Providing Mental Health Services
YOUTH in
Chronically Homeless Families
CURRENT ISSUES
By Courtney Smith
May 2009
Presentation Background
• This presentation was created by Courtney Smith with
major contributions from the Pediatrics Work Group of
the Health Care for the Homeless Clinicians’ Network.
• Pediatric clinical topics were identified during a
national meeting of homeless health care clinicians in
2008
– Coordination of mental health and substance
abuse services for homeless youth
– Provision of mental health services tailored to youth
from chronically homeless families
• In 2009, the Pediatrics Work Group surveyed homeless
health care providers in collaboration with Courtney
Smith regarding the two topics listed above. This
presentation is a result of those surveys.
www.nhchc.org
May 2009
YOUTH in Chronically Homeless Families
Homeless Youth
McKinney Vento Act Definition
Individuals between birth &
18 years old who are
accompanied by one or
more homeless parent(s) or
caregiver(s)
May 2009
US
Department
of Education.
No Child Left
Behind: The
McKinney
Vento
Homeless
Assistance
Act (2004).
Retrieved
April 7, 2009
from
http://www.e
d.gov/progra
ms/homeless/
guidance.pdf
YOUTH in Chronically Homeless Families
Homeless
McKinney Vento Act Definition
Individuals or families that
lack a fixed, regular, and
adequate nighttime
residence
May 2009
US Department
of Housing and
Urban
Development.
Homeless
Emergency
Assistance and
Rapid Transition
to Housing Act
of 2009.
Retrieved
November 9,
2009 from
http://www.go
vtrack.us/congr
ess/bill.xpd?bill
=s111-896.
YOUTH in Chronically Homeless Families
Chronically Homeless
McKinney Vento Act Definition
Continuously homeless for a
year or more or at least four
homeless episodes during
the last three years
May 2009
UD Department
of Housing and
Urban
Development.
Homeless
Emergency
Assistance and
Rapid Transition
to Housing Act
of 2009.
Retrieved
November 9,
2009 from
http://www.go
vtrack.us/congr
ess/bill.xpd?bill
=s111-896.
WHY is this issue important?
1 in 50
American Children
are
Homeless
Each Year
May 2009
National
Center of
Family
Homelessness
2008
WHY is this issue important?
FAMILIES
The largest subgroup of
the homeless population
is located in rural areas
May 2009
Vissing
1996
WHY is this issue important?
Mental Health
is significantly affected by…
Unstable living conditions
• Poor sleeping quarters
• Bug infestations
• Communicable diseases
May 2009
WHY is this Issue Important?
Mental Health
is significantly affected by…
Extreme poverty
• Food insecurity
• Nutrient deficiencies
• Inadequate clothing
May 2009
WHY is this issue important?
Mental Health
is significantly affected by…
Physical health
• Prevention
• Acute care
• Chronic disease
May 2009
WHY is this issue important?
Mental Health
is significantly affected by…
Abuse
• Sexual
• Physical
• Emotional
May 2009
WHY is this issue important?
Mental Health
is significantly affected by…
High-risk behaviors
• Substance use
• Sexual risk-taking
• Illegal activities
May 2009
WHY is this issue important?
Many aspects of
homelessness initiate,
compound, or perpetuate
the symptom frequency
and severity of a wide
variety of mental health
issues
May 2009
WHY is this issue important?
Some Common Mental Health
Diagnoses in Homeless Children
•
•
•
•
•
•
•
•
•
Acute reaction to stress
Attention Deficit Disorder
Anxiety disorder
Depression
Insomnia
Isolation
Mood disorder, NOS
Nightmares
Post-Traumatic Stress Disorder
May 2009
WHY is this issue important?
Seven Risk Factors
For Mental Illness In Children
The parent…
1. Does not have a high school
degree
2. Has died
May 2009
Masten, A., Miliotis,
D., GrahamBermann, S.,
Ramirez, M., &
Neeman, J. (1993).
Children in
Homeless Families:
Risks to Mental
Health and
Development.
Journal of
Consulting and
Clinical Psychology.
61(2); 335-343
WHY is this issue important?
Seven Risk Factors
For Mental Illness In Children
The child has…
3. One parent
4. Experienced divorce or
separation of parents
5. Been in foster care
May 2009
Masten, A., Miliotis,
D., GrahamBermann, S.,
Ramirez, M., &
Neeman, J. (1993).
Children in
Homeless Families:
Risks to Mental
Health and
Development.
Journal of
Consulting and
Clinical Psychology.
61(2); 335-343
WHY is this issue important?
Seven Risk Factors
For Mental Illness In Children
The child has…
6. Experienced abuse
7. Witnessed violence
May 2009
Masten, A., Miliotis,
D., GrahamBermann, S.,
Ramirez, M., &
Neeman, J. (1993).
Children in
Homeless Families:
Risks to Mental
Health and
Development.
Journal of
Consulting and
Clinical Psychology.
61(2); 335-343
National Survey
Coordination of
Mental Health Services for Youth in
Chronically Homeless Families
A CLINICAL PRIORITY FOR:
2008 Health Care for the
Homeless Clinicians’ Network
Pediatrics Work Group
May 2009
National Survey
What are the current best
practices in mental health
services for youth from
chronically homeless families?
May 2009
National Survey RESPONDERS
8 Responses received from a variety of
service providers:
•
•
•
•
•
•
•
•
Child and Adolescent Psychiatrist
Clinical Manager
Family Physician
Housing Coordinator
Licensed Social Worker
Physician Assistant
Public Health Nurse
Social Work Intern
May 2009
National Survey RESULTS
1 out of the 8 care providers
stated that his/her agency
provides:
Mental Health
Services Tailored to
Youth from
Chronically Homeless
Families
May 2009
National Survey RESULTS
2 out of the 8 providers worked
in agencies that:
specialized
in serving
homeless youth
May 2009
National Survey RESULTS
The remaining 5 providers worked
at agencies that:
• provided general mental health services
that were population nonspecific
or
• made mental health referrals for
homeless youth to other agencies
May 2009
National Survey RESULTS
Only 1 provider reported that
his/her agency had
recommended best practices
for providing mental health
services to youth from
chronically homeless families
May 2009
National Survey RESULTS
Best Practices as defined by one clinical
manager
• Providing outreach
• Delivering home-based services including
systems involvement (e.g. schools,
community, family, and peers)
• Utilizing motivational interviewing,
dialectical behavioral therapy and
cognitive behavioral therapy
• Practicing care on a homeless family
services team
May 2009
National Survey RESULTS
Reported barriers encountered
when trying to provide best
practice mental health services to
youth:
• Limited treatment time
• Funding
• Difficulty coordinating with other
agencies, e.g. child protection
services or schools
May 2009
National Survey RESULTS
Barriers (continued):
• Limited clinical capacity and
training
• Needs outweigh resources
• Extended referral wait time
• Lack of housing vouchers
May 2009
National Survey RESULTS
Barriers faced by care providers
when trying to provide
recommended best practiced
services
• Lack of specialized staff
• Availability of services in
area
• Limited resources specific
to youth
May 2009
Several of these
barriers are
organizationbased, or due to
lack of
government/
agency funding.
However a few
of these barriers
can be
addressed
through
improved
practices
Funding: How are Services for
The Homeless Funded?
Funding
Sources
include:
HUD: Housing
and Urban
Development
HHS: Health and
Human Services
VA: Veterans
Affairs
Labor: US Dept of
Labor
Justice: US Dept
of Justice
May 2009
The National
Alliance to
End
Homelessness,
2008
Funding: How are Services for
The Homeless Funded?
• Local, State, and Community funding differs
greatly and these differences in funding
streams greatly affect the services that can
be provided
• President Obama recently signed the
Omnibus Appropriations Act of 2009 which
included $75 million for Substance Abuse and
Mental Health Services Administration
(SAMHSA) homeless programs
• The legislation also included $59.7 million for
the Projects for Assistance in Transition from
Homelessness (PATH) program.
May 2009
National Survey Results
• Barriers faced by care providers when
trying to provide recommended best
practiced services
– Limited treatment time
– Lack of funding
– Lack of collaborations with other
agencies (e.g. child protection services
and schools)
– Capacity restrictions
– Long referral wait time
– Lack of housing
– Lack of specialized staff
– Limited services specific to youth
May 2009
Importance of Community
Integration & Agency Partnerships
• Community integration often occurs during
the transition of mentally ill individuals into
other services and/or housing options
• This transition often requires agency
partnerships that allow for care providers to
work together to assist individuals transition
from one program to another
• In order to do this a care provider does not
simply discharge a youth from services once
the program is complete but instead assists
them into their new surroundings/services
until transition is complete
May 2009
Importance of Community
Integration & Agency Partnerships
• 1994 - Waratah Area Homeless Outreach
Psychiatric Services implemented intervention to
serve homeless individuals
• 10 years later this intervention was assessed
• The 3 key factors of this intervention:
– engage clients in a culturally competent
manner
– use assertive outreach techniques
– Collaboration with other agencies
• Results of the use of assertive outreach,
integration of treatment and housing programs,
along with continuous care for community
integration showed significant decreases in
urban and rural homelessness
May 2009
Homles, A.,
Hodge. M.,
Newton, B.,
Bradley, G.,
Bluhm, A.,
Hodges, J., Didio,
L., & Doidge, G.
(2005).
Development of
inner urban
homeless mental
health service.
Australian
Psychiatry. 13(1);
64-69.
Importance of Community
Integration & Agency Partnerships
• In 2004 Yanos, Barrows & Temberis looked into
how the integration of homeless individuals into
stable and transitional housing coincides with
their integration into a community, with the
hypothesis that specifically believed housing type
impacted community integration significantly
• Results of this study found that the degree in
which individuals were integrated into their new
community before ending services affected
mental health symptoms and relapse incidences
May 2009
Yanos, P., Barrows, S., &
Temberis, S. (2004)
Community Integration
in the Early Phase of
Housing Among
Homeless Persons
Diagnosed with Severe
Mental Illness: Successes
and Challenges.
Community Mental
Health Journal. 40(2);
133-151.
Barriers to Care
• Barriers faced by care providers when
trying to provide recommended best
practiced services
– Limited treatment time
– Lack of funding
– Lack of collaborations with other
agencies (e.g. child protection services
and schools)
– Capacity restrictions
– Long referral wait time
– Lack of housing
– Lack of specialized staff
– Limited services specific to youth
May 2009
Lack of Housing
• 90,889 units of emergency shelter,
transitional housing, and permanent
supportive housing are available for
families nationwide
• Most people on public housing and
Section 8 waiting lists are families with
extremely low incomes. It is likely that
many of them have experienced or are
currently experiencing homelessness
• 38 states have state housing trust funds
May 2009
National Center on
Family
Homelessness, 2008
Lack of Housing
• Several studies have shown that
housing is a key element in
reducing mental health symptoms
and stabilization among the
homeless population
• Transitional services and
continuous services while housed
are associated with decreases in
homeless relapse and mental
health hospitalization
May 2009
Herman,
Conover, Felix,
Nakagawa &
Mills, 2007;
Johnson,
Samberg,
Calsyn,
Blasinsky,
Landow&
Goldman,1999;
Yanos, Barrows
& Temberis,
2004)
Lack of Housing
• Recent studies have shown
that providing permanent,
supportive housing for people
with serious mental illnesses is
more cost-effective than
services currently provided by
the public hospital, prison, and
shelter systems
May 2009
Herman, Conover,
Felix, Nakagawa &
Mills, 2007; Johnson,
Samberg, Calsyn,
Blasinsky, Landow&
Goldman,1999;
Yanos, Barrows &
Temberis, 2004)
Barriers to Care
• Barriers faced by care providers when
trying to provide recommended best
practiced services
– Limited treatment time
– Lack of funding
– Lack of collaborations with other
agencies (e.g. child protection services
and schools)
– Capacity restrictions
– Long referral wait time
– Lack of housing
– Lack of specialized staff
– Limited services specific to youth
May 2009
Lack of Specialized Staff
• To better serve the homeless
population, health care providers
should be aware of the unique
issues and risk factors faced by this
population
• Trainings are readily available
through interactive videos, group
sessions, or publications to help staff
provide culturally competent and
tailored care to this population
May 2009
Lack of Specialized Staff
Training specialized staff should include
topics on:
• Understanding the impact of traumatic stress
and creating trauma-informed services
• Addressing the needs of children living in
shelters
• Understanding the mental health needs of
people who are homeless
• Educating staff about burnout, secondary
trauma, and self-care
• Motivational interviewing techniques
• Involving consumers in program s
• Evaluating programs
(The National Center on Family Homelessness, 2008a)
May 2009
Barriers to Care
• Barriers faced by care providers when
trying to provide recommended best
practiced services
– Limited treatment time
– Lack of funding
– Lack of collaborations with other
agencies (e.g. child protection services
and schools)
– Capacity restrictions
– Long referral wait time
– Lack of housing
– Lack of specialized staff
– Limited services specific to youth
May 2009
Availability of Services & Limited
Resources
• Regaining stability is key to treating
mental illness of youth from chronically
homeless families
• Services and resources can be limited
due to staffing, funding, or grant
restrictions.
• Collaborations with other agencies can
ease these restrictions and pool
resources to provide services such as:
housing, physical and mental health
care, and counseling
May 2009
Availability of Services & Limited
Resources
• 1999 - Evaluation of a 5-year intervention, Access
to Community Care and Effective Services and
Supports (ACCESS) program utilized across 18
sites
• ACCESS program promoted Aggressive
Community Treatment (ACT) for homeless
individuals with mental illness
• Through community collaborations in each site,
the ACCESS programs offered advocacy,
outreach, medical evaluation, prescriptions,
medication maintenance, housing assistance,
entitlement, and budgeting services to this
population
May 2009
Johnson, M., Samberg, L.,
Calsyn, R., Blasinsky, M,
Landow, W., & Goldman, H.
(1999). Case Management
Models for Persons Who are
Homeless and Mentally Ill:
The ACCESS Demonstration
Project. Community Mental
Health Journal. 35(4); 325346.
Availability of Services & Limited
Resources
• A similar study was done in 2008 on
the use of resources collaboration
across agencies to provide the
homeless mentally ill population
was more resources
• The results showed that integrated
services were associated with an
increased use of outpatient
services for medical, mental, and
substance abuse treatment
May 2009
Mares, A., Greenberg, G., &
Rosenheck, R. (2008) Clientlevel Measures of Service
Integration Among
Chronically Homeless
Adults. Journal of
Community Mental Health.
44; 367-376.
Recommendations & Further
Research
• Due to the limited survey responses,
further research is recommended on
best practices used by agencies to
provide mental health services to
homeless youth from chronically
homeless families
• Also more research is recommended
regarding services provided in rural
areas
May 2009
Recommendations & Further
Research
• After further investigation into the topic of
mental health services provided and best
practices for youth from chronically
homeless families it is suggested that a
resources guide book be published for
national service providers to utilize as a
training and references tool
• There is a lack of research on this particular
population due to the transient nature of
homeless families and the difficulty of
standardizing research among different
types of homelessness; further research on
a national and local level is necessary in
order to find the best way to serve this
population
May 2009
Resources
• The National Center on Family
Homelessness
– America’s Youngest Outcast: State Report Card
on Child Homelessness
• The National Health Care for the Homeless
Council
• Homeless Children’s Network
• Coalition on Human Need
• National Alliance to End Homeless
• Children’s Defense Funds
• National Network for Youth
• PolicyLink
• National Center for Healthy Housing
• Voices for America’s Children
May 2009
References
•
•
•
•
•
•
•
Erikson, E. H. (1956). The problem of ego identity. Journal of the American
Psychoanalytic Association. 4, 56-121.
Haley, N., Roy, E., Leclerc, P., Boudreau, J.F., Boivin, J.F. (2004).
Characteristics of adolescent street youth with a history of pregnancy.
Journal of Pediatric and Adolescent Gynecology, 17, 313-320.
Health Care for the Homeless Clinicians’ Network. (2008). Adapting Your
Practice: Treatment and Recommendations on Reproductive Health Care
for Homeless Patients. Retrieved February 18, 2009, from
http://www.nhchc.org/Publications/ReproductiveHealth2008.pdf
Herman, D., Conover, S., Felix, A., Nakagawa, A., & Mills, A. (2007). Critical
Time Intervention: Models for Preventing Homelessness in High Risk Groups.
Journal of Primary Prevention. 2; 97-105
Homles, A., Hodge. M., Newton, B., Bradley, G., Bluhm, A., Hodges, J.,
Didio, L., & Doidge, G. (2005). Development of inner urban homeless
mental health service. Australian Psychiatry. 13(1); 64-69.
Johnson, M., Samberg, L., Calsyn, R., Blasinsky, M, Landow, W., &
Goldman, H. (1999). Case Management Models for Persons Who are
Homeless and Mentally Ill: The ACCESS Demonstration Project. Community
Mental Health Journal. 35(4); 325-346.
Mares, A., Greenberg, G., & Rosenheck, R. (2008) Client-level Measures of
Service Integration Among Chronically Homeless Adults. Journal of
Community Mental Health. 44; 367-376
May 2009
References (continued)
•
The National Alliance to End Homelessness. (August 2008) Understanding
How HUD and SAMHSA programs Work Together. Retrieved on April 9,
2009 from http://www.endhomelessness.org/content/article/detail/2116
• The National Center of Family Homelessness. America’s Youngest
Outcasts: State Report Card on Child Homelessness. (2008). Retrieved on
April 7, 2009 from
http://www.homelesschildrenamerica.org/report_extent.php
• The National Center of Family Homelessness. Training. (2008a). Retrieved
on April 7, 2009 from http://www.familyhomelessness.org/?q=node/25
• United States Department of Education. No Child Left Behind: The
McKinney Vento Homeless Assistance Act (2004). Retrieved April 7, 2009
from http://www.ed.gov/programs/homeless/guidance.pdf
• United States Department of Housing and Urban Development. Homeless
Emergency Assistance and Rapid Transition to Housing Act of 2009. Retrieved
November 9, 2009 from
http://www.govtrack.us/congress/bill.xpd?bill=s111-896.
• Vissing, Y. Out of Sight, Out of Mind: Homeless Children and Families in
Small Town America, 1996. The University Press of Kentucky; Lexington.
• Yanos, P., Barrows, S., & Temberis, S. (2004) Community Integration in the
Early Phase of Housing Among Homeless Persons Diagnosed with Severe
Mental Illness: Successes and Challenges. Community Mental Health
Journal. 40(2); 133-151.
May 2009