ASAP

Clinical Pediatrics 2014, Vol 53(1) 38 –40 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813499067 cpj.sagepub.com

Article

As more families in the United States become at or below the poverty level, many will also become desig- nated as homeless. Among these, homeless youth will number more than 1 million.1 As these families become known to the health care system, it is important to iden- tify them as homeless and to determine the circum- stances precipitating their homelessness. Understanding the specific reasons for homelessness enables the health care provider to deliver focused services within 2 con- texts of homelessness: involuntary and voluntary.

The involuntary homeless are victims of circum- stances that force them to live openly on the streets, con- tinuously use temporary housing, couch surf, share housing with other families, or reside in a shelter as their principal residence.1,2 These families may be a product of poverty, low wages, or domestic incident. Tracking the numbers of youth among the involuntary homeless is difficult because they may not be a part of a social wel- fare system or have not entered the legal system.

Voluntary homeless are the missing person adult or runaway youth. Runaway youth are 18 years and younger. They are more likely to describe themselves as homeless rather than a runaway because they feel forced to leave their residence because of abuse or rejection.3 Numbering the voluntary homeless may be less tedious than number- ing the involuntary homeless when tracked by police missing person reports. But, regardless to the context of homelessness, the more than 1 million homeless youth

has a staggering 750 000 who are school-aged children and younger who have no stable residence on a given night.1 This magnitude of homeless youth quantifies the need for establishing an early and strong rapport with their families to facilitate the best outcomes.

Engaging adult family members of homeless youth cannot be overemphasized. Adult members of the home- less family have higher incidence of depressive symp- toms and one third of homeless mothers reportedly have attempted suicide at least once.4 The impact of adult family member’s mental health dynamics translates into increased rates of anxiety, depression, behavioral, and developmental concerns among homeless youth with whom these adults abide.4 Additionally, homeless youth have poorer overall health associated with global somatic complaints, increased rates of asthma, ear infec- tions, stomach problems, and disorders in speech.4-6

The interconnectedness of adult mental health on the family highlights the need for a mental health assessment on youth as well. A mental health screening will better depict the health landscape of both the indi- vidual and family. Overall, 4% to 8% of adolescents

499067CPJXXX10.1177/0009922813499067Clinical PediatricsAnthony research-article2013

1PCC Community Wellness Center–Austin, Chicago IL, USA

Corresponding Author: Inger Anthony, PCC Community Wellness Center–Austin, 1421 W. Harrison Street, Chicago, IL 60607-3201, USA. Email: [email protected]

Meeting the Challenge: Responding to Health Care Needs of Homeless Youth

Inger Anthony, DNP, MS, APN, CPNP-PC1

Abstract Purpose. This article presents a worldview of youth who are victims of homelessness. A view of family dynamics and how they affect the emotional, psychological, social, and physical health of homeless youth is presented. Results. Homeless youth and their families are at high risk for poor health outcomes. Those who present for health care services are least likely to return to the same site for follow-up care. Conclusion. Understanding the dynamics of homelessness and its effect on youth and family will facilitate efforts to engage the family and increase the likelihood for follow-up with the same provider. A patient-centered cognitive approach when managing these youth and their family will improve communication, potentiate engagement, whet creative decision making, and facilitate continuity of care.

Keywords youth, sexual minority, voluntary homeless, involuntary homeless, couch surf, temporary housing, house sharing, continuity of care, engage

at CALIF STATE UNIV LONG BEACH on September 10, 2016cpj.sagepub.comDownloaded from

Anthony 39

are clinically depressed with the mean age of onset being age 14 years.7-9 Positive assessments for self- harm behaviors and suicide ideation are likely to be associated with a positive depression screen. Runaway sexual minority (lesbian, gay, bisexual, or transgen- dered) have an added risk for intentional self-harm. In fact, 59% of sexual minority males and 38% of sexual minority females attribute their attempts at suicide to issues concerning their sexual orientation.10 Although there is no single mental health screening tool that can be applied to all pediatric ages, the need for one is clear. The Pediatric Symptom Checklist (PSC) is a mental health screening tool applicable to ages 4.5 to 19 years.11 The brevity of the PSC lends its application to both primary care and the acute care settings. However, this is a parent report tool. Further develop- ment of the PSC instrument as a self-reporting tool would make it ideal for self-reporting young children and adolescents during a brief office visit or the quick- paced emergency department.

The dependence of younger children on adults to facilitate access to health care is legalistically obvious, but the interdependence of health care–seeking home- less adolescents has gender-specific characteristics. Gender specificity is more notable among runaway youth. Specifically, runaway females appear for care more often than runaway males and are usually accom- panied by a friend.2,12 Sexual minority adolescents and young adults generally appear alone for services.2,12

There are 6 areas of health care to be addressed when homelessness is part of the family landscape: physical health, nutrition, mental health, sexual health, substance use, and victimization.3 All 6 assessment areas deserve a family-focused review followed by a patient-centered assessment. Although a family assessment is probably unrealistic considering the dynamics afflicting the fam- ily, a social worker referral is warranted so that the lead family member has the option to complete a family assessment. Coordinating care with the social worker will also assist in securing resources for the family while leaving the provider exclusively available for assessing and responding to individual medical needs.

When conducting the physical exam, assessments that trigger a red flag include problems with personal hygiene, skin rashes, global constitutional complaints, and problems due to prolonged exposure to the environ- ment.3 A nutritional assessment in conjunction with lab work may reveal nutritional deficiencies.3,4 Females seeking to confirm a pregnancy should receive early confirmation and intervention to minimize their high risk for perinatal and neonatal complications inherent with gravid adolescents.

Homeless youth are at increased risk for victimiza- tion.3,13 Adolescents further increase their risk for vic- timization when they respond to their problems with illegal activity, such as theft, prostitution, pornogra- phy, or drugs. And, because sexual minority males and females report homelessness 4 to 13 times more than their heterosexual peers, they are more likely to be victimized by virtue of their sexual orientation.1,13,14 The predisposition for the sexual minority to rely on vice to sustain themselves explains in part why sexu- ally transmitted disease appears 5 times higher in sex- ual minority males and 2 times higher in sexual minority females when compared with their hetero- sexual counterparts.7

The worldview of homeless youth is integral to facil- itating the patient–provider relationship and fruition of a focused health assessment. The magnitude of risk and the complexity of the patient–provider relationship stress the importance of having a structured encounter to maximize health management. To facilitate a focused interview, techniques that ask questions that proceed from general to intimate can be integrated from the HEADSS tool.15 This strategy is especially critical when interviewing the sexual minority among whom disclo- sure16 is impeded by learned mistrust and fear of stigma.2 In addition to the general questions of a focused inter- view, when conducting an interview with the runaway, there are 5 questioning themes to be addressed: the real- ity of exiting street life, how to negotiate dangerous ter- ritory, rethinking return to family, inherent hazards of being a runaway female, and how to navigate the health care system.2

Facilitating the process of engagement is primary to establishing a long-term connection with homeless youth and their families. The provider who understands the dynamics of homelessness and its effect on youth and family can readily identify with and address their concerns in the context of homelessness. A patient-cen- tered cognitive approach when managing these youth will improve communication, potentiate engagement, whet creative decision making and facilitate continuity of care.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

at CALIF STATE UNIV LONG BEACH on September 10, 2016cpj.sagepub.comDownloaded from

40 Clinical Pediatrics 53(1)

References

1. Tierney W, Gupton J, Hallett R. Transitions to Adulthood for Homeless Adolescents: Education and Public Policy. Center for Higher Education and Policy Analysis/Jupiter Images; 2008

2. Haldenby A, Berman H, Forchuk C. Homelessness and health in adolescents. Qual Health Res. 2007;17:1232-1244.

3. Council on Scientific Affairs, American Medical Association. Health care needs of homeless and runaway youths. JAMA. 1989;262:1358-1361.

4. Bassuk EL, Weinreb LF, Buckner JC, Browne A, Salomon A, Bassuk S. The characteristics and needs of sheltered homeless and low-income housed mothers. JAMA. 1996;276:640-646.

5. Glicken, M. (2006). Learning from Resilient People: Lessons We Can Apply to Counseling and Psychology. Thousand Oaks, CA: Sage; 2006.

6. Perrin E, Cohen K, Gold M, Ryan C, Sawin-Williams R, Schorzman C. Gay and lesbian issues in pediatric health care. Curr Prob Pediatr Adolesc Health Care. 2004;34:355-398.

7. Woodgate R. Living in the shadow of fear: adoles- cents’ lived experience of depression. J Adv Nurs. 2006;56:261-269.

8. Liu J, Chen X, Lewis G. Childhood internalizing behav- ior: analysis and implications. J Psychiatr Ment Health. 2011;18:884-894.

9. Dekkar M, Ferdinand R, van Lang N, Bongers I, Ende J, Verhulst F. Developmental trajectories of depressive

symptoms from early childhood to late adolescence: gender differences and adult outcome. J Child Psychol Psychiatry. 2007;48:657-666.

10. Fortune S, Sinclair J, Hawton K. Adolescents’ views on preventing self-harm. A large community study. Soc Psychiatry Psychiatr Epidemiol. 2008;43:96-104.

11. Jellinek MS, Murphy JM, Massachusetts General Hospital. Pediatric symptom checklist. 1988. http://www. massgeneral.org/psychiatry/assets/PSC-35.pdf. Retrieved July 15, 2013.

12. Kuhl J, Jarkon-Horlick L, Morrissey R. Measuring bar- riers to help-seeking behavior in adolescents. J Youth Adolesc. 1997;26:637-650.

13. Corliss H, Goodenow C, Nichols L, Austin B. High bur- den of homelessness among sexual-minority adolescents: findings from a representative Massachusetts high school sample. Am J Public Health. 2011;101:1683-1689.

14. Milburn NG, Ayala G, Rice E, Batterham P, Rotheram- Borus MJ. Discrimination and exiting homelessness among homeless adolescents. Cultur Divers Ethnic Minor Psychol. 2006;12:658-672.

15. Woods ER, Neinstein LS. Office visit, interview tech- niques, and recommendations to parents. In: Neinstein LS, Gordon CM, Katzman DK, Rosen DS, Woods ER, eds. Adolescent Health Care: A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008: 32-43.

16. Riley BH. GLB adolescent’s “coming out”. J Child Adolesc Psychiatr Nurs. 2010;23:3-10.

at CALIF STATE UNIV LONG BEACH on September 10, 2016cpj.sagepub.comDownloaded from