, 1990). Types o f s u p p o r t needed for homeless w o m e n with children include long-term s u p p o r t e d hous- ing, financial support, health care, j o b skills training, c o m p e n s a t o r y education, and child care (McChesney, in press; Weinreb & Bassuk, 1990; Wittman, 1989).

F o r w o m e n with alcohol or other drug problems, Weinreb a n d Bassuk (1990) r e c o m m e n d e d a t r e a t m e n t model that addresses b o t h their homelessness a n d their alcohol or other d r u g use. T h e model includes long-term, structured, and supported drug-free residential programs that m a i n t a i n family integrity. This model provides the stability and predictability o f a drug-free e n v i r o n m e n t and the comprehensive services necessary to address the multiple health, psychosocial, and financial difficulties c o m m o n to some homeless families. O t h e r models for delivery o f tailored t r e a t m e n t to homeless women have been developed, including a recent research demonstra- tion designed to evaluate the effectiveness o f a residential t r e a t m e n t p r o g r a m specifically for poly-drug-addicted homeless w o m e n with preschool children ( C o m f o r t et al., 1990). An alternative model might provide the option for w o m e n to have a v o l u n t a r y b u t t e m p o r a r y separation from their children during detoxification or at other times in their t r e a t m e n t program.

Summary To date, only a few studies o f homeless w o m e n with chil- d r e n have been c o m p l e t e d t h at r e p o r t an y findings on alcohol o r other d ru g use. Some researchers have reported t o m e t h at t h ey h a d b een encouraged t o exclude alcohol o r o t h er d r u g assessment f r o m their studies, o r t h at at the least t h e y were encouraged t o n o t r e p o r t " d a m n i n g " in- formation a b o u t alcohol or drug use b y homeless mothers. This lack o f reliable empirical information is unfortunate, i n a s m u c h as the m o st accu rat e an d comprehensive de- piction o f homeless w o m e n with children is essential to the design o f adequate policies, programs, an d services for them.

Despite its limitations, the existing literature suggests t h at in m a n y respects, homeless w o m e n with children are m u c h like o t h e r p o o r w o m e n with children. However, alcohol an d o t h er d ru g use m a y b e an i m p o r t a n t risk factor for homelessness, one t h at interferes with some w o m e n ' s ability t o c o m p e t e for scarce resources such as housing, e m p l o y m e n t , or services. Studies f u r t h e r suggest t h at homeless w o m e n with children w h o have alcohol or other d ru g problems require highly tailored and integrated services that address their homelessness, treatment needs, an d family issues. Access to t r e a t m e n t is an essential ele- m e n t in service interventions for some w o m e n because alcohol or other d ru g use m a y jeopardize other health, financial, e m p l o y m e n t , o r social interventions (Robert- son, in press-a; Weinreb & Bassuk, 1990).

A t the epidemiological level, research on homeless w o m e n with children is needed t h at specifically assesses the prevalence o f alcohol an d other d ru g abuse and its relation to m e n t a l health problems, the health o f the chil- dren, t reat m en t and other service utilization patterns, and the family's course o f homelessness. O n the t r e a t m e n t level, research d e m o n s t r a t i o n projects are needed that e x a m i n e innovative strategies for providing d ru g treat- m e n t to this population (Weinreb & Bassuk, 1990). At the policy level, choices have t o be m a d e with a clear understanding o f the consequences o f such choices, in- cluding whose needs get prioritized an d at what costs to individual women, families, an d the larger c o m m u n i t y .

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