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CORK Bibliography: Adolescent Homeless and Runaways

81 citations. January 1997 to present

Prepared: March 2008

Baer JS; Ginzler JA; Peterson PL. DSM-IV alcohol and substance abuse and dependence in homeless youth. Journal of Studies on Alcohol 64(1): 5-14, 2003. (28 refs.)

Objective: The purpose of this study is to describe endorsement rates of substance use criteria among homeless adolescents and to evaluate the reliability of diagnostic formulations among a group of adolescents who use more frequently and more heavily than other samples of adolescents. Method: Substance use rates and DSM-IV abuse and dependence criteria were assessed among 198 (109 male) homeless youths between the ages of 13 and 19, as part of a larger study. Endorsement rates and reliability analyses were completed for diagnostic criteria assessed for alcohol, marijuana, amphetamines and heroin. Results: Consistent with other studies of homeless youth, data revealed high rates of substance use and high rates of substance dependence. Both dependence and abuse diagnoses were associated with greater rates of use. DSM-IV criteria showed acceptable internal reliability, although variability was observed when applied to different substances. Of the drugs assessed, problems with heroin use appeared to be best, and marijuana use least, represented by dependence criteria. Criteria pertaining to continued use despite interference with role obligations and the experience of craving were consistently related to other dependence criteria. Conclusions: DSM-IV substance dependence criteria appear to have good internal reliability within a sample of adolescents who use at extremely high rates. Continued development of diagnostic systems for adolescent substance use should consider the social context of use, differential patterns of symptoms across different substances and the inclusion of additional criteria found reliable among adolescent samples

Bailey SL; Camlin CS; Ennett ST. Substance use and risky sexual behavior among homeless and runaway youth. Journal of Adolescent Health 23(6): 378-388, 1998. (37 refs.)

Purpose: To (a) characterize human immunodeficiency virus (HIV)- related risk behaviors of homeless youth; (b) determine whether substance use is associated with risky sexual behavior in this population; and, if so, (c) explore explanations for this relationship. Methods: A purposive sample of 327 homeless youth (ages 14-21 years) in Washington, DC, were surveyed in 1995 and 1996. Survey items were adapted from items used in a national study of adult substance use and sexual behavior and measured global (lifetime) and event-specific (most recent sexual encounter) behaviors. Results: Sexual activity with many partners, "survival" sex, and substance use were common. However, needle use was rare, and consistent condom use was evident in half the sample. Nearly all correlations between global measures of substance use and risky sex were statistically significant, but only a few of the event-specific correlations were significant. Marijuana use during the most recent sexual encounter was associated with nonuse of condoms, but this relationship disappeared in the multivariate model. However, crack use during the last encounter was associated with condom use; this relationship remained significant in the multivariate model. Lack of motivation to use condoms, longer histories of sexual activity and homelessness, symptoms of drug dependency, not discussing HIV risks with partner, and being female were also associated with nonuse of condoms. Conclusions: Homeless youth do use condoms, even within the context of substance use and casual sex. Results suggest that prevention and targeted intervention efforts have had some positive effect on this population, but young homeless women are in need of targeted prevention. Finally, additional research is needed to investigate the observed relationship between crack use and condom use in this sample.

Baron SW. Street youths and substance use: The role of background, street lifestyle, and economic factors. Youth & Society 31(1): 3-26, 1999. (70 refs.)

This research examines the role that various background, labor marker, and street lifestyle factors play in street youths' drug and alcohol use. Using a sample of 200 homeless male street youths, the researcher found that exposure to parental substance abuse increases street youths' risk of alcohol and hard-drug use. Further histories of physical abuse are related to the use of psychedelic drugs. The data also indicate that long-term homelessness influences hard-drug use, whereas drug- and alcohol-using peers influence the use of alcohol, marijuana and psychedelic drugs. Participation in property crime increases street youths' use of all types of drugs and alcohol, whereas drug distribution is linked to greater soft-drug use. Finally, job histories and depression are linked to alcohol and hard-drug use, whereas self-blame for unemployment increases alcohol use

Baron SW; Hartnagel TF. Street youth and criminal violence. (review). Journal of Research in Crime and Delinquency 35(2): 166-192, 1998. (103 refs.)

This research examines the roles of various subcultural, economic, and victimization factors in the violent behavior of 200 homeless male street youths. Findings reveal that factors associated with the street subculture, including long-term homelessness and criminal peers, increase the respondent's risk for violence on the street and provide rules concerning honor protection, and retribution. However, the heavy rise of drugs and alcohol on the street plays only a minor role in explaining violent behavior in this population, and the violence associated with these substances appears to be recreational. Findings also suggest that minimal economic resources and perceptions of a blocked opportunity structure also leave the youths at risk for various violent activities. Results also indicate that victimization on the street and a history of physical abuse in the home are related to the respondents' violent behavior Results are discussed in terms of different types of violent behavior.

Baron SW; Kennedy LW. Deterrence and homeless male street youths. Canadian Journal of Criminology 40(1): 27-60, 1998. (81 refs.)

The study explores the effects of the threat of formal punishment on the criminal behaviour of homeless male street youths paying particular attention to how these threats are shaped by their living conditions and other factors in their lifestyles. Results reveal that while many street youths fear legal sanctions, more serious offenders do not. Instead their fear of punishment is reduced by their poverty, drug use, association with criminal peers, and missing normative constraints. The study finds that serious street youth offenders are immersed in a lifestyle where crime, drugs, and criminal peers feed off of one another isolating them from conventional society. The findings suggest that traditional models of deterrence must be reexamined when dealing with extremely "at risk" groups.

Baybuga MS; Celik SS. The level of knowledge and views of the street children/youth about AIDS in Turkey. International Journal of Nursing Studies 41(6): 591-597, 2004. (29 refs.)

The purpose of this study was to discover the level of knowledge and views of the street children and youth in Turkey about AIDS. Five focus group discussions were held with 44 children. On the data collection form there were questions about their age, status of working and living status on the streets, gender, source of information about AIDS, high-risk groups, and knowledge on the ways of transmission and getting protected from AIDS. According to the study results, more than half of the participants (56.8%) did not have any knowledge about AIDS. 63.6% stated that they received their information about AIDS from public media. In addition, the participants of this study listed the main causes of transmission of AIDS as having sexual relationship with prostitutes (22.3%) and sharing razors, toothbrushes, footwear, food (27.6%). When asked the ways to protect oneself from AIDS, 28.9% stated that individual hygiene was very important while 21.0% stated not sleeping with prostitutes, single marriages, and condom use were very important ways to protect oneself from AIDS. 37 children of the total participants stated they were also at risk for AIDS. The main reasons of defining themselves at risk were being substance addicts (24.3%) and unhygienic practices (21.6%). The main conclusion of this study is that street children/youth have insufficient and incorrect knowledge about transmission and protection from AIDS and risk groups.

Boivin JF; Roy E; Haley N; du Fort GG. The health of street youth: A Canadian perspective. Canadian Journal of Public Health 96(6): 432-437, 2005. (70 refs.)

Objective: To review epidemiologic studies of the health of street youth in industrialized countries, with a special focus on Canadian youth. Methods: We identified 52 peer-reviewed studies from searches of the MEDLINE database and bibliographies of published papers, for data on blood-borne and sexually transmitted infections, mental health problems, pregnancy, violence and mortality. Results: Rates of hepatitis B, hepatitis C, and HIV infection are much higher among street youth than among their non-street peers. Likewise, the prevalence of all mental health problems assessed in street youth is greater than that in non-street youth. Pregnancy is more frequent among street than household youth. Street youth also experience high levels of violence: a large proportion report physical abuse or assault. Finally, mortality is about 11 times the expected rate based on age and sex and is mainly caused by suicide and drug overdose. Conclusion: Current research results are useful to orient public health interventions for street youth, but further epidemiologic research is needed. The need for Canadian data is particularly acute in specific areas including mental health, violence, pregnancy, and sexually transmitted infections such as, for example, herpes infection and syphilis.

2005, Canadian Public Health Association

Booth RE; Zhang YM. Conduct disorder and HIV risk behaviors among runaway and homeless adolescents. Drug and Alcohol Dependence 48(2): 69-76, 1997. (53 refs.)

This study was designed to assess the prevalence of conduct disorder (CD) among runaway and homeless adolescents and to investigate associations between CD and HIV risk behaviors. The Diagnostic Interview Schedule for Children and a standardized HIV risk assessment questionnaire were administered to 219 runaway and homeless adolescents recruited from a drop-in center serving high-risk youth. One-half of the males and 60% of the females were diagnosed with CD. In multivariate analyses, CD was the strongest predictor of lifetime use of heroin and/or cocaine and exchanging sex for money, drugs, food or shelter, as well as the number of drugs used and the number of sex partners in the 3 months preceding the interview. The high rate of CD in this population, and the association between CD and both drug and sex-related HIV risk behaviors, indicate a need for interventions that consider the influence of this psychiatric diagnosis on high-risk behaviors.

Booth RE; Zhang YM; Kwiatkowski CF. The challenge of changing drug and sex risk behaviors of runaway and homeless adolescents. Child Abuse & Neglect 23(12): 1295-1306, 1999. (53 refs.)

Objective: To assess HIV-related drug and sex risk behaviors and evaluate factors associated with change in risk behaviors among runaway and homeless adolescents, 244 street youth were recruited from a community drop-in center serving high-risk youth. Method: Using a cross-sectional design, approximately half of study participants received training in a peer-based intervention that included principles derived from the health belief model, while the remaining subjects received no intervention. Subjects were interviewed at baseline, immediately following the intervention (for those receiving the training) and 3 months later. Logistic regression and analysis of covariance were used to analyze intervention effects. Results: Compared to youth in the control condition, runaways receiving the intervention significantly increased their knowledge about HIV. Contrary to the health belief model, in multivariate analyses knowledge and greater perceived chance for HIV were associated with high risk behavior. On the other hand, lower concern about HIV infection was also associated with high risk behavior, supporting the health belief model. Conclusions: Despite the intervention's success in increasing knowledge of HIV and AIDS, the association between knowledge, perceived likelihood of infection and high risk behaviors suggest that, without other alternatives, runaways will maintain their risks. The association noted between lower concern and high risk behaviors underscores the challenge faced in developing effective interventions with this population.

Bousman CA; Blumberg EJ; Shillington AM; Hovell MF; Ji M; Lehman S et al. Predictors of substance use among homeless youth in San Diego. Addictive Behaviors 30(6): 1100-1110, 2005. (29 refs.)

This study examined the frequency of substance use among 14- to 24-year-old homeless youth (N=113) recruited from two community drop-in centers and explored the relationship between substance use and hypothesized psychosocial predictors. Audio-computer-assisted self-interviewing (A-CASI) was used for assessment. Including alcohol and tobacco, the mean number of different drugs used was 3.55 for lifetime and 2.34 for the last 3 months. A three-block hierarchical multiple regression was conducted to determine potential predictors of overall drug use (the sum of all different drugs used) during the last 3 months. Block 1 included demographic variables, Block 2 included a parental monitoring variable, and Block 3 included peer and environmental variables derived from learning theories. Parental monitoring (-) and peer variables (+) predicted overall 3-month drug use. The final model explained 36% of the variance in overall drug use. Results suggest that homeless adolescent drug use exists at high levels and is related to parental monitoring and peer modeling of other risk behaviors. These results may inform future prevention strategies for homeless youth and other high-risk populations.

Bridgman R. I helped build that: A demonstration employment training program for homeless youth in Toronto, Canada. (review). American Anthropologist 103(3): 779-795, 2001. (102 refs.)

In this case study I present preliminary findings on the development of Eva's Phoenix -- a pilot project designed to provide housing and employment-training opportunities for homeless youth in Toronto, Canada. I focus on the construction-training program for youth and explore some of the tensions that can arise in a project of this nature. These include consulting youth about the project's directions and facilitating their participation, representational authority in relation to how the project is promoted, and the need to reconcile different values and expectations for delivering the program on the part of partnering organizations and the youth themselves. I challenge perceptions of welfare and welfare reform in relation to youth and offer some insights into what types of services and interventions can potentially help homeless youth.

Chen XJ; Tyler KA; Whitbeck LB; Hoyt DR. Early sexual abuse, street adversity, and drug use among female homeless and runaway adolescents in the midwest. Journal of Drug Issues 34(1): 1-21, 2004. (59 refs.)

Research on homeless and runaway adolescents has shown that this population is at high risk for illicit drug use. Though sexual abuse has been widely considered in the etiology of illicit drug use, we know less about how early sexual abuse affects young people's decisions to run away, to use drugs, and to engage in other deviant behavior on the streets. Based on interviews with 361 female homeless and runaway adolescents in four midwestern states, the current study revealed a high prevalence of drug use, especially use of cocaine among youths with sexual abuse histories. Path analyses showed that early sexual abuse indirectly affected drug use on the streets via running away at an earlier age, spending more time on the street, and use of deviant strategies to survive (e.g., affiliation with deviant peers, trading sex, and use of nonsexual deviant subsistence strategies).

Clatts MC; Spring E; Davis WR; Backes G; Linwood C; Bresnahan M et al. The harm reduction model: An alternative approach to AIDS outreach and prevention for street youth in New York City. IN: Erickson PG; Riley DM; Cheung YW; O'Hare PA, eds. Harm Reduction: A new direction for dug policies and programs. Toronto: University of Toronto Press, 1997. pp. 393-409. (25 refs.)

This chapter has two specific aims: first, to provide a brief overview of the demographic and behavioral characteristics of the street youth population in New York City; second, to describe the way in which the harm reduction model has been applied to the development of comprehensive AIDS outreach and prevention services targeted to street youth. It provides an overview of the demographic characteristics of this population, a history of AIDS prevention services, factors central to application of harm reduction to street youth.

Cochran BN; Stewart AJ; Ginzler JA; Cauce AM. Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. American Journal of Public Health 92(5): 773-777, 2002. (40 refs.)

Objectives. The goal of this study was to identify differences between gay, lesbian, bisexual, and transgender (GLBT) homeless youths and their heterosexual counterparts in terms of physical and mental health difficulties. Methods. A sample of 84 GLBT adolescents was matched in regard to age and self-reported gender with 84 heterosexual adolescents. The 2 samples were compared on a variety of psychosocial variables. Results. GLBT adolescents left home more frequently, were victimized more often, used highly addictive substances more frequently, had higher rates of psychopathology, and had more sexual partners than heterosexual adolescents. Conclusions. Homeless youths who identify themselves as members of sexual minority groups are at increased risk for negative outcomes. Recommendations for treatment programs and implications for public health are discussed.

Craig TKJ; Hodson S. Homeless youth in London: II. Accommodation, employment and health outcomes at 1 year. Psychological Medicine 30(1): 187-194, 2000. (23 refs.)

Background. While there is considerable evidence of a high prevalence of psychiatric disorder among homeless youth, much less is known about its long-term course or the impact it may have on accommodation outcomes. Method. A random sample of 161 homeless people 16-21 years of age were recruited from consecutive attendees at two of London's largest facilities for homeless young people. These young people were traced and re-interviewed a year later to examine accommodation, occupation and health outcomes. Results. A total of 107 (67%) people were successfully re- interviewed. Psychiatric disorder was identified in 55% at follow up. Two thirds of those with a psychiatric disorder at index interview remained symptomatic at follow-up. Persistence of psychiatric disorder was associated with adverse childhood experiences and rough sleeping. Satisfactory accommodation outcomes were achieved by 45 subjects (42 %). Better accommodation outcomes were associated with three variables measured at the index assessment: ethnic minority status; educational achievement; and, the presence of accommodation plans negotiated through a resettlement agency. While psychiatric disorder at index interview was not associated with accommodation outcome, persistent substance use in the follow-up year was associated with poor accommodation outcome. Over half of the young people had been involved in petty crime and just under a third had been convicted for more serious criminal activity. Offending and antisocial behaviour in the follow-up year were related to a history of conduct disorder, persistent substance abuse and poor accommodation outcomes. Conclusions. Young homeless people are characterized try multiple social and medical needs. Successful resettlement of this population may depend upon integrated services that address problems of persisting substance use and mental illness as well as the immediate housing need.

Darling N; Palmer RF; Kipke MD. Do street youths' perceptions of their caregivers predict HIV-risk behavior? Journal of Family Psychology 19(3): 456-464, 2005. (36 refs.)

This study examined street youths' perceptions of their caregivers and the association between these perceptions and HIV-risk behavior in a random probability sample of 715 12-to 23-year-old street youths from Los Angeles and San Diego, CA (mean age, 18.7 years). All participants had been homeless at some point during the past 12 months, with 70% recruited from nonshelter sites. Although youths reported high rates of hostility, unavailability, substance use, and legal problems among their caregivers, 86% reported that their caregivers had at least one attribute associated with support. Caregiver problems were associated with youth having had more sexual partners in the past 30 days and having higher risk drug use. High caregiver support was associated with more sexual partners and lower use of condoms with steady partners. Caregiver attributes did not predict condom use with transient partners.

De Rosa CJ; Montgomery SB; Kipke MD; Iverson E; Ma JL; Unger JB. Service utilization among homeless and runaway youth in Los Angeles, California: Rates and reasons. Journal of Adolescent Health 24(3): 190-200, 1999. (16 refs.)

Purpose: To describe the service utilization patterns of homeless and runaway youth in a "service-rich" area (Los Angeles, California); identify demographic and other correlates of utilization; and contextualize the findings with qualitative data. Method: During Phase 1 of this study, survey data were collected from an ethnically diverse sample of 296 youth aged 13-23 years, recruited from both service and natural "hang-out" sites using systematic sampling methods. During Phase 2, qualitative data were collected from 46 youth of varying ethnicities and lengths of time homeless. Results: Drop-in centers and shelters were the most commonly used services (reported by 78% and 40%, respectively). Other services were used less frequently [e.g., medical services (28%) and substance abuse treatment (10%) and mental health services (9%)]. Utilization rates differed by ethnicity, length of time in Los Angeles, and city of first homeless episode (Los Angeles vs. all others). Shelter use was strongly associated with use-of all other services. Despite youths' generally positive reactions to services, barriers were described including restrictive rules, confidentiality and reporting problems, and negative interactions with staff members. Youth suggested improvements including more targeted services, more long- term services, revised age restrictions, and mote and/or better job training and transitional services to get them off the streets. Conclusions: Because shelters and drop-in centers act as gateways to other services and offer intervention potential for these hard-to- reach youth, it is vital that barriers to use of these services are eliminated.

DeMatteo D; Major C; Block B; Coates R; Fearon M; Goldberg E et al. Toronto street youth and HIV/AIDS: Prevalence, demographics, and risks. Journal of Adolescent Health 25(5): 358-366, 1999. (19 refs.)

Purpose: The purposes of this study were: (a) to identify human immunodeficiency virus (HIV) prevalence in Toronto street youth through paired blood and saliva specimens; (b) to identify the HIV risk and prevention behaviors of street involved youth; and (c) to identify demographic or other factors that may contribute to the risk of street youth becoming infected with HIV/acquired immunodeficiency syndrome (AIDS) in the future. Methods: This was a cross-sectional convenience study of street-involved youth aged 14-25 years. The youth participated in interviews to identify HIV-related knowledge and personal risk and preventive behaviors. Following interviews, they were asked to provide a saliva sample, blood spot or both. They could refuse one or both samples without jeopardizing their involvement or receiving an honorarium. Two males were the only participants who declined to provide a sample. Results: Fifteen of 695 (2.2%) youth tested positive for HIV infection. All were male, ranging in age from 18 to 25 years. Same and opposite sex, intravenous (IV) drug use, prostitution, and incarceration were risk factors associated with positive HIV test results. The rate of HIV infection was seven times greater for the group 20 years of age and older (20-25) compared to the younger group aged 14-9 years. The proportion testing positive for HIV from small cities, towns, and rural communities in Ontario was 40%; yet, they represented 21% of the study population. Most (57%) youth had been an their own far no more than 3 years and had moved frequently. Nearly two thirds (60%) had stayed in hostels or homeless shelters in the previous 6 months. Conclusion: Street youth in Canada are at high risk of HIV infection with their risk increasing with age. Unprotected (same and opposite) sex, IV drug use, prostitution and incarceration were linked to their HIV infections. The high level of mobility identified by street youth challenges governments, communities, and public health officials to develop appropriate prevention strategies and to carefully monitor the spread of HIV infection in this vulnerable population.

Diaz T; Dusenbury L; Botvin GJ; Farmer Huselid R. Factors associated with drug use among youth living in homeless shelters. IN: Botvin GJ; Schinke S, eds. The Etiology and Prevention of Drug Abuse among Minority Youth. New York: Haworth Press, 1998. pp. 91-110. (36 refs.)

There have been only a limited number of studies that examine drug use among homeless youth and there have been no studies to date on drug use with adolescents living in homeless families, This study examined predictors of tobacco, alcohol, and marijuana use with homeless adolescents and preadolescents (N = 234) living in shelters for homeless families. Structured interviews were conducted an self-reported drug use, as well as background variables, social environmental influences, and individual characteristics hypothesized to promote drug use. Logistic-regression analyses revealed that social influences (friends and family drug use) are strong predictors of experimental drug use and intentions to use drugs, as are several psychological factors (psychological well-being, assertiveness, and social support). Implications of the findings for effective prevention programs for homeless and other high risk youth are discussed.

Diaz T; Dusenbury L; Botvin GJ; Farmer-Huselid R. Factors associated with drug use among youth living in homeless shelters. Journal of Child & Adolescent Substance Abuse 6(1): 91-110, 1997. (38 refs.)

There have been only a limited number of studies that examine drug use among homeless youth and there have been no studies to date on drug use with adolescents living in homeless families, This study examined predictors of tobacco, alcohol, and marijuana use with homeless adolescents and preadolescents (N = 234) living in shelters for homeless families. Structured interviews were conducted an self- reported drug use, as well as background variables, social environmental influences, and individual characteristics hypothesized to promote drug use. Logistic-regression analyses revealed that social influences (friends and family drug use) are strong predictors of experimental drug use and intentions to use drugs, as are several psychological factors (psychological well-being, assertiveness, and social support). Implications of the findings for effective prevention programs for homeless and other high risk youth are discussed.

Eastwood EA; Birnbaum JM. Physical and sexual abuse and unstable housing among adolescents with HIV. AIDS and Behavior 11(6, Supplement S): S116-S127, 2007. (63 refs.)

Stable housing is a necessary component of treatment of adolescents with HIV. This study examines the housing status at two points in time of a sample of 224 adolescents with HIV seen at an adolescent medicine clinic in New York City. It addresses whether unstable housing is associated with several forms of abuse, and what factors predict continued instability. 38.6% (n = 86) had a prior history of unstable housing, reduced to 12.9% at the time of program entry. Multivariate logistic regression models predicting current and prior unstable housing revealed two variables related to both outcomes: physical abuse and referral from youth/social services entities. Continued unstable housing was associated with all abuse variables and adolescent history of arrest. When adolescents in abusive situations come to the attention of programs for youth, they have a positive impact on transitioning most adolescents to safer households, potentially improving adolescents' accessing of health care services.

Forster LMK; Tannhauser M; Barros HMT. Drug use among street children in southern Brazil. Drug and Alcohol Dependence 43(1/2): 57-62, 1996. (21 refs.)

We studied the self-reported activities engaged in by children found wandering on the streets of Porto Alegre, Brazil, aiming to describe their drug abuse habits and practice of thefts or mendicancy. One hundred-and-five youngsters, 6-18 years old, were interviewed in the streets. Although the external appearance of the interviewed children lacked cues as to their life-style differences, three diverse life-style characteristics were depicted among them. Almost 25% of the children lived with their families and went to school (FAMSCH) and 46% lived with their families but didn't go to school (FAM). The other 29% spent all day long and slept in the streets (STREET). The most frequently used drug for the total group of children was tobacco, followed by alcohol; with a much higher prevalence of use of both alcohol and tobacco among children from the STREET subgroup. Alcohol was used by more than 25% of the STREET children and tobacco by 58% of the children from this subgroup, in a regular (almost daily) basis. Less than 12% of the FAMSCH children used illicit drugs. Inhalants were the preferred drugs for illicit drug experimental use. Only 4% of the children attending school sniffed solvents in a regular basis. Regular abuse of inhalants was reported much more frequently by the STREET subgroup of children, reaching a prevalence of 40%. Self-report of marijuana smoking was described to be regular by 4% of the FAMSCH children and 26% by the STREET children. A significantly higher number of the children who lived with their families in comparison to the STREET children described work activities (selling food, washing cars or polishing shoes) while out in the streets. On the other hand the practice of thefts was self-reported mainly by the children from the STREET group and only by the ones who used illicit drugs. Children who lived with their families reported less mendicancy and thefts than street children. These results show that very poor children might spend many hours of the day by themselves in the streets of a big city accompanied by children who are never under adult supervision. In spite of being alone for some hours a day and making friends with others who might use drugs, having a family and regularly attending school decreases the risk of delinquent acts and drug use.

Ginzler JA; Cochran BN; Domenech-Rodraguez M; Cauce AM; Whitbeck LB. Sequential progression of substance use among homeless youth: An empirical investigation of the gateway theory. Substance Use & Misuse 38(3/6): 725-758, 2003. (41 refs.)

We examined the sequence of substance-use initiation in 375 street youth (age 13-21) who were interviewed from 1994-99 in Seattle, Washington. Based on the "gateway theory," participants were categorized into six profiles to describe the order in which they initiated use of various substances (i.e., alcohol, marijuana, other drugs), or classified as nonprogressors if they had not tried all three classes of drugs. Youth progressing in the hypothesized gateway order (i.e., alcohol preceding marijuana, followed by other drugs) initiated their use at an earlier age than youth who had not progressed through all three substance classes. However, there was no relationship between a substance initiation profile and current substance-use. Implications include the recognition that street youth may follow different patterns of use than normative groups, and that interventions geared toward youth who use substances heavily must include contextual factors, in addition to substance-use history.

Gleghorn AA; Marx R; Vittinghoff E; Katz MH. Association between drug use patterns and HIV risks among homeless, runaway, and street youth in Northern California. Drug and Alcohol Dependence 51(3): 219-227, 1998

We examined relationships between drug use patterns and HIV risk behaviors among 1121 street-recruited homeless, runaway, and 'street youth' in Northern California. Comparisons demonstrated that youth using any heroin, methamphetamine, or cocaine exhibited more sexual risks than non-users, while primary stimulant and combined heroin/stimulant users showed greatest sexual risk. Combined heroin/stimulant injectors showed higher risk injection practices than primary heroin or primary stimulant injectors, including frequent injections and backloading syringes. Interventions for street youth should be tailored to current drug use patterns since those using combinations of heroin and stimulants may require more comprehensive prevention, support and treatment services.

Greene JM; Ennett ST; Ringwalt CL. Substance use among runaway and homeless youth in three national samples. American Journal of Public Health 87(2): 229-235, 1997. (27 refs.)

OBJECTIVES: Standardized estimates of the prevalence of substance use by runaway and homeless youth between the ages of 12 and 21 in various settings were compared with each other and with estimates for youth in the general population. METHODS: Four surveys were used: (1) a nationally representative survey of runaway and homeless youth residing in federally and non-federally funded shelters; (2) a multicity survey of street youth; (3) a nationally representative household survey of youth with and without recent runaway and homeless experiences; and (4) a nationally representative household survey of youth whose previous runaway/homeless status was unknown. RESULTS: For almost every substance, substance use prevalence was highest among street youth. Shelter youth and household youth with recent runaway/homeless experiences reported similar rates. In the household surveys, substance use rates were lowest and were generally comparable. CONCLUSIONS: Many homeless and runaway youth use tobacco, alcohol, and other drugs at rates substantially higher than nonrunaway and nonhomeless youth, indicating a need for comprehensive and intensive substance abuse prevention and treatment services for these youth.

Greene JM; Ringwalt CL. Youth and familial substance use's association with suicide attempts among runaway and homeless youth. Substance Use & Misuse 31(8): 1041-1058, 1996. (19 refs.)

This study examined how youth suicide attempts are associated with youth and familial substance use among two samples of runaway and homeless youth (RHY) (a) a nationally representative sample of RHY residing in shelters, and (b) a multi-city, purposive sample of RHY found on the street. Data were collected using personal interviews from 640 shelter youth and 600 street youth in 1992. Logistic regression analyses revealed that, after controlling for key demographic characteristics, youth who had used substances (particularly sedatives, hallucinogens, and inhalants) were much more likely than those who had not used substances to have ever attempted suicide. In addition, after controlling for their own substance use, youth with family members who had used substances were twice as likely as those without such family members to have ever attempted suicide. This study suggests the importance of developing and focusing suicide prevention efforts on RHY known to have used (or are using) substances and to have substance-using family members.

Haasen C; Prinzleve MiZ; Heike R; Juergen G; Franziska F; Gabriele J et al. Cocaine use in Europe: A multi-centre study. European Addiction Research 10(4): 139-146, 2004. (49 refs.)

An increase in the use of cocaine and crack in several parts of Europe has raised the question whether this trend is similar to that of the USA in the 1980s. However, research in the field of cocaine use in Europe has been only sporadic. Therefore, a European multi-centre and multi-modal project was designed to study specific aspects of cocaine and crack use in Europe, in order to develop guidelines for public health strategies. Data on prevalence rates were analysed for the general population and for specific subgroups. Despite large differences between countries in the prevalence of cocaine use in the general population, most countries show an increase in the last few years. The highest rate with a lifetime prevalence of 5.2% was found for the United Kingdom, although with a plateau effect around the year 2000. With regard to specific subgroups, three groups seem to show a higher prevalence than the general population: (1) youth, especially in the party scene; (2) socially marginalized groups, such as homeless and prostitutes or those found in open drug scenes; (3) opiate-dependent patients in maintenance treatment who additionally use cocaine. Specific strategies need to be developed to address problematic cocaine use in these subgroups.

2004, S. Karger AG

Haber MG; Toro PA. Homelessness among families, children, and adolescents: An ecological-developmental perspective. (review). Clinical Child and Family Psychology Review 7(3): 123-164, 2004. (258 refs.)

This paper reviews and evaluates the literatures on children in families that are homeless and on adolescents who are homeless on their own. After presenting several emerging theoretical approaches, we propose a broad ecological-developmental perspective that recognizes that, although persons in these groups often lack resources and experience negative events that can amplify the risk for poor outcomes, they also have resources and adaptive potential. The perspective also recognizes that homelessness may have different meanings and outcomes at different points in development and that we need to consider interactions between individual development and multiple levels of social organization in order to foster new solutions to homelessness. On the basis of this perspective, we discuss directions for treatment and preventive interventions as well as social policy.

2004, Kluwer Academic

Halcon LL; Lifson AR. Prevalence and predictors of sexual risks among homeless youth. Journal of Youth and Adolescence 33(1): 71-80, 2003. (46 refs.)

This study examined prevalence of sexual risks among homeless adolescents and described factors associated with those risks. Community-based outreach methods were used successfully to access this difficult-to-reach population. The sample included 203 homeless youth aged 15-22 recruited from community sites. Questionnaire items addressed demographics, sexual behaviors, alcohol/drug use, STI history and testing, and pregnancy history. In cross-sectional analysis, 58.7% of males and 75.6% of females reported recent sexual intercourse. Of those, one third of males and half of the females used no barrier method with at least one partner. Both gender (female) and race/ethnicity (non-Black) were associated with having intercourse without a barrier contraceptive method. Over one fifth reported a history of "survival sex" or receiving money, drugs, clothing, shelter, or food for sex. These results show disturbingly high rates of a number of sexual risks, reinforcing the need for targeted interventions with this highly vulnerable population.

Huang CC; Barreda P; Mendoza V; Guzman L; Gilbert P. A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia. Archives of Disease in Childhood 89(9): 821-826, 2004. (16 refs.)

Aims and Methods: A comparative study of abandoned street children and formerly abandoned street children was conducted in La Paz, Bolivia, representing the first such comparative assessment. Between August and December 1997, all abandoned street children in La Paz, Bolivia, who were willing to participate (n = 124) were interviewed repeatedly at night using standardised questionnaires to collect information on family history, demographics, socioeconomics, drug use, and physical/sexual abuse. The same questionnaires were administered to all former abandoned street children who chose to enter a local orphanage ( n = 35). Results: The persistent street children differed greatly from those who entered the orphanage, most markedly in their higher risk of police abuse (95% versus 38%), absence from school (84% versus 19%), engagement in robbery (26% versus 4%), paint thinner use (88% versus 41%), alcohol use (58% versus 12%), and a serious medical problem (53% versus 20%). The risks for street children increased rapidly with age. Conclusions: A cascade of adverse outcomes afflicts the vast majority of abandoned street children in La Paz, which cumulate with age and diminish the likelihood of successful rehabilitation through lasting placement in an orphanage or residential home. Informed by these findings, the investigators operate a home for abandoned street children in La Paz.

Inciardi JA; Surratt HL. Children in the streets of Brazil: Drug use, crime, violence, and HIV risks. Substance Use & Misuse 33(7): 1461-1480, 1998. (54 refs.)

The presence of vast numbers of unsupervised and unprotected children is a phenomenon that is common throughout Latin America, and in few places are the street children more visible, and reviled, than in Brazil. Estimates of their numbers in Brazil have ranged from 7 to 17 million, but more informed assessments suggest that between 7 and 8 million children, ages 5 to 18, live and/or work on the streets of urban Brazil. Accounts of drug misuse among street youths in Brazil are commonplace. Numerous scientific studies and media stories have reported the widespread use of inhalants, marijuana and cocaine, and Valium among street children. Also common is the use of coca paste and Rohypnol. Risk of exposure to HIV is rapidly becoming an area of concern because of the large number of street youths engaging in unprotected sexual acts, both renumerated and nonrenumerated. Moreover, Brazil's street children are targets of fear. Because of their drug use, predatory crimes, and general unacceptability on urban thoroughfares, they are frequently the targets of local vigilante groups, drug gangs, and police "death squads." Although there have been many proposals and programs for addressing the problems of Brazilian street youth, it would appear that only minimal headway has been achieved. [Translations are provided in the International Abstracts Section of this issue.]

Johnson KD; Whitbeck LB; Hoyt DR. Substance abuse disorders among homeless and runaway adolescents. Journal of Drug Issues 35(4): 799-816, 2005. (29 refs.)

This paper presents lifetime and 12-month prevalence rates and comorbidity data for substance abuse disorders among homeless and runaway adolescents. Data are from baseline interviews of a longitudinal diagnostic study of 428 (187 males and 241 females) homeless and runaway adolescents aged 16 to 19 years (mean age = 17.4 year, SD = 1.05). The data were collected by full-time interviewers on the streets and in shelters in eight Midwestern cities of various populations. About two thirds (60.5) of the runaways met lifetime criteria for at least one of three substance disorders (alcohol abuse, alcohol dependence, drug abuse), and nearly one half (48.1%) met 12-month criteria for at least one of the disorders. Nearly all of the adolescents (93%) who met criteria for a substance disorder met criteria for at least one other mental disorder. Those factors most predictive of meeting lifetime criteria include parenting practices, experience of abuse, and association with deviant peers.

Johnson TP; Aschkenasy JR; Herbers MR; Gillenwater SA. Self-reported risk factors for AIDS among homeless youth. AIDS Education and Prevention 8(4): 308-322, 1996. (47 refs.)

This study assessed HIV risk behaviors in a sample of homeless youth in a large urban area and examined factors associated with these behaviors. Self-reported behaviors were assessed via interviews with 196 homeless youth in Chicago in all 10 urban shelters serving this group and in 5 street locations. Overall, 83.7% reported at least one of these risk factors: multiple sex partners; high-risk partners; inconsistent condom use; history of sexually transmitted disease; anal sex; prostitution; and/or intravenous drug use. An index of these behaviors was associated with being male, having unmet personal needs, being interviewed in street locations, and having a history of sexual abuse. Findings suggest that strategies that may decrease risk behaviors among homeless youth include the elimination of their need to rely on illicit activities for income, provision of basic needs, education regarding existing services, increased outreach efforts, and early identification of and protection from childhood sexual abuse.

Kamieniecki GW. Prevalence of psychological distress and psychiatric disorders among homeless youth in Australia: A comparative review. (review). Australian and New Zealand Journal of Psychiatry 35(3): 352-358, 2001. (56 refs.)

Objective: To review the prevalence literature on psychological distress and psychiatric disorders among homeless youth in Australia, and to compare these rates with Australian youth as a whole. Method: Computerized databases were utilized to access all published Australian studies on psychological distress (as measured by standardized symptom scales and suicidal behaviour) and psychiatric disorders among homeless youth; in addition, unpublished Australian studies were utilized whenever accessible. A total of 14 separate studies were located, only three of which have included non-homeless control groups. In the current review, prevalence data from uncontrolled youth homelessness studies are compared with data from Australian community and student surveys. Results: Homeless youth have usually scored significantly higher on standardized measures of psychological distress than all domiciled control groups. Youth homelessness studies have also reported very high rates of suicidal behaviour, but methodological limitations in these studies make comparisons with community surveys difficult. Furthermore, rates of various psychiatric disorders are usually at least twice as high among homeless youth than among youth from community surveys. Conclusions: Homeless youth in Australia have extremely high rates of psychological distress and psychiatric disorders. As homeless youth are at risk of developing psychiatric disorders and possibly self-injurious behaviour the longer they are homeless, early intervention in relevant health facilities is required.

Kidd SA. Factors precipitating suicidality among homeless youth: A quantitative follow-up. Youth & Society 37(4): 393-422, 2006. (75 refs.)

Homeless youth are a population at a high risk for suicidal behavior. A previous exploratory study emphasized the importance of feeling trapped or helpless, which appeared to mediate the impact of other risk variables. Confirmatory work was needed to test this inductively derived model. Two hundred eight homeless youths completed surveys on the streets and in agencies in New York City and Toronto. Structural equation modeling was used to test a theoretical model developed from exploratory work, and regression analyses were used to examine the influence of home and street contextual variables. The centrality of the trapped experience in a model incorporating drug use and dependence, abusive family history, loneliness, low self-esteem, and suicidality was confirmed. Other findings included a marked reduction in reported suicidal behavior following participants' leaving home, with family violence, being thrown out of the home, neglect, poor physical health, and having suicidal friends showing strong relationships with suicidality.

Kidd SA; Miner S; Walker D; Davidson L. Stories of working with homeless youth: On being "mind-boggling". Children and Youth Services Review 29(1): 16-34, 2007. (31 refs.)

This study examines the narratives of 15 youth workers on their experiences with service provision for homeless and street-involved youth. Workers discussed a need to have a versatile approach which can be tailored to an individual youth's circumstances. Establishing a connection based upon valuing, respecting, and liking a youth allows for the development of a trusting relationship which is essential for effective interventions. Also addressed was the social context of this work including relationships among staff, agency structure, and the impact of the stigmatization of homelessness. Lastly, the process of becoming an effective worker was addressed, including the establishment of clear boundaries, recognizing the rewarding aspects of the work, and avoiding burnout.

Kipke MD; Montgomery SB; Simon TR; Iverson EF. "Substance abuse" disorders among runaway and homeless youth. Substance Use & Misuse 32(7/8): 969-986, 1997. (18 refs.)

This study used systematic sampling methods to recruit a sample of 432 homeless youth from both service and natural "hang-out" sampling sites. According to DSM-III criteria, the majority of respondents were classified as having an alcohol and/or illicit "drug abuse" disorder (71%). The results from multivariate logistic regression analyses indicate that cumulative length of time homeless is positively associated with risk for an "abuse" disorder. The implications of these findings and recommendations for service interventions are discussed.

Kipke MD; Weiss G; Wong CF. Residential status as a risk factor for drug use and HIV risk among young men who have sex with men. AIDS and Behavior 11(6, Supplement S): S56-S69, 2007. (63 refs.)

There is growing behavioral and epidemiological evidence to suggest that young men who have sex with men (YMSM) are at high risk for becoming HIV-infected. Unfortunately, relatively little research has been conducted to examine the range of individual, social, and community-level factors that put these young men at increased risk. To address existing gaps in the literature, the Healthy Young Men's (HYM) Study was launched in Los Angeles to examine the range of factors associated with HIV risk and protective behaviors within an ethnically diverse sample of 526 YMSM recruited using a venue-based stratified probability sampling design. In this paper we present findings that demonstrate that YMSM who experience residential instability, who have been forced to leave their home because of their sexuality, and/or who are precariously housed are at significantly greater risk for drug use and involvement in HIV risk-related behaviors.

Klee H; Reid P. Drugs and youth homelessness: Reducing the risk. Drugs: Education, Prevention and Policy 5(3): 269-280, 1998. (32 refs.)

The increase in youth homelessness in the UK and also internationally, although a cause for public concern, is proving resistant to efforts to contain it. Perhaps all association with drug misuse is one of the most serious social consequences of this trend, threatening the health of many young people with long-lasting effects. The family history and the current privations of the lives of 200 young, homeless drug users in Greater Manchester were studied in depth. The primary aim was to reveal the nature and range of coping responses to the hazards they faced. A major way of coping was through self-medication with drugs. The young and newly homeless, if not using drugs already, were likely to be absorbed into a drug-oriented community. If they were, like many young people, using drugs recreationally, then their involvement was likely to increase. Older, long-term users were using more drugs and using them more frequently. Possible interventions ale discussed that recognize the heterogeneity of the homeless population and the complexity of their needs, taking into account personal history and current levels of support.

Kral AH; Molnar BE; Booth RE; Watters JK. Prevalence of sexual risk behaviour and substance use among runaway and homeless adolescents in San Francisco, Denver and New York City. International Journal of STD & AIDS 8(2): 109-117, 1997. (57 refs.)

We aim to assess the prevalence of HIV sexual risk behaviours and substance use among runaway and homeless adolescents in San Francisco, Denver and New York City. Survey data were examined from 775 runaway and homeless adolescents recruited from street settings and youth agencies during 1992/1993. Nearly all (98%) reported having engaged in sexual intercourse, of whom 49% first had intercourse by the age of Condom use during all vaginal intercourse in the previous months was reported by 42%. Among males, 23% indicated that they had exchanged sex fog money, as did 14% of the females. Ninety-seven per cent had used alcohol or drugs and 21% had injected drugs. Overall, 75% reported having had sex while under the influence of alcohol or drugs. Systematic epidemiological studies of this population and the development of innovative interventions are essential to reduce the threat of HIV among runaway and homeless youth.

Martijn C; Sharpe L. Pathways to youth homelessness. Social Science & Medicine 62(1): 1-12, 2006. (33 refs.)

Research documents high levels of psychopathology among homeless youth. Most research, however, has not distinguished between disorders that are present prior to homelessness and those that develop following homelessness. Hence whether psychological disorders are the cause or consequence of homelessness has not been established. The aim of this study is to investigate causal pathways to homelessness amongst currently homeless youth in Australia. The study uses a quasi-qualitative methodology to generate hypotheses for larger-scale research. High rates of psychological disorders were confirmed in the sample 35 homeless youth aged 14-25. The rates of psychological disorders at the point of homelessness were greater than in normative samples, but the rates of clinical disorder increased further once homeless. Further in-depth analyses were conducted to identify the temporal sequence for each individual with a view to establishing a set of causal pathways to homelessness and trajectories following homelessness that characterised the people in the sample. Five pathways to homelessness and five trajectories following homelessness were identified that accounted for the entire sample. Each pathway constituted a series of interactions between different factors similar to that described by Craig and Hodson (1998. Psychologyogical Medicine, 28, 1379-1388) as "complex subsidiary pathways". The major findings were that (1) trauma is a common experience amongst homeless youth prior to homelessness and figured in the causal pathways to homelessness for over half of the sample; (2) once homeless, for the majority of youth there is an increase in the number of psychological diagnoses including drug and alcohol diagnoses, and (3) crime did not precede homelessness for all but one youth; however, following homelessness, involvement in criminal activity was common and became a distinguishing factor amongst youth. The implications of these findings for future research and service development are discussed.

Martinez TE; Gleghorn A; Marx R; Clements K; Boman M; Katz MH. Psychosocial histories, social environment, and HIV risk behaviors of injection and noninjection drug using homeless youths. Journal of Psychoactive Drugs 30(1): 1-10, 1998. (48 refs.)

Injection drug use is a common risk behavior for HIV infection among homeless, runaway and street youths. However, the psychosocial histories and current social environment of these youths are not well understood. The authors recruited 186 homeless, runaway and street youths using systematic street-based sampling methods, and assessed psychosocial histories, current daily activities, and sexual and drug-related risk behaviors using qualitative and quantitative techniques. Youths reported high lifetime rates of injection drug use (45%), recent drug and alcohol use (100%), and current homelessness (84%). Injection drug using youths were more likely than noninjection drug using youths to report traumatic psychosocial histories, including parental substance use and forced institutionalization, use of alcohol and other noninjection drugs, a history of survival sex, and the use of squats or abandoned buildings as shelter. These findings underscore the need for multifaceted service and prevention programs to address the varied needs of these high-risk youths.

McKenzie M; Tulsky JP; Long HL; Chesney M; Moss A. Tracking and follow-up of marginalized populations: A review. Journal of Health Care for the Poor and Underserved 10(4): 409-429, 1999. (44 refs.)

Maintaining study cohorts is a key element of longitudinal research. Participant attrition introduces the possibility of bias and limits the generalizability of a study's findings, but with appropriate planning it is possible to sustain contact with even the most transient participants. This paper reviews the essential elements of tracking and follow-up of marginalized populations, which are (1) collection of contact information, (2) thorough organization of tracking efforts, (3) attention to staff training and support, (4) use of phone and mail follow-up, (5) use of incentives, (6) establishing rapport with participants, (7) assurance of confidentiality, (8) use of agency tracking, (9) use of field tracking, and (10) attention to safety concerns. Diligent application of these tracking strategies allows researchers to achieve follow-up rates of 75 percent to 97 percent with vulnerable populations such as homeless, mentally ill adults, injection drug users, and runaway youth.

McMorris BJ; Tyler KA; Whitbeck LB; Hoyt DR. Familial and "on-the-street" risk factors associated with alcohol use among homeless and runaway adolescents. Journal of Studies on Alcohol 63(1): 34-43, 2002. (69 refs.)

Objective: This study investigated factors associated with alcohol use among homeless and runaway adolescents, using a risk- amplification model. Method: Homeless and runaway adolescents (N = 536, 60% female) were recruited and interviewed by outreach workers directly on the streets, in shelters and in drop-in centers in four Midwestern states. The average age was 16 years; ages ranged from 12 to 22. Results: Parent alcohol problems were indirectly linked to adolescent drinking through familial abuse and its relationship to deviant peers, time on own and risky subsistence behaviors. Parent alcohol problems also predicted offspring alcohol use through parental rejection and its association with deviant peers and with risky subsistence behaviors. The strongest direct effects on alcohol use were hanging out with antisocial friends and participating in deviant behaviors in order to survive on the street. Conclusions: This study sheds light on the nature of alcohol use in a high-risk population, Family background and "on-the-street" (time on own) factors must be taken into consideration when treating alcohol misuse in street youth. The alternative is a vicious cycle whereby homeless youth may become homeless adults.

Noto AR; Nappo SA; Galduroz JC F; Mattei R; Carlini EA. Use of drugs among street children in Brazil. Journal of Psychoactive Drugs 29(2): 185-192, 1997. (33 refs.)

The purpose of this study has been to assess drug consumption among children in five Brazilian state capitals during 1993. The sample was composed of street children who were given assistance in institutions, and data was collected by means of anonymous individual interviews. Five hundred sixty five boys and girls were interviewed: 74.3% reported having used drugs (not including alcohol and tobacco) at least once in their life. Solvents, followed by marijuana, were the most cited drugs. important regional differences were observed concerning other drugs. Consumption of cocaine, including crack, seems restricted to the southeast region, whereas psychotropic medication was consumed more in the northeast of the country. Drug initiation among these children seems to be a consequence of street life and is part of their group lifestyle.

Nyamathi AM; Christiani A; Windokun F; Jones T; Strehlow A; Shoptaw S. Hepatitis C virus infection, substance use and mental illness among homeless youth: A review. AIDS 19(Supplement 3): S34-S40, 2005. (51 refs.)

Objectives: Homeless youth are at a high risk of substance abuse, mental illness and blood-borne infections, such as hepatitis C. In this paper, we review the implications of these conditions, discuss the unique challenges faced by homeless youth, and explore potential strategies for harm reduction and intervention in this vulnerable population. Results: Interventions that combine youth-centered, service-based care, street out-reach, case management, and motivational interviewing with integrated health services such as hepatitis A/B vaccination, and mental health and substance abuse programmes, are presented as innovative approaches to address the healthcare needs of homeless youth. Conclusion: Recommendations for age-appropriate interventions and further research are made.

Ogel K; Taner S; Tosun M; Liman O; Demir T. Juvenile offences among hospitalized adolescent inhalant users in Istanbul: A comparison regarding place of residence. Journal of Psychoactive Drugs 38(3): 297-304, 2006. (41 refs.)

In this research, juvenile offenses and associated behaviors among adolescent inhalant users in Istanbul were investigated and inhalant users living in the street were compared to inhalant users living with their families. An interview questionnaire developed by the researchers was administered to 200 male adolescent inhalant users who were hospitalized during 2002-2003. More than half of the sample had committed juvenile offenses at least once in their lifetime, 16.3% had entered a house of corrections, 91.5% had friends who committed juvenile offenses, and the majority had been taken to a police station at least once in their lifetime. The rates for juvenile offenses, being taken to the police station, committing crimes to obtain money to buy drugs, and obtaining income through illegal activities were higher among adolescents living in the street than adolescents living with their families. Although the juvenile offense rate was higher among adolescents living in the street, it can be suggested that both groups live in subcultures that have a tendency towards crime, and inhalant use is part of these subcultures. Juvenile offense interventions can be useful for all inhalant users.

Olley BO. Social and health behaviors in youth of the streets of Ibadan, Nigeria. Child Abuse and Neglect 30(3): 271-282, 2006. (31 refs.)

Objectives: This study documents the extent and impact of perceived patterns of behavior in a sample of youths of the streets of Ibadan, Nigeria, with the purpose of implementing a Life Skills Educational (LSE) intervention. Method: The study uses both qualitative and quantitative methods of data collection. Qualitatively, two Focus Group Discussions (FGD) and two in-depth interviews (IDI) with 20 boys and 2 community leaders were conducted on separate occasions for the purpose of eliciting commonly exhibited behaviors and patterns of street youth. Quantitatively, 169 youths (89.3% male) were consecutively interviewed from five subcultural areas in Ibadan, Nigeria. Street youths were accessed through a snowballing technique made possible by "Area boys" (AB, adults, who serve as a symbol of authority for street children). Results: The mean age of participants was 18.4 years. The majority was on the street for financial reasons, had been on the street for more than 1 year, and had not completed their primary schooling. While youths of the street were economically viable, 69% had a history of alcohol abuse, 14% of drug abuse, and 24% operated as drug couriers; 46% reported school refusal, 27% school suspension, and 47% school truancy. Forty-nine percent admitted to being sex workers and 11% had been raped and were, therefore, at risk of contacting sexually transmitted diseases (STD). One-third of youths had been arrested for various offenses, including street fighting and drug use. While females were in the minority, they were more likely to engage in antisocial behaviors compared with boys. Conclusions: Although many youths of the street display antisocial behaviors, they also are an economically viable group. Some of their antisocial behaviors may have been exhibited within the context of economic survival. Implementing a life skill program to address these antisocial behaviors may help to increase the well being of street youths in developing countries in Africa.

Paradise MJ; Cauce AM. Substance use and delinquency during adolescence: A prospective look at an at-risk sample. Substance Use & Misuse 38(3/6): 701-723, 2003. (43 refs.)

This paper focuses on the relationship between adolescent substance use and delinquent behavior in a sample of homeless young people. Confirmatory factor analyses indicated that delinquency and substance use are best described as discrete factors, and competing theoretical models of the longitudinal association between these two factors were examined using structural equations modeling techniques. The results suggest that delinquent behavior is associated with changes in alcohol, marijuana, and drug use across time. This effect was statistically significant over relatively brief lags in time of six months or less. Combined with previous results, these findings challenge the utility of single-factor explanations of adolescent deviance for at-risk populations and suggest that the relationship between substance use and externalizing across time may be more dynamic than previously thought. Implications for intervention are also discussed.

Park S; Kim HS; Kim H; Sung KT. Exploration of the prevalence and correlates of substance use among sheltered adolescents in South Korea. Adolescence 42(167): 603-616, 2007. (38 refs.)

Substance use among sheltered adolescents is very serious in South Korea-a nation in the process of rapid industrialization and urbanization. However, few studies have investigated substance use among the adolescents which is a growing concern of the changing society of this nation. This study examined the prevalence of substance use and explored risk factors that predict substance abuse by sheltered adolescents. Through a questionnaire survey of sheltered adolescents, data on substance use and the risk factors were collected. The sample of the adolescents included 44 (33.3%) males and 88 (67.2%) females; their mean age was 15.8 years (SD = 1.62). The results of a logistic regression analysis showed that alcohol expectancy, physical abuse, and peer pressure were all statistically significantly associated with substance abuse. Findings on the critical issues are expected to lead to the development of urgently needed prevention programs for the high-risk adolescents in South Korea.

Parks RW; Stevens RJ; Spence SA. A systematic review of cognition in homeless children and adolescents. (review). Journal of the Royal Society of Medicine 100(1): 46-50, 2007. (33 refs.)

Objectives: The cognitive function of homeless children and adolescents may be overlooked, albeit understandably, when societal interventions focus on their immediate housing needs. Nevertheless, homelessness might be hypothesized to carry many risks for the developing mind and brain. We wanted to discover whether this hypothesis had been tested previously. Design: A systematic review to examine whether cognitive impairments were reported in homeless children and adolescents. Setting: Objective, systematic review of standard databases, examined by key word searches. Participants: Children and adolescents. Main outcome measures: Formal assessments of cognition. Results: We found that in spite of there being many homeless children in the world, fewer than 2000 have been assessed cognitively and reported in the literature. Yet when compared with those who are domiciled, these children tend to have lower intellectual functioning and decreased academic achievement. Furthermore, adolescents evince cognitive impairments in the contexts of drug, physical, and sexual abuse. Conclusions: We suggest that cognitive and mental health screening be incorporated into those intervention programs deployed to facilitate societal reintegration of homeless children and adolescents.

Peterson PL; Baer JS; Wells EA; Ginzler JA; Garrett SB. Short-term effects of a brief motivational intervention to reduce alcohol and drug risk among homeless adolescents. Psychology of Addictive Behaviors 20(3): 254-264, 2006. (58 refs.)

The short-term results of a randomized trial testing a brief feedback and motivational intervention for substance use among homeless adolescents are presented. Homeless adolescents ages 14-19 (N = 285) recruited from drop-in centers at agencies and from street intercept were randomly assigned to either a brief motivational enhancement (ME) group or I of 2 control groups. The I-session motivational intervention presented personal feedback about patterns of risks related to alcohol or substance use in a style consistent with motivational interviewing. Follow-up interviews were conducted at I and 3 months postintervention. Youths who received the motivational intervention reported reduced illicit drug use other than marijuana at I-month follow-up compared with youths in the control groups. Treatment effects were not found with respect to alcohol or marijuana. Post hoc analyses within the ME group suggested that those who were rated as more engaged and more likely to benefit showed greater drug use reduction than did those rated as less engaged. Limitations of the study are discussed as are implications for development of future substance use interventions for this high-risk group.

Pollio DE; Thompson SJ; Tobias L; Reid D; Spitznagel E. Longitudinal outcomes for youth receiving runaway/homeless shelter services. Journal of Youth and Adolescence 35(5): 859-866, 2006. (33 refs.)

This research examined outcomes and use of specific types of services 6 weeks, 3 and 6 months post-discharge for a large sample of runaway/homeless youth using crisis shelter services. Data were collected for 371 runaway/homeless youth using emergency shelter and crisis services at eleven agencies across a four-state midwestern region. Outcomes were assessed for runaway behavior, family relationships, substance use, school behavior, employment, sexual behavior, and self-esteem. Additionally, the impact of services on outcomes was assessed. Findings indicated that although youth achieved a wide variety of positive outcomes 6 weeks post-discharge, there were signs of attenuation of certain outcomes by the 6 month follow-up. Service use after discharge did not demonstrate a strong impact on maintaining outcomes. The substantive findings reported here present encouraging evidence for providers of services for runaway/homeless youth. Crisis shelter services appear to facilitate broad-based short-term gains, but do not appear sufficient to maintain these gains over an extended period.

Rassool GH; Kilpatrick B. Working with diverse populations. IN: Rassool GH, ed. Substance Use and Misuse: Nature, Context and Clinical Interventions. London: Blackwell Science, 1998. pp. 236-248. (53 refs.)

This chapter, in a textbook for nurses, in a very brief fashion considers the needs of diverse populations, those whose needs are under-represented or are poorly served by traditional programs. The groups discussed include ethnic minorities, the young, the elderly and the homeless. The epidemiology for each group is outlines along with the appropriate nursing response.

Reid P; Klee H. Young homeless drug users: Ways of coping with harassment. Journal of Community & Applied Social Psychology 10(1): 69-75, 2000. (22 refs.)

This paper explores young homeless drug users' ways of coping with harassment. Discussions of coping and harassment are based on the cognitive appraisal model. Coping accounts were essentially problem- focused and action-oriented. Results indicate the need for more policy developments to prevent homelessness and for specific interventions around homelessness and harassment.

Reid P; Klee H. Young homeless people and service provision. Health & Social Care in the Community 7(1): 17-24, 1999. (22 refs.)

This paper focuses on access to services, and views of service provision amongst young homeless people aged 14-25 years. Two hundred young homeless people were interviewed in locations throughout Greater Manchester, the majority in towns surrounding the city of Manchester. A semistructured interview schedule was used with interviews being taped and transcribed to provide additional qualitative data. The operational definition of homelessness included not only those who were roofless, but also those residing in hostels, bed and breakfast accommodation, or staying temporarily with friends. Topics examined include: access to services such as housing, health, advice and information; appraisal of service provision; confidence in securing help; and the use of both formal and informal support services. Results show that the provision and use of services for young homeless people varies widely across the county, with the majority of services being concentrated in the city of Manchester. Respondents made good use of certain services such as streetwork agencies, but exhibited a lack of confidence in securing help with the most basic needs, such as food. A desire to avoid being labelled as 'homeless' appeared to make some people unwilling to make use of non-statutory agencies specifically for homeless people. Overall, respondents found particular difficulties in accessing help from statutory services, such as housing and health. Findings point to the necessity of providing adequately resourced services which reach out to young homeless people.

Rice E; Milburn NG; Rotherram-Borus MJ; Mallett S; Rosenthal D. The effects of peer group network properties on drug use among homeless youth. American Behavioral Scientist 48(8): 1102-1123, 2005. (41 refs.)

The authors examine how the properties of peer networks affect amphetamine, cocaine, and injection drug use over 3 months among newly homeless adolescents, aged 12 to 20 in Los Angeles (n = 217; 83% retention at 3 months) and Melbourne (n = 119; 72% retention at 3 months). Several hypotheses regarding the effects of social network properties on the peer influence process are developed. Multivariate logistic regression analyses show that higher concentrations of homeless peers in networks at recruitment were associated with increased likelihood of amphetamine and cocaine use at 3-month follow-up. Higher concentrations of injecting peers were associated with increased risk of injection drug use 3 months later Change in network structure over time toward increased concentrations of homeless peers was associated with increased risk of cocaine use and injecting. Higher density networks at baseline were positively associated with increased likelihood of cocaine and amphetamine use at 3 months.

Rosenthal D; Mallett S; Myers P. Why do homeless young people leave home? Australian and New Zealand Journal of Public Health 30(3): 281-285, 2006. (25 refs.)

Objective: To describe the reasons homeless young people leave home and differences between males and females. Methods: Homeless young people between the ages of 12 and 20 years (n=692) completed surveys conducted by trained interviewers using Questionnaire Delivery System on laptop computers as part of a large study. Participants indicated the importance of each of 22 reasons for leaving home on a four-point scale, from 'not important' (1) to 'very important' (4). Results: Conflict with parents was the only reason reported as important by at least two-thirds of respondents. Desire for independence and/or adventure was rated as important by nearly one-half of young men and women. Eighteen reasons were rated as 'not or somewhat important' by most young people. These included issues associated with school, sexuality, sexual abuse and trouble with the law. Young women were more likely than young men to report that sexual abuse, anxiety/depression, and/or pregnancy were important reasons for leaving home. The converse held for personal alcohol and drug abuse, trouble with the police, and breach of community order or parole. With few exceptions, importance ratings of the 22 reasons were not highly correlated. Conclusions and Implications: Service providers should consider how the diverse elements of family environment contribute to homelessness. A focus on familial problems may lead to other important reasons being overlooked, namely a desire for independence and adventure. Services and supports need to take into account whether young people leave home because of a life crisis or because they seek independence.

Roy E; Haley N; Leclerc P; Lemire N; Boivin JF; Frappier JY. Prevalence of HIV infection and risk behaviours among Montreal street youth. International Journal of STD & AIDS 11(4): 241-247, 2000. (17 refs.)

We aim to estimate HIV prevalence and associated risk factors among street youth in Montreal, Canada. We conducted a one-year cross- sectional anonymous study in 1995. We recruited youth aged 13-25 years meeting specific criteria for itinerancy through the 20 major Montreal street youth agencies. Participation included a structured interview and provision of an oral specimen for HIV testing. Among the 909 subjects studied, 99.3% had been sexually active, 25.9% had exchanged sex for money, gifts, drugs, a place to sleep, or other things; 31.8% reported anal sex; and 36.4% reported having ever injected drugs. Overall, HIV prevalence was 1.9% (1.1% in girls and 2.2% in boys). Multivariate logistic regression showed that being over 20 years of age (adjusted odds ratio (AOR) 7.09), having injected drugs (AOR 4.48), having engaged in prostitution (AOR 3.32), and being born outside Canada (AOR 4.41) were all independently associated with HIV infection.

Roy E; Haley N; Leclerc P; Sochanski B; Boudreau JF; Boivin JF. Mortality in a cohort of street youth in Montreal. Journal of the American Medical Association 292(5): 569-574, 2004. (41 refs.)

Context: Many studies have shown a high prevalence of sexually transmitted diseases, human immunodeficiency virus (HIV) infection, viral hepatitis, drug dependence, and mental health problems among street youth. However, data on mortality among these youth are sparse. Objectives: To estimate mortality rate among street youth in Montreal and to identify causes of death and factors increasing the risk of death. Design, Setting, and Population: From January 1995 to September 2000, 1013 street youth 14 to 25 years of age were recruited in a prospective cohort with semiannual follow-ups. Original study objectives were to determine the incidence and risk factors for HIV infection in that population; however, several participants died during the first months of follow-up, prompting investigators to add mortality to the study objectives. Mortality data were obtained from the coroner's office and the Institute de la Statistic du Quebec. Main Outcome Measures: Mortality rate among participants and factors increasing the risk of death. Results: Twenty-six youth died during follow-up for a mortality rate of 921 per 100000 person-years (95% confidence interval [CI], 602-1350); this represented a standardized mortality ratio of 11.4. The observed causes of death were as follows: suicide (13), overdose (8), unintentional injury (2), fulminant hepatitis A (1), heart disease (1); 1 was unidentified. In multivariate Cox regression analyses, HIV infection (adjusted hazard ratio [AHR]=5.6; 95% Cl, 1.9-16.8), daily alcohol use in the last month (AHR=3.2; 95% Cl, 1.3-7.7), homelessness in the last 6 months (AHR=3.0; 95% Cl, 1.1-7.6), drug injection in the last 6 months (AHR=2.7; 95% Cl, 1.2-6.2), and male sex (AHR=2.6; 95% Cl, 0.9-7.7) were identified as independent predictors of mortality. Conclusions: Current heavy substance use and homelessness were factors associated with death among street youth. HIV infection was also identified as an important predictor of mortality; however, its role remains to be clarified. These findings should be taken into account when developing interventions to prevent mortality among street youth.

Roy S; Lemire N; Haley N; Boivin JF; Frappier JY; Claessens C. Injection drug use among street youth: A dynamic process. Canadian Journal of Public Health 89(4): 239-240, 1998. (6 refs.)

In 1995, we conducted a one-year cross-sectional anonymous study to estimate HIV prevalence and associated risk factors among street youth in Montreal. A total of 919 participant's aged 13 to 25 years were recruited with the collaboration of 20 street youth agencies. An HIV prevalence rate of 1.85% (95% CI 1.12-2.89) was found, which was 3.7 times higher than the rate estimated for the general Montreal population. Injection drug use was one of the risk factors associated with infection. In fact, 36% of street youth had ever injected drugs and 23% had injected in the previous six months. These rates represent the highest rates of injection drug use ever reported among street youth in the literature. These disturbing findings prompted to develop a prospective cohort study in which we monitor the evolution of drug-related behaviors among street youth.

Shultz JM; Garcia LM; Greer PJ. HIV surveillance of drug abuse and sexual risk behaviors among homeless persons in Miami-Dade County, Florida. IN: Community Epidemiology Work Group, eds. Epidemiologic Trends in Drug Abuse. Volume II: Proceedings. December 1998. Bethesda MD: National Institute on Drug Abuse, 1999. pp. 425-431. (6 refs.)

Homeless persons are at high risk for infection with HIV. Among 16 sites participating in a nationwide HIV seroprevalence survey of homeless adults and runaway youth, clients of the Miami clinic had the highest rate of HIV infection (15.9%) -- twice as high as the second ranking clinic. This reports provides the demographic characteristics of the homeless population, risk behaviors, time trends. A significant and broadly generalizable decline in HIV rates was observed, overall seroprevalence declining steadily from 23.2% to 7.2%; this was true for all risk groups. During this period there was concerted efforts by the police to destroy homeless sites and move individuals into either shelters or jails. Also, the clientele of the clinics changed with shift to lower risk subsets of clients.

Public Domain

Slesnick N. Variables associated with therapy attendance in runaway substance abusing youth: Preliminary findings. American Journal of Family Therapy 29(5): 411-420, 2001. (29 refs.)

Service providers and researchers note that youth with substance abuse problems are difficult to engage in treatment and, when engaged, often drop out early. Estimates of the alcohol and drug abuse rate of runaway youth range from 70% to 95%. This study evaluated predictors of therapy attendance in a sample of substance abusing youth recruited through two southwestern runaway shelters. Runaway youth and their families (N = 36) were engaged into a 15- session ecologically-based family therapy (EBFT) intervention. Fewer days between the pretreatment assessment and the first therapy session, as well as less perceived parental care, predicted more therapy sessions attended. No relationship was found between level of substance use and treatment attendance. The findings highlight the importance of engaging families in therapy soon after the youth's arrival to the shelter, as treatment motivation may decrease as the crisis lessens.

Slesnick N; Kang MJ; Bonomi AE; Prestopnik JL. Six- and twelve-month outcomes among homeless youth accessing therapy and case management services through an urban drop-in center. Health Services Research 43(1, Part 1): 211-229, 2008. (37 refs.)

Research Objective. To evaluate the impact of case management and individual therapy offered through a drop-in center for homeless youth on substance use, mental health, housing, education, employment, and medical care utilization. Study Population. All youth (n=172) between the ages of 14-24 who accessed treatment services through an urban, southwestern drop-in center were included. Data Source. Semistructured and self-report questionnaires were administered to youth between October 2002 and April 2005. Study Design. A repeated measures design was utilized. Youth were assessed at baseline, 6 months, and 12 months postbaseline. Hierarchical linear modeling was used to test the hypotheses. Principal Findings. Statistically significant improvements were found in substance abuse, mental health, and percent days housed up to 12 months postbaseline. Decreased alcohol and drug use was associated with an increase in housing. However, most youth did not acquire permanent housing, and education, employment, and medical service utilization did not significantly change over time. Conclusions. While treatment offered through drop-in centers for homeless youth can positively impact homeless youth, policy, funding, and service provision need greater focus, collaboration, and support if youth homelessness is to be successfully addressed.

Slesnick N; Meade M. System youth: A subgroup of substance-abusing homeless adolescents. Journal of Substance Abuse 13(3): 367-384, 2001. (78 refs.)

Purpose: While many youths residing at homeless shelters will return home, many are placed in group or foster homes. Few researchers have examined the experiences of adolescents with a history of these out-of-home placements. This study examined shelter residents and compared the experiences of system and non-system youth. Methods: Information regarding youths' family functioning, substance use, depression and related problem behaviors was obtained from substance abusing system (n = 62) and non-system (n = 82) adolescents staying at local runaway shelters. Results: System males engaged in significantly more delinquent behaviors than did non-system males and system females. Alcohol and drug problem consequences were positively associated with longevity in the system, while having ever attempted suicide was negatively associated with system longevity. System youth reported: 1) taking more prescribed psychotropic medications 2) experiencing more sexual abuse, and 3) less parental overprotection, as compared to non-system youth. Gender differences were found in which females reported more conflictual problem solving interactions with their parents than did males, as well as more comorbid diagnoses. Implications: Although longitudinal research is needed, findings argue that without intervention efforts targeted at identified problem behaviors, youth are at risk to continue their system involvement into adulthood.

Slesnick N; Meyers RJ; Meade M; Segelken DH. Bleak and hopeless no more: Engagement of reluctant substance-abusing runaway youth and their families. Journal of Substance Abuse Treatment 19(3): 215-222, 2000. (52 refs.)

Runaway/homeless shelters document high levels of substance abuse among runaway youth, at least double that of school youth. These youth present a constellation of problems and research suggests that this population may be unique in the range and intensity of associated problems. Most studies to date have collected self-report data on these youth; virtually no research has examined treatment effectiveness with the population. Given the void of treatment outcome research with these youths, there is need for identifying potent interventions. Given that issues of engagement and retention must assume prominence in the development of new treatments, this article presents a family-based treatment engagement strategy successfully employed with a sample of substance-abusing youth staying in a southwestern shelter. Youth and primary caretakers are engaged separately by the therapist utilizing motivating factors appropriate to context of the families' lives and to the developmental position of the client.

Slesnick N; Prestopnik JL; Meyers RJ; Glassman M. Treatment outcome for street-living, homeless youth. Addictive Behaviors 32(6): 1237-1251, 2007. (34 refs.)

Comprehensive intervention for homeless, street living youth that addresses substance use, social stability, physical and mental health issues has received very little attention. In this study, street living youth aged 14-22 were recruited from a drop-in center and randomly assigned to the Community Reinforcement Approach (CRA) or treatment as usual (TAU) through a drop-in center. Findings showed that youth assigned to CRA, compared to TAU, reported significantly reduced substance use (37% vs. 17% reduction), depression (40% vs. 23%) and increased social stability (58% vs. 13%). Youth in both conditions improved in many other behavioral domains including substance use, internalizing and externalizing problems, and emotion and task oriented coping. This study indicates that homeless youth can be engaged into treatment and respond favorably to intervention efforts. However, more treatment development research is needed to address the barriers associated with serving these youth.

Smyth BP; O'Brien M. Children attending addiction treatment services in Dublin, 1990-1999. European Addiction Research 10(2): 68-74, 2004. (18 refs.)

In Europe, adolescent substance misuse increased during the 1990s. Ireland has among the highest rates of substance misuse among schoolchildren in Europe. We sought to describe the socio-demographic and drug misuse profile of children presenting to addiction treatment services in Dublin during the 1990s. Of the 9,874 individuals who sought addiction treatment, 1,953 (20%) were aged less than 18 years. There was a sharp increase in the number of children after 1993. The main drug of abuse was an opiate in 48% of cases. Compared to adults, the children were more likely to be female and less likely to inject. As the decade progressed the proportion of girls increased, injecting was reported more frequently and there was a dramatic rise in heroin misuse. Child heroin users were more likely to be female and to be homeless compared to their adult counterparts. This study highlights the need for a dedicated service for child drug users in Dublin.

Solorio MR; Milburn NG; Andersen RM; Trifskin S; Rodriguez MA. Emotional distress and mental health service use among urban homeless adolescents. Journal of Behavioral Health Services & Research 33(4): 381-393, 2006. (22 refs.)

The Expanded Behavioral Model for Vulnerable Populations was used to examine the predisposing, enabling, and need factors associated with mental health service use in a homeless adolescent sample (N=688). Among all youth, 32% perceived a need for help with mental health problems and 15% met Brief-Symptom Inventory (BSI) criteria for emotional distress. The rate of mental health service use in our sample was 32%. One enabling factor, having a case manager/discussed mental health concerns, and one need factor, which met criteria for BSI, were found to be associated with mental health service use in the past 3 months. The majority of youth who used mental health services had obtained services from crisis centers. Among those who perceived a need for help with mental health problems but who did not use services, the most common barrier was not knowing where to go or what service to use (57%). These findings suggest that due to the high prevalence of mental health problems among homeless youth, it would be helpful for service providers coming into contact with youth to make them aware of existing community resources for mental health services; making youth aware of these resources may in turn decrease the rate of crisis center use and instead allow youth to receive mental health services in outpatient settings that provide continuity of care.

Taylor-Seehafer M; Jacobvitz D; Steiker LH. Patterns of attachment organization, social connectedness, and substance use in a sample of older homeless adolescents - Preliminary findings. Family & Community Health 31(1, Supplement S): S81-S88, 2008. (46 refs.)

Social researchers continue to strive to understand the development and social decision-making processes of homeless adolescents. While it has been established that attachment is a salient factor with regard to childhood maltreatment and later psychosocial problems, there is a dearth of information on how homeless youths' thoughts and feelings about attachment may also be linked to behavioral risks including alcohol and substance use. This exploratory study examines older homeless adolescent's perspectives on attachment, trauma, and substance use via the semistructured Adult Attachment Interview and survey data. The findings illuminate the relationship between these factors and implications for future research and work with this population.

Thiesen FV; Barros HMT. Measuring inhalant abuse among homeless youth in southern Brazil. Journal of Psychoactive Drugs 36(2): 201-205, 2004. (24 refs.)

In order to measure urinary level of hippuric acid among Brazilian homeless youth suspected of having inhaled toluene in previous hours, urine samples were voluntarily collected from the youth around two hours after they arrived at an "open-school" in Porto Alegre, Brazil. Hippuric acid levels were determined by gas chromatography in urine specimens of 50 homeless children and adolescents. In 86% of the urine specimens, hippuric acid levels were within the range of 3.6 g/g creatinine and 46.1 g/g creatinine. Very high urinary hippuric acid level may indicate voluntary toluene abuse. A cut-off urinary hippuric acid level value needs to be established for toluene self-exposure diagnosis.

Thompson SJ. Risk/protective factors associated with substance use among runaway/homeless youth utilizing emergency shelter services nationwide. Substance Abuse 25(3): 13 -26, 2004

Rates of alcohol, tobacco, and marijuana use among runaway/homeless youth are substantially higher than found among American high school students. To understand the risk and protective factors associated with substance use, this study (1) assessed cigarette, alcohol, and marijuana use among a national sample of runaway/homeless youth, (2) identified risk/protective factors associated with lifetime substance use, and (3) examined risk/protective factors associated with six month frequency of substance use. Unduplicated cases (n = 11,841) from the 1997 Runaway/Homeless Youth Management Information System (RHY MIS) were analyzed. Results showed that substance use levels are greater than previously reported for this population. Predictors of cigarette, alcohol, and marijuana use and frequency were predominately individual youth risk factors and demographics rather than family risk factors. Providers in emergency youth shelters are in a prime position to assess substance use behaviors, as well as the associated risk factors. Provision of appropriate screening and referral to other services is essential to meet the needs of these youth.

Tyler KA. A qualitative study of early family histories and transitions of homeless youth. Journal of Interpersonal Violence 21(10): 1385-1393, 2006. (17 refs.)

Using intensive qualitative interviews with 40 homeless youth, this study examined their early family histories for abuse, neglect, and other family problems and the number and types of transitions that youth experienced. Multiple forms of child maltreatment, family alcoholism, drug use, and criminal activity characterized early family histories of many youth. Leaving home because of either running away or being removed by child protective services often resulted in multiple transitions, which regularly included moving from foster care homes to a group home, back to their parents, and then again returning to the streets. Although having experienced family disorganization set youth on trajectories for early independence, there were many unique paths that youth traveled prior to ending up on the streets.

Tyler KA; Johnson KA. Pathways in and out of substance use among homeless-emerging adults. Journal of Adolescent Research 21(2): 133-157, 2006. (30 refs.)

Although high rates of alcohol and drug use have been found among homeless young people, less is known about who is responsible for their initiation, the reasons for their continued use, and why some individuals eventually transition out of using whereas others do not. Based on qualitative interviews with 40 homeless individuals 19 to 21 years of age in the Midwest, results revealed that the majority of respondents were initiated into substance use by friends and acquaintances, although family also played a significant role. Almost one half of respondents reported using substances to cope with early family abuse, stress, and life on the streets. Additionally, the majority indicated that they had no intentions of quitting. Substance misuse that is left untreated may lead to chemical dependency among homeless emerging adults and may contribute to long-term homelessness.

Tyler KA; Johnson KA. Trading sex: Voluntary or coerced? The experiences of homeless youth. Journal of Sex Research 43(3): 208-216, 2006. (27 refs.)

This study examined the circumstances surrounding a homeless youth's "decision" to trade sex for food, money, shelter, or drugs. Forty homeless youth in 4 Midwestern states participated in individual, in-depth qualitative interviews. Interviewers recruited youth through both service agencies and street outreach. The findings revealed that approximately one third of the sample had some experience with trading sex, whether it was in the form of having traded sex, having been propositioned to trade sex but having refused, or having friends or acquaintances that had traded sex. Young people's reports indicated that they had traded sex for things they deemed necessary in order to survive (i.e., food, shelter, money, or drugs) and that they did not want to trade sex, but did so because they were desperate and lacked alternatives. Additionally, others were coerced, manipulated, or forced to do so, indicating that the decision to trade sex is not always voluntary. We discuss the implications of these findings in terms of cumulative effects on youths' later development. Directions for future research among this population are also discussed.

Walters AS. HIV prevention in street youth. Journal of Adolescent Health 25(3): 187-198, 1999. (66 refs.)

Homeless adolescents have remained an underserved population throughout the human immunodeficiency/acquired immune deficiency syndrome epidemic. This article reviews the recent literature investigating human immunodeficiency virus (HIV) risk behavior among street youth. Prevalence rates of both adolescent homelessness and HIV seropositivity are unknown. However, data from a number of samples document a high prevalence of HIV risk behavior, sexually transmitted diseases, and alcohol/drug use among homeless adolescents. A number of individual and social factors, often associated with street survival, propel adolescents toward highrisk behavior. For some adolescents, testing HIV positive is perceived as advantageous in the procurement of basic needs such as food and shelter. HIV risk-reduction interventions must take into consideration the cause of homelessness, access to and participation in shelter services, and individual factors (such as the effects of sexual orientation and ethnicity) that frequently have not been systematically included in previous research. HIV risk for many homeless adolescents stems directly from their state of homelessness. National policies and funding are needed to address the health needs of these youth.

Whitbeck LB; Johnson KD; Hoyt DR; Cauce AM. Mental disorder and comorbidity among runaway and homeless adolescents. Journal of Adolescent Health 35(2): 132-140, 2004. (33 refs.)

Purpose: To investigate prevalence of mental disorder and comorbidity among homeless and runaway adolescents in small to medium sized cities in four Midwestern states. Methods: The study presents lifetime, 12-month prevalence, and comorbidity rates for five mental disorders (conduct disorder, major depressive episode, posttraumatic stress disorder, alcohol abuse, and drug abuse) based on UM-CIDI and DISC-R structured interviews from the baseline interviews of a longitudinal diagnostic study of 428 (187 males; 241 females) homeless and runaway adolescents aged 16-19 years (mean age = 17.4 years, SD = 1.05). The data were collected by full-time street interviewers on the streets and in shelters in eight Midwestern cities of various populations. Separate logistic regression models were used to investigate factors associated with meeting criteria for any disorder and two or more disorders. Results: Lifetime prevalence rates were compared with rates for same-aged respondents from the National Comorbidity Survey (NCS). Homeless and runaway adolescents were six times more likely than same-aged NCS respondents to meet criteria for two or more disorders and were from two to 17 times more likely to meet criteria for individual disorders than. Conclusions: Homeless and runaway adolescents in small and mid-sized Midwestern cities report significant levels of mental disorder and comorbidity that are comparable and often exceed that reported in studies of larger magnet cities.

Wincup E; Buckland G; Bayliss R. Youth Homelessness and Substance Use: Report to the Drugs and Alcohol Research Unit. London: Home Office, 2003. (77 refs.)

This report presents the findings of a research study of substance' use among 160 homeless young people (25 years of age and under) in England and Wales. Homeless young people reported high lifetime, last year and last month prevalence rates for illicit drug use and illicit use of prescribed medication. Of the 160 homeless youth interviewed 71% were male and 29% were female (mean age was 20 years). Ninety-five percent had used drugs, often at a young age (typically around age 14). Levels of use of cannabis, amphetamine and ecstasy were particularly high, but a substantial minority had used heroin and crack cocaine. Seventeen percent were identified as problem drug users. While 18% did not drink alcohol at all, a considerable proportion adopted risky drinking patterns: frequently exceeding sensible daily limits and binge drinking. Fourteen percent were identified as problem drinkers. Most of the young people interviewed became homeless for the first time at an early age, and this often followed episodes of running away. Findings from this study suggest the need for early interventions, highlighting the possible dangers of poly-drug use. Awareness of the health risks of problem drug use, particularly injecting, needs to be stressed. Interventions need to promote awareness of ways to avoid accidental overdoses and provide drug users with coping skills. Prevention efforts need to target young males and emphasize the dangers of binge drinking. Other topics addressed include homelessness and health promotion activities.

Public Domain

Woods ER; Samples CL; Melchiono MW; Harris SK. Boston HAPPENS Program: HIV-positive, homeless, and at-risk youth can access care through youth-oriented HIV services. Seminars in Pediatric Infectious Diseases 14(1): 45-53, 2003

The Boston HAPPENS Program is a collaborative network of care consisting of multiservice outreach agencies; community health centers; and hospitals for HIV-positive, homeless, and hard-to-reach youth. In four years of data collection, the program served more than 2,000 youth, including 54 HIV-positive youth. The youth were 19.9 +/- 2.9 years old; 64 percent female; 45 percent youth of color; 11 percent gay/lesbian, bisexual, or undecided; and 13 percent homeless or runaway. Homeless youth were much more likely to have been involved with a mental health system (47% vs. 12%, P < 0.001), the criminal justice system (20% vs. 2%, P < 0.001), high-risk sexual behaviors (21% vs. 3%, P < 0.001), and substance abuse (25% vs. 6%, P < 0.001) than were other youth served by the program. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect under-served youth to health care. Outreach and human immunodeficiency virus (HIV) counseling and testing services can offer important portals of entry into health services for at-risk youth. Support services such as outreach, case management, and mental health services are needed to complement medical services by all youth at-risk for contracting HIV. Support services are necessary for the initiation and retention of youth in care so that early case identification and complex treatment regimens can be initiated and tailored to the individual.

Yoder KA; Hoyt DR; Whitbeck LB. Suicidal behavior among homeless and runaway adolescents. Journal of Youth and Adolescence 27(6): 753-771, 1998. (73 refs.)

The present study considered risk factors associated with suicidal ideation and the likelihood of a suicide attempt in a sample of 297 homeless and runaway youth from four Midwestern states. It was hypothesized that sociodemographic characteristics, family factors, suicide exposure, street factors, externalizing behavior, and internalizing behavior would be related to suicidal ideation and to the likelihood of a suicide attempt. It was also hypothesized that suicidal ideation would mediate the relationship between the other predictor variables and the likelihood of a suicide attempt. Over half the sample (53.9%) endorsed some level of suicidal ideation, and over one quarter (2.6.3%) attempted suicide in the year prior to the interview Univariate and multivariate results indicated that sexual abuse by a family member, knowing a friend who attempted suicide, drug abuse, and internalization were highly related to suicidal ideation. In the absence of suicidal ideation, sexual abuse, sexual victimization while on their own, and internalization were highly related to the likelihood of a suicide attempt. Finally, the hypothesized mediating effect was found for both sexual abuse and internalization.

Yoder KA; Whitbeck LB; Hoyt DR. Gang involvement and membership among homeless and runaway youth. Youth & Society 34(4): 441-467, 2003. (58 refs.)

The present study documented the extent of gang involvement and gang membership in a sample of 602 homeless and runaway youth from four midwestern states. The study also compared gang members, gang-involved youth who were not members, and nongang youth on several dimensions including sociodemographic characteristics, family background, school experiences, street experiences and exposure, emotional problems, alcohol and drug use, and other delinquent and deviant behaviors. Findings indicated that a significant number of these youth were gang members (15.4% of the sample) or involved in gangs (32.2% of the sample). Youth gang members and gang-involved youth reported more family legal problems, had been suspended from school more, ran away at a younger age, used more alcohol and drugs, were exposed to more deviant peers, and attempted suicide more than did nongang youth. In addition, youth gang members reported less parental monitoring, more severe abuse, more street victimization, and more deviant subsistence strategies than did either gang-involved or noninvolved youth.