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December 4, 2002
Renaissance Washington Hotel, Washington, D.C.

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Sponsored by: National Institute on Drug Abuse

Meeting Summary

A panel of eight researchers and NIDA program staff convened to discuss current issues facing runaway, homeless, and street youth, and to provide recommendations to direct future research. The meeting was divided into three segments: short presentations by each researcher; a general discussion; and a period to make recommendations for future research. The following meeting synopsis contains three parts: brief summaries of the eight presentations; a series of questions organized by themes that emerged during discussion; and recommendations put forth by the meeting participants.

Brief Summaries of Presentations

Colette Auerswald, M.D., M.S., Assistant Professor of Pediatrics in the Division of Adolescent Medicine at the University of California at San Francisco, presented "Youth Homelessness in San Francisco: A Life Cycle Approach." The aim of this street-based, ethnographic project was to study the social and cultural context of street life. Twenty street youth, aged 15 to 23 years old, were recruited from street sites in San Francisco. Analysis of field notes and transcripts yielded a proposed model on the life cycle of youth homelessness consisting of the following stages: first on the street; initiation to the street; stasis; disequilibrium; extrication; and recidivism. The life cycle model suggests that street youth who are most open to intervention are those who are in transitional states, i.e., those who have just arrived on the street, those who are in crisis (disequilibrium), or those attempting to leave the street (extrication).

Les B. Whitbeck, Ph.D., Professor of Sociology at the University of Nebraska-Lincoln, presented "Drug Abuse and Comorbid Disorders Among Homeless and Runaway Adoloscents." The objective of this longitudinal, diagnostic study was to determine lifetime, 12-month prevalence, comorbidity rates, and factors associated with alcohol and drug use among homeless youth. The sample (N=429) captured homeless and runaway youth aged 16 to 19 years old in seven Midwestern cities. Multivariate results indicated that age of adolescence, being male, having a rejecting parent, having a caretaker who has been in treatment for substance abuse, running away at an early age, engaging in high rates of deviant subsistence strategies, and affiliation with deviant peers were positively associated with meeting lifetime criteria for substance abuse. Parental monitoring was negatively associated with meeting criteria for lifetime substance abuse.

Susan T. Ennett, Ph.D., Associate Professor in the Department of Health Behavior and Health Education, School of Public Health, University of North Carolina at Chapel Hill, presented "Runaway and Homeless Youth: Context for Risky Behavior." The objective of this research was to apply a social network approach to understanding the social and environmental contexts that exacerbate or mitigate risk among runaway and homeless youth. The study sampled 327 youth aged 14 to 21 years old from service agencies and street settings in Washington, DC. Findings indicated that one-quarter of the sample had no network at all, and that network absence may be associated with greater substance use and increased sexual risk behavior compared to network presence. Overall, social networks were both risk-enhancing and risk-decreasing.

Michele Kipke, Ph.D., Professor in the Department of Pediatrics and Preventive Medicine, University of Southern California, presented "Street Youth and HIV: Use of Social Network Analysis to Examine Drug Use Patterns and HIV Risk Profiles." Two studies were described: a study of homeless youth conducted in Hollywood, and a study of injection drug users and their sexual partners in Los Angeles. The aim of the first study was to understand the course of homelessness, as well as drug use and HIV risk, among a sample of 409 youth aged 13 to 23 years old. Using ethnographic methods, six different peer groups were identified which exhibited different risk behaviors. For instance, hustlers/sex workers were more likely to have been tested for HIV. The aim of the second study was to examine individual, familial, and interpersonal factors associated with HIV risk and protection among a sample of 320 injection drug users and their sexual partners aged 15 to 23 years old. Using social network maps, it was demonstrated that drug use and risk behaviors varied depending upon peer group and city of residence.

Elise Roy, M.D., M.Sc., medical consultant with the Montreal Public Health Department and Quebec Institute of Public Health, presented "Injection Drug Use and Its Consequences on the Health of Montreal Street Youth." The objective was to detail the variety of health risks facing Montreal street youth who use drugs, such as infectious disease exposure, injection drug use initiation, and mortality. In one study, 1,013 youths aged 14 to 25 years old were sampled every six months for five years. Independent predictors of mortality included being HIV positive, daily alcohol use, homelessness, polydrug use and drug injection. Primary predictors of initiation into injection drug use included younger age (< 18 years old) homelessness in the past six months and having an injection drug using friend among girls.

Michael Clatts, Ph.D., Director of the Institute for International Research on Youth At Risk at National Development and Research Institutes, presented "Sources of Complexity in the Epidemiology of Drug and Sexual Risk Among Street-Involved YMSM: Recommendations for Future Research. The objectives of this presentation were to use an existing study of Young Men who have Sex with Men (YMSM) to highlight key issues facing street youth, such as sexual identity development, drug use, and high risk behaviors. The study sampled 569 YMSM aged 17 to 27 years old in New York City. Findings indicated that a majority of youth had runaway from home and/or engaged in sex work during their lifetime. On average, running away from home or engagement in sex work occurred at earlier ages than crack use initiation and injection drug use initiation. Hence, housing instability and engagement in sex work may be predictors of hard drug use and other poor health outcomes.

Laura Roberts, M.D., Professor and Vice Chair for Administration in the Department of Psychiatry at the University of New Mexico School of Medicine, presented "Ethics, Stigma, and the Care of Rural Runaway Youth in New Mexico." The objectives were to highlight health needs and service disparities facing rural populations based upon ongoing research in New Mexico. In particular, rural runaway youth have fewer resources, social supports, and services compared to urban homeless youth. Additionally, rural runaways face special cultural and language issues, and increased isolation and marginalization. Consequently, rural runaways experience lower standards of care - both clinically and ethically.

Natasha Slesnick, Ph.D., Research Assistant Professor at the University of New Mexico, presented "Treatment for Substance-Abusing Runaway and Homeless Youth." The objectives were to present two samples of homeless youth - street youth and runaway youth - and describe barriers to treatment. The street youth sample consisted of 53 persons with an average age of 18.4, while the runaway youth sample comprised 124 youth with an average age of 14.8. The street youth were more likely to be injection drug users, have a greater number of lifetime sex partners, and to have dropped out of school. Among runaways, barriers to treatment included denial of a problem, fear of treatment, and prior negative experiences with treatment providers. Among street youth, barriers to treatment included no home address or telephone, serious mental illness and drug addiction, and being unable to provide housing to minors.

Questions Emerging from Discussion

  1. Social Course of Homelessness
    • What are the different life stages of youth homelessness?
    • What happens to homeless youth when they become adults?
    • What can be learned from homeless youth who have successfully exited the street?
    • What is the nature of the interactions between street-involved, non-homeless youth and homeless youth?
    • How does the population of homeless youth overlap with other high-risk populations of youth, such as incarcerated youth and foster care youth?
  2. Drug Use
    • What is the natural history of drug use among homeless youth?
    • How are homeless youth using drugs, e.g., mode of administration, settings, and what are the associated health risks?
  3. Methodology
    • How can current data on homeless youth be compared given differences in methodologies and instruments?
    • How can homeless youth be tracked for longitudinal studies?
    • How can a representative sample of homeless youth be created?
  4. Interventions
    • What are the barriers to service utilizations among homeless youth?
    • How can interventions be started early enough to prevent homelessness among youth?
    • How does meeting the basic needs of homeless youth (particularly the need for safe shelter) affect the course of their substance use?
  5. Costs of homelessness
    • What is the public health impact of youth homelessness on the larger society?
    • What is the monetary cost of youth homelessness to the public?
    • What are the social and monetary costs of intervening versus not intervening in this population?

Recommendations for Future Research

  1. General
    • Review current studies on homeless youth and appraise what has been learned substantively, theoretically, and methodologically. Use this knowledge to revaluate basic assumptions about the homeless youth population.
    • Devise a common definition of homeless youth that can be incorporated into new research instruments and applied to existing data sets on homeless youth.
    • Gain an accurate count of homeless youth across the United States - including undocumented youths and recent immigrants. Such a revised count would foster a better understanding of the extent of the problem of homelessness among youth, but also underscore the amount of resources needed to address the problem.
  2. Methodological
    • Conduct comparative, multi-site studies of homeless youth. These studies should attempt to capture the heterogeneity of the homeless youth population, such as sexual identity, cultural differences, IDU vs. non-IDU, urban vs. rural differences. The organization and implementation of multi-site research is an important concern, e.g., cooperative agreement vs. consortium arrangement.
    • Devise a common set of core questions that can be applied across sites and subpopulations of homeless youth. However, each site should be encouraged to develop additional question based upon local subpopulations of youth.
    • Incorporate international sites into multi-site studies in order to compare domestic and international populations of homeless youth populations. These comparisons could enhance interventions directed at both populations.
    • Utilize ethnographic studies to understand barriers to service utilization from homeless youths' perspectives and determine locations of hidden populations of homeless youth. Develop creative interventions based upon these findings.
    • Focus research efforts on understanding and describing the systematic causes of homelessness among youth.
  3. Interventions
    • Design interventions specifically for youth populations - not adapted from existing interventions that target adults, for instance. In particular, more "low-threshold" interventions need to be developed in order to reach a wider range of youth.
    • Disseminate "best practices" to researchers and practitioners that have worked with homeless youth across different cities.
    • Develop and disseminate evidence-based findings on the legal and ethical issues surrounding research on homeless youth. This knowledge would better protect youth who serve as research subjects, potentially enhance the range of youth exposed to beneficial research studies, and also assist investigators in writing more effective grant applications.
  4. Funding
    • Reconsider existing funding mechanisms, such as B-START, R03s, and R21s, as a viable mechanism to attract young investigators to studying homeless youth.
    • Initiate training programs focused on teaching graduate and post-doctoral students key methodological skills and substantive knowledge to foster careers in the area of homeless youth.
    • Develop specific RFAs on the topic of homeless youth - which sends a message that this population is a research priority.
  5. Developing a Field of Research
    • Integrate research on homeless, runaway, and street youth into a coherent, recognizable field.
    • Publish a special issue of a journal focusing on homeless youth. Topics that could be addressed include: What do we know about homeless youth? What methods work in accessing and tracking homeless youth? What are the pathways to drug use among homeless youth?
    • Develop an ongoing scientific meeting on homeless youth. The meeting could be held annually for up to five years. Ideally, the meeting would be a satellite meeting of a larger conference, and rotate to a different conference each year. This meeting could be supported through a specific funding mechanism, such as the R13.
    • Create a consortium on homeless youth across federal agencies, e.g., NIDA, NIMH, to share methodological approaches, and devise a common set of definitions and questions. Such a pooling of resources could create a critical mass on the topic of homeless youth.
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