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HHS -SOURCE National Research Studies on Successful Outreach Interventions of Youth WHO Have No Safe place to Dwell

February 5, 2017

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Qualitative Studies

The majority of U.S. studies utilize quantitative methods of analysis while qualitative studies are more common among international studies (Toro, 2007). As noted by Kidd (2003), the experiences and ideas of street youth themselves have been neglected in the literature, but their perspectives and active involvement in service development are likely crucial for developing and improving intervention services. Karabanow and Rains (1997) note that obtaining the perspective of the youth is especially important since services for runaway and homeless youth are largely voluntary and consultation with youth is critical to the development of appropriate, engaging services. To that end, four international studies (two Australian, two Canadian) and three U.S. studies were identified that used a qualitative design for understanding youths’ treatment or service experiences. Regardless of the country of origin or shelter versus street youth, these studies reported similar themes. In nearly every study, youth reported having negative experiences with helping agencies and professionals (Darbyshire, Muir-Cochrane, Feredy, Jureidini, & Drummond, 2006Ensign & Gittesohn, 1998Kidd, 2003Thompson et al., 2006). The studies recommended that interventions be designed which consider the strengths (versus the weaknesses) of homeless youth, that needs differ significantly among individuals, and that services must be tailored to the life context and the desires of the youth (Ensign & Gittelsohn, 1998French, Reardon, & Smith, 2003Kidd, 2003; Nebbitt, House, Thompson, & Pollio, 2006; Thompson, McManus, Lantry, Windsor, & Flynn, 2006). In particular, youth in several studies reported that trusting the service provider (Ensign & Gittelsohn, 1998French et al., 2003Kidd, 2003Thompson et al., 2006), feeling cared for (Karabanow & Rains, 1997), not feeling judged (French et al., 2003), and inclusionary rather than exclusionary practices (such as not being punitive for missed appointments) (Darbyshire et al., 2006) were prerequisites for successful engagement in services and for positive outcomes.

Methodological Issues

Qualitative research offers rich information regarding the perceptions and experiences of the youth themselves, which is less easily garnered from survey reports. While many of the conclusions in the qualitative studies also reflect some of those from quantitative research, unique information especially regarding individual differences was also provided. The studies reviewed here varied significantly in their methods with data being collected through individual interviews and focus groups with widely varying sample sizes of between 10 and 80 youth. It is not clear that information obtained from focus groups would be comparable to that obtained through individual interviews since it is possible that the interpersonal dynamics of the two interview contexts elicit different kinds of information depending upon perceived pressure, support or comfort with the situation.

Only two studies explicitly stated inclusion criteria (Darbyshire et al., 2006Kidd, 2003) with the other studies broadly including samples that accessed a drop-in center (French et al., 2003Thompson et al., 2006) or shelter (Ensign & Gittelsohn, 1998Karabanow & Rains, 1997Nebbitt et al., 2007). Some studies focused solely on youth who were considered ‘success stories’ (Nebbitt et al., 2007), or were engaged into services (Darbyshire et al., 2006French et al., 2003Karabanow & Rains, 1997Thompson et al., 2006) which is useful for elucidating those factors associated with successful engagement or outcomes. Interviews with those not considered ‘success stories’ can be equally informative in that this information can elucidate factors that service providers and agencies can improve.

Age ranges of youth varied significantly with one study including adolescents only (e.g., 12 to 17 years) (Ensign & Gittelsohn, 1998) but with most including both adolescents and adults in their sample (e.g., 15 to 24 years). Inasmuch as age is associated with different developmental needs and access to different social resources, consideration of age in future qualitative studies could be useful for identifying such potential differences and for enhancing program services. While balance between internal and external validity is always a struggle, regardless of a qualitative or quantitative research design, given the diversity of homeless and runaway youth, different themes are likely to appear based upon their prior experiences, resources, and demographics, therefore, these variables should be more fully considered in future studies. All of the studies interviewed youth at one point in time, often while services were being offered; interviewing youth at various points in time might offer an even richer perspective of attitudes and experiences as the impact of treatment is known to change over time (e.g., Pollio et al., 2006) and experiences with treatment, likely also change.

International Research

Several studies indicate that the number of street youth is increasing worldwide (Booth, 2006Dekel, Peled, & Spiro, 2003West, 2003). Toro (2007) notes that research on homelessness began to appear in the late 1990’s outside of the U.S. and that the majority of this research focuses on single homeless adults. Even so, intervention evaluation studies with runaway and homeless youth from five countries (Israel, United Kingdom, China, South Korea and Uganda) were identified.

The government of Uganda implemented a program to resettle street youth from the capital city to family or local agencies (Jacob et al., 2004). It was noted that at the end of the first year, 700 children had been removed from the streets of the city and resettled by police. Systematic follow-up of resettled children was not conducted by researchers, but a nongovernmental organization (NGO) noted that 50% of the children that the NGO visited were no longer resettled in their villages. Moreover, the authors reported that of those children interviewed regarding the program, every child reported that they had been beaten or had seen others beaten, caned or cut during the round-up in the capital city or at the holding facility. The authors reported that this intervention has created an underworld in which children hide on the streets and avoid the police. On the positive side, this effort brought awareness to the problem of street children from which further efforts can be developed.

The central government of China also sought to intervene in the growing problem of runaway and homeless youth. The government established Protection and Education Centers for Street Children which offer basic needs, shelter and emergency medical care and arranges for the children to be returned to their family (Lam & Cheng, 2008). Determination of the effectiveness of this program included a 7-month ethnographic study of 50 street children interviewed by the authors in Shanghai. The authors concluded that most of the street children interviewed avoid these centers because of the behavioral restrictions associated with them and because the children did not wish to return home. Furthermore, most of the informants returned to the streets following their stay at the center. The authors conclude that more appropriate services that consider the needs and desires of the children are needed. A similar conclusion was reached by Dekel et al. (2003) in their evaluation of Israeli runaway shelters. The authors tracked 345 Israeli adolescents who resided in one of two runaway shelters at six to 12 weeks after their discharge from the shelter. While the majority of adolescents were discharged to their family’s home, at follow-up, only 54% were staying with their family, 18% were in an out-of-home placement and 28% were on the streets or with friends. The authors note that placement options once leaving the shelter are limited, and because of this, many youth are placed or returned home when it is not the best or most appropriate solution.

Two studies examined outcomes of ‘add-on’ services to a shelter program. Taylor, Stuttaford, and Vostanis (2007) sought to examine the clinical outcomes of homeless youth (ages 16–29) who received mental health services from 18 homeless shelters in different regions of the United Kingdom. Overall, half of the youth (n = 76) who sought services (which included cognitive-behavioral therapy, substance use treatment and psychoeducation) discontinued after the first session. Although the lack of an intent to treat analysis and lack of control group limit conclusions that can be drawn, significant improvements in aggressive behavior, self-injury, drug/alcohol use, depression, and other mental health problems were observed from pre- to post-treatment among youth. Similarly, Hyun, Chung, and Lee (2005) tested the effectiveness of a cognitive behavioral group therapy on clinical outcomes among a small sample of shelter-residing adolescents in Seoul, South Korea. Differences between the CBT group and the no-treatment control group were not reported, although adolescents who participated in the CBT group reported increased self-efficacy and decreased symptoms of depression from pre- to post-treatment.

Methodological Issues

Evaluations of governmental reaction to youth homelessness are imperative so that modifications to those interventions can be made to maximize the success of the interventions. In order to increase confidence in the conclusions drawn from the program evaluation designs, multiple post-intervention assessments obtained longitudinally, identification of valid indicators of success, the use of psychometrically sound measures, and tracking of all youth (regardless of their engagement in services) should be used. With programs struggling to maintain funding, such evaluation has been limited internationally and within the U.S.

Discussion

Even though only a small number of studies have examined the impact of shelters, drop-in centers and intervention approaches, the literature to date offers several preliminary conclusions regarding service and intervention effectiveness, as well as future directions. First, runaway shelters show some short term benefits to youth, but long-term benefits have not yet been demonstrated. Possibly, the services provided by the shelters are not effectively targeting the underlying causes of the presenting symptoms, or are not comprehensively addressing the range of needs of the families. Limited research suggests that the predictors of homelessness or residing in a shelter differ from the predictors of exiting homelessness or returning home (Baker et al., 2003Slesnick, Bartle-Haring, Dashora, Kang, & Aukward, 2008). More research is needed to determine if the shelters’ intervention targets are those that predict long-term resolution of problem behaviors. For example, given that the family of shelter-residing adolescents often has not yet disintegrated beyond intervention, and because of its role in the runaway crisis, targeting the family in intervention efforts might have great potential to prevent future homelessness and stays at a runaway shelter. While researchers have called for the development and evaluation of family-based interventions for shelter based youth (e.g., Chamberlain & MacKenzie, 2004Teare et al., 1992), little such research has been conducted. Also, too few studies are available to determine the effectiveness of drop-in centers, with only one study tracking outcomes among youth (Slesnick et al., 2008). While that study indicated that youth accessing intervention services through a drop-in appear to show positive outcomes across a range of outcomes up to one year post-baseline, clearly more evaluation research is needed.

Second, case management is a widely utilized intervention approach for homeless individuals (Zerger, 2002) but little research is available to guide conclusions regarding its utility with homeless youth. Controlled evaluations of case management for use with homeless adults are sparse as well, but, to date, only one study has evaluated case management with homeless youth (Cauce et al., 1994). As noted above, that study showed that enhanced case management was not more effective than less intensive case management. Two studies using adult samples showed similar outcomes when an intensive case management intervention was compared to a less intensive intervention (Hurlburt, Hough, Wood, 1996Toro et al., 1997). Possibly, case management alone may be insufficient to address the issues of individuals experiencing homelessness, and psychosocial treatment combined with case management may have better potential. Research that further evaluates the potential of case management and its essential elements, including duration and intensity is needed.

Third, two trials indicate that brief, motivational interventions are not effective with street/drop-in recruited youth. One outcome of Motivational Interviewing (Miller & Rollnick, 2002) sessions is to increase access and/or attendance in other treatment services. Motivational approaches have shown positive effects for this outcome among some non-homeless samples including substance abusers (e.g., Miller & Wilbourne, 2002). Since homeless youth are known to have difficulty developing trust with service providers, early intervention success likely depends upon the development of a trusting relationship. Trust builds with time, and possibly with more frequent contact than offered through a very brief intervention such as Motivational Interviewing. Zerger (2002) concludes that while elements of Motivational Interviewing might be effective for engaging homeless individuals, the consensus is that the homeless population cannot benefit from such short-term interventions given the multitude and complexity of their problems.

Fourth, interventions that focus on HIV prevention and sexual risk alone do not appear effective in reducing risk behaviors among shelter and street/drop-in recruited youth. Possibly, individual problems or risk behaviors among individuals experiencing homelessness cannot be treated apart from the needs of the whole person (Kraybill & Zerger, 2003). That is, many runaway and homeless youth need assistance accessing food, education, transportation, clothing, shelter/housing, identification, financial assistance, legal aid, medical and dental care and job training, and for some, improving family relations. Addressing one area in isolation of the other areas is not likely to be as effective as an intervention that addresses multiple and overlapping areas of need (Bronfenbrenner, 1979). Fragmented service provision is a frequently cited barrier among these youth and suggests that integrated interventions which address the range of needs through one service provider might be better than those that link youth to various systems of care that work in a parallel fashion (Zerger, 2002). For adolescents who have fewer resources and power by nature of their younger age and developmental status compared to adults, integrated interventions might be especially potent. At least, comprehensive intervention approaches are worthy of future study, even if their primary target, or funding source, is HIV, substance abuse or mental health.

Fifth, the qualitative studies converged on similar conclusions even though a variety of samples were obtained, and the methods used for collecting and reducing the data differed across studies. This suggests that at least some of the experiences of youth are relatively similar, regardless of age, gender, ethnicity, shelter versus street recruited, or location. Most youth described the importance of trust, confidentiality, not feeling judged, with the authors of the studies concluding that flexible, caring and tailored services that meet the needs of the youth are essential for successful engagement and maintenance into services. In general, the international studies reported similar outcomes of shelter-based efforts to reunite adolescents with their families as found in the U.S. That is, although viable for some, interventions that unilaterally return adolescents home (or to the available alternative living situations) are not viable for a certain proportion of runaway and homeless youth who may be unwilling or not welcome to return home.

Finally, runaway and homeless youth are diverse, and flexible treatment is needed to address this diversity. For example, studies report wide age ranges in research samples. Also, among non-homeless samples, research suggests that childhood abuse, substance use and traumatic brain injury can contribute to developmental struggles and impact treatment response (DeBellis et al., 2001Glasser, 2000). Interventions need to consider the cognitive and emotional developmental stage of youth, but also, the specific content or targets of intervention will vary based upon the youths’ reasons for running away or homelessness. Additionally, little mention of minority youth is offered within the literature. Among adults, being non-white is associated with a lower likelihood of receiving independent housing or exiting homelessness (Shinn et al., 1998). Thus, minority youth likely face more hurdles in their efforts towards stabilization than non-minority youth. And lastly, since youth are at different points in the homeless trajectory, any intervention chosen should be tailored to accentuating the potential resources and protective factors available to the youth and/or family.

Future directions

While intervention research is increasing in both quantity and quality, methodological challenges characterize research efforts. For example, to understand the impact of interventions, longer term follow-up is needed. Because many of these youth and families have unstable living situations, or are literally homeless, tracking requires significant time and expense, as well as creative problem solving and trust building between the research staff and client. Also, while facilitator blindness to participant’s treatment intervention reduces observer-expectancy effects, in order to successfully track clients for follow-up assessments, facilitators might need the guidance from therapists who might know the location of their client.

As noted, many intervention efforts consider return of the adolescent to the family as primary (as mandated by the Runaway and Homeless Youth Act) while services for street living youth focus on achieving re-integration and independence among youth. In Action Research (Argyris, 1994), the social participants who are dealing with the actual problem are brought into the research process. Action research suggests that these participants have knowledge and understanding of the problem that cannot be accessed by an outsider no matter how strong their research techniques. Rather than imposing legislators’, service providers’ or researchers’ priorities on youth, more action-based research may be needed so that services are developed in accordance with the needs and desires of the youth.

Finally, future studies should utilize intent to treat designs and report session attrition and overall treatment attendance rates. Such information can assist with future treatment development and refinement efforts. Also, given that youth report the importance of trust, confidentiality and not being judged, training of service providers to be especially focused on these aspects of relationship building may be critical for successfully engaging and maintaining runaway and homeless youth in interventions. While strict rules, structured service settings and disciplinary efforts may not function to engage these youth, short-term intervention efforts with caring, non-judgmental staff appear beneficial.

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  • Teare JF, Peterson RW, Furst D, Authier K, Baker G, Daly DL. Treatment implementation in a short-term emergency shelter program. Child Welfare. 1994;73(3):271–281.
  • Tenner AD, Trevithick LA, Wagner V, Burch R. Seattle youth care’s prevention, intervention, and education program: A model of care for HIV- positive, homeless, and at-risk youth. Journal of Adolescent Health. 1998;23:96–106. [PubMed]
  • Thompson SS, McManus H, Lantry J, Windsor L, Flynn P. Insights from the street: Perceptions of services and providers by homeless young adults. Evaluation and Program Planning. 2006;29(1):34–43.
  • Thompson SJ, Pollio DE, Bitner L. Outcomes for adolescents using runaway and homeless youth services. Journal of Human Behavior and the Social Environment. 2000;3(1):79–97.
  • Thompson SJ, Pollio DE, Constantine J, Reid D, Nebbitt V. Short-term outcomes for youths receiving runaway homeless shelter services. Research on Social Work Practice. 2002;12(5):589–603.
  • Thompson SJ, Safyer AW, Pollio DE. Examining differences and predictors of family reunification among subgroups of runaway youth using shelter services. Social Work Research. 2001;25(3):163–172.
  • Toro PA, Passero RJM, Bellavia CW, Daeschler CV, Wall DD, Thomas DM, et al. Evaluating an intervention for homeless persons: Results of a field experiment. Journal of Consulting and Clinical Psychology. 1997;65(3):476–484. [PubMed]
  • Toro PA, Tompsett CJ, Lombardo S, Philippot P, Nachtergael H, Galand B, et al. Homelessness in Europe and the United States: A comparison of prevalence and public opinion. Journal of Social Issues. 2007;63:505–524.
  • Tsemberis SJ, Moran L, Shinn M, Asmussen SM, Shern DL. Consumer preference programs for individuals who are homeless and have psychiatric disabilities: A drop-in center and a supported housing program. American Journal of Community Psychology. 2003;32:305–317. [PubMed]
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  • West A. At the margins: street children in Asia and the Pacific. Asian Development Bank; 2003.
  • Zerger S. Substance abuse treatment: What works for homeless people?: A review of the literature. Nashville, TN: National Health Care for the Homeless; 2002.

Table 1

Summary of reviewed studies.

Study Treatment Groups Sample Characteristics Follow-Up Points (Rates) Findings
Service Evaluations:
Barber et al., 2005
  1. Shelter service evaluation examining immediate and short term outcomes (n=202); single group design
Youth age 18–21, 59% female, 55% African American, 19% Latino, 3% White, 14% Multiethnic, 8% other 2 weeks (81%), 3 months (70%), 6 months (91%) post-treatment At 6 month follow-up: 82% of youth established stable housing and over one third were employed. Significant decreases in behavioral and emotional problems were reported between baseline and 6 months
Pollio et al., 2006
  1. Shelter service evaluation examining outcomes and use of services (n=371); single group design
Shelter youth, average age 14.7 years, 61% female, 73% White 6 weeks, 3 months, 6 months post-baseline (approximately 25–30% attrition at each point) Number of days on the run significantly decreased at each follow-up compared to baseline data. Significant increases in family contact and perception of family support were found at all three follow-up points. Negative school events and employment status showed mix results with positive changes between 6 weeks and 3 months, but negative changes by the 6 month follow-up.
Slesnick et al., 2008
  1. Drop-in center service evaluation: CRAa and case management service (n=172); 32 sessions offered; single group design
Drop-in youth age 14–24, 59% male, 37.2% White, 31.4% Hispanic, 12.2% Native American, 7.6% African American, 11.6% Multiethnic 6 months (73%), 12 months (76%) post-baseline Among youth who had used alcohol or drugs at baseline, average substance use significantly decreased. Gender, percent days in school, and percent days being housed predicted alcohol and drug use. Psychological distress significantly decreased. Females reported a greater increase in percent days housed over time.
Steele and O’Keefe, 2001
  1. Shelter service evaluation including broad-spectrum health intervention: STD screening and treatment, weekly counseling sessions, case mgmt. (n=106); single group design
Shelter-residing youth age 16–21, 72% female, ethnicity distribution not reported 9 months post-baseline (follow-up rates not reported) Youth reduced drug dependence by 38%, and STD rates fell from 60% at baseline to 7% at program completion. Forty-two percent had obtained employment at follow-up compared to 0% at baseline.
Thompson et al., 2002
  1. Short-term shelter services: temporary housing, skills training, referral services (n=368)
  2. Long-term day treatment: longer term rehabilitation and education services in addition to ST services (n=54); nonrandom design
  1. ST shelter youth, average age 14.7 years, 60% female, 73% White
  2. LT shelter youth, average age 15.3 years, 11% female, 60% White
  1. 6 weeks (71%) post-discharge
  2. 6 weeks (87%) post-baseline
Youth in ST treatment showed significant improvement in days on the run, family support, suspension and detention rates, employment status, sexual activity, and self esteem. No significant differences were found in outcome variables between the ST and LT groups.
McMahon, 1994
  1. 3–5 day treatment intervention (n=44)
  2. 10–30 day treatment intervention (n=44); Random assignment
Shelter youth, average age 14 years, 76% female, 26% African American, 42% Anglo, 30% Hispanic, 1% Other Not applicable (post-test only design) Recidivism rates were the same for both treatment groups: 50% of youth in each group committed at least one other offense. Recidivism rates in the 3–5 day treatment group decreased significantly when youth and their families participated in aftercare counseling post-discharge.
Intervention Studies
Auerswald et al., 2006 Field-based STD screening and PDPTb intervention (n=216, 157 randomly chosen for 6 month follow-up); random assignment design Street youth age 15–24, 66% male, 57% White, 21% African American, 6% Native American, 3% Latino, 1% Pacific Islander, 8% Multiethnic 6 months (70%) post-baseline All follow-up youth who initially tested positive for an STD, tested negative at the 6 month follow-up. New instances of infection did occur for some youth at follow-up who tested negative at baseline.
Baer et al., 2007
  1. BMIc(n=75); 4 sessions offered
  2. Treatment as usual (n=52); random assignment
Drop-in center youth age 14–19, 56% male, 58% White, 19% Multiethnic, 9% Native American, 8% African American, 4% Hispanic, 2% Asian or Pacific Islander 1 month (82.9%), 3 months (76.1%) post-baseline Overall, youth significantly increased (drug) abstinence rates and decreased drop-in service utilization from baseline to 3 month follow-up. Alcohol use significantly dropped by the 3 month, but not 1 month follow-up. Marijuana use decreased at all time points. No significant differences in abstinence rates or substance use were found between conditions. An increase in drop-in service utilization in BMI youth was the only significant difference between treatment conditions.
Booth et al., 1999
  1. Peer-based, health risk intervention: youth trained to administer HIV prevention program to peers (n=72), 4 sessions provided
  2. Control group: no training (n=75); nonrandom design
Youth age 12–19 recruited from a drop-in center, 51% male, 73% White, 125 Hispanic, 8% African American, 5% Native American, 3% other 2 days (no rate reported), 3 months (60%) post-baseline Youth in the treatment condition significantly increased HIV/AIDS knowledge compared to the control group. Youth in both conditions decreased sexual risk behavior; treatment youth decreased heroin/cocaine use while control youth remained the same. An increase in AIDS knowledge was associated with a greater likelihood of high risk sex. Youth who perceived their chance of being infected with HIV as 50% or greater were more likely to use heroin or cocaine.
Cauce et al., 1994
  1. Project Passage: intensive case mgmt. (n=55)
  2. Treatment as usual: regular case mgmt. (n=60); random assignment
Homeless youth age 13–21, 57% male, 59% White, 22% African American, 8% Hispanic, 7% Native American, 4% other 3 months post-baseline (results based on the first 115 to complete the 3 month follow-up) At the 3 month follow-up, significant decreases in problem behavior, substance use, and depressive symptoms, plus increases in self-esteem were found in both treatment and control groups. Slightly greater improvement in aggression, externalizing behaviors, and life satisfaction were found in the Project Passage sample.
Ferguson and Xie, 2008
  1. SEI f: vocational training and mental health intervention (n=16)
  2. Treatment as usual (n=12); nonrandom design
Drop-in center youth age 18–24, 71% male, 39% African American, 21% Hispanic, 28% Caucasian, 14% mixed or other, 3% Asian Immediately following intervention (69% SEI group, 67% treatment as usual group) SEI youth significantly increased total life satisfaction in comparison to the control group. A significant difference in the number of sexual partners was also found with SEI youth increasing and control youth decreasing their number of partners. Youth in the treatment condition increased contact with family while youth in the control group decreased contact.
Gleghorn et al., 1997 Time 1: 1. HIV intervention (n=246) 2. Comparison group (n=183) Time 2: 1.HIV intervention (n=392) 2. Comparison group (n=325); nonrandom design Youth age 12–23, currently or recurrently homeless, involved in the street economy, 83% male, 81.5% White Before (T1)and during (T2) intervention (rates not applicable; T1 and T2 youth different) Treatment and recent intravenous drug use significantly predicted contact with outreach workers. Treatment also predicted number of referrals in the past 6 months. Youth identified as punk/squatter were more than twice as likely to have used a condom with their last partner. White youth were half as likely as non-White youth to have used a condom with their last partner. Females and those using drugs intravenously were more likely to follow up with HIV-referrals.
Peterson et al., 2006
  1. Motivational Enhancement (n=92), 4 sessions offered
  2. Assessment only (n=99)
  3. Assessment at follow-up only (n=94); random assignment
Youth age 14–19 recruited from drop-in centers, 54.7% male, 72.3% White, 15.9% Multiethnic, 3.2% African American, 3.2% Native American, 3.2% Hispanic, 1% Asian/Pacific Islander or other 1 month (82%), 3 months (80%) post-baseline Intervention participation did not affect alcohol or marijuana use. The treatment group showed a greater reduction in illicit drug use compared to the assessment only group. Youth in a later stage of change (contemplation or action-maintenance) had less drug use. Youth highly engaged in the intervention showed a significantly greater reduction in drug use compared to those with low engagement and those in the control groups.
Rew et al., 2007
  1. Gender-based intervention (n=285), 8 sessions offered
  2. Control group (n=196)
  3. Youth who participated in both intervention and control groups (n=89); nonrandom design
Street youth age 16–23, 61% male, 58% White, 11% Hispanic, 9% African American, 8% Multiethnic, 6% Native American, 1% Asian, 3% other Immediately before (T1) and after (T2) the intervention, up to 6 weeks (T3) post-intervention (no rates reported) Treatment youth had greater HIV/AIDS knowledge at T2 than control youth, but knowledge decreased by T3. Overall, knowledge decreased between baseline and the final follow-up for both conditions. No effect on condom self efficacy or intent to use condoms was found. Youth in the control condition significantly decreased safe sex behavior between baseline and T3.Females in the treatment condition significantly increased self-efficacy for breast self exams, and had greater HIV/AIDS knowledge by T3 compared to intervention males and control males and females.
Rotheram-Borus et al., 1991
  1. HIV intervention (n=78), 20 sessions offered
  2. Control group (n=67); nonrandom design
Shelter youth age 11–18, 64% female, 63% African American, 22% Hispanic, 8% White, 7% other 3 months, 6 months post-baseline (77% completed a 3 and/or 6 month follow-up assessment) The intervention did not affect abstinence rates. The number of intervention sessions attended was significantly related to consistent condom use and sexual risk patterns. Those attending 15 or more sessions increased condom use by 30% between baseline and 6 month follow-up, and reduced sexual risk behavior from 20% at baseline to zero by the 3 and 6 month follow-up.
Rotheram-Borus et al., 2003
  1. Street Smart HIV intervention (n=101), 10 group sessions offered]
  2. Control group (n=86); nonrandom design
Shelter youth age 11–18, 50.8% male, 54% African American, 30% Hispanic, 16% White or other 3 (57%), 6 (62%), 12 (50%), 18 (49%), and 24 (70%) months post-baseline Females in the intervention group reduced their number of recent sexual partners and rates of unprotected sex, and increased their rate of abstinence. Older females tended to have more sexual partners and participate in unprotected sex. Higher number of sexual partners, unprotected sex, and abstinence rates at baseline predicted higher rates at follow-ups for males and females. Marijuana use at baseline was a significant predictor of marijuana use at follow-up for both males and females. Females in the intervention group reduced alcohol use and number of drugs used.
Slesnick and Prestopnik, 2005
  1. EBFTd(n=65), 15 sessions offered 2. Treatment as usual (n=59); random assignment
Youth age 12 to 17, 59% female, 41% Hispanic, 37% White, 7% African American, 4% Native American, 10% other 3 (87%), 9 (86%), 15 (89%) months post-baseline Females reported higher family conflict, aggression, internalizing behavior, and depression than males. Males reported significantly more sexual abuse. Youth reporting both physical and sexual abuse reduced substance use at a greater rate when assigned to EBFT. Adolescents in both conditions showed significant improvement in other non-substance related domains (i.e., family functioning and mental health).
Slesnick and Prestopnik, In press
  1. EBFT (n=37), 16, home based, sessions offered
  2. FFTe (n=40), 16, office based, sessions offered
  3. Treatment as usual (n=42); random assignment
Shelter youth, age 12–17 years, 55% female, 29% White, 44% Hispanic, 11% Native American, 5% African American, 11% other or mixed ethnicity 3 (82%), 9 (79%), 15 (73%) months post-baseline EBFT participants showed higher engagement and session completion than FFT participants. Higher externalizing behavior and history of sexual abuse significantly predicted youth engagement in EBFT. EBFT and FFT youth significantly reduced percent days of drug and alcohol use while TAU youth remained steady. Males and females in EBFT significantly reduced drug and alcohol use over time, while only males reduced use in FFT. TAU showed no significant decreases in substance use. Younger youth in EBFT and FFT reduced internalizing behavior; TAU youth did not.
Slesnick et al., 2007
  1. CRA (n=96), 16 sessions offered
  2. Treatment as usual (n=84); random assignment
Drop-in center youth age 14–22, 66% male, 41% White, 30% Hispanic, 13% Native American, 3% African American, 1% Asian, and 12% Multiethnic 6 months (86%) post-baseline CRA youth had a greater reduction in drug use, depression, and internalizing behavior. CRA youth improved social stability in comparison to the control group. All youth in the CRA condition significantly reduced depression scores, while only younger youth (age 19 and under) decreased depression. Youth in both conditions reduced drug use, and improved coping skills, internalizing and externalizing problems and delinquent behaviors.
Tenner et al., 1998 Individual interviews regarding an HIV intervention (n=272) Street-involved, homeless and sexual minority youth; 37% gay, lesbian, or bisexual Not applicable HIV testing among street-involved, homeless, and sexual minority youth increased. Program awareness also increased, but no change was found in HIV risk behavior. HIV-positive youth were not referred to medical services more often than youth without HIV.
International Studies
Dekel et al., 2003 Individual interviews with youth, parents, and/or social workers (information about youth collected from at least one source: n=345) Homeless youth age 13–19; 80% born in Israel 6–12 weeks after leaving the shelter (70%) Fifty-four percent of youth had returned home at follow-up while 18% moved to another home situation, and 28% were living in an unconventional place such as the streets. Youth who went back to unconventional environments were older than youth who returned home or to a home-like environment. At follow-up, 66% of youth were still living at their intended destination upon departure from the shelter. Youth living at home at follow-up had frequent contact with family while at the shelter, had a relatively short shelter stay, and usually left the shelter for home. Youth in unconventional living arrangements had little contact with family while at the shelter, had short shelter stays, and left the shelter in unplanned ways for unstable environments.
Hyun et al., 2005
  1. Cognitive-behavioral therapy (n=14)
  2. Control group (n=13); random assignment
Shelter youth, all male sample 8 weeks post-baseline (100%) Self-efficacy scores significantly increased for the treatment group at follow-up. Depression scores significantly decreased for the treatment group. No changes in self-efficacy or depression were found for the control group. Self-esteem scores did not change in either group.
Jacob et al., 2004 Program evaluation of Model for Orphan Resettlement and Education (MORE) (n=402) Orphans and street youth age 5–17; 91.8% male; youth from Uganda Not applicable Street youth and orphans virtually disappeared from the streets after program implementation. Strengths of the program include government action and taking responsibility for homeless youth and decreased incentives for youth to live on the streets. Weaknesses include an increasing fear of police, substandard conditions at the shelter, rising costs, and lack of educational opportunities for youth inside the shelter. The lack of structure and increasing costs of the program threaten its sustainability.
Lam and Cheng, 2008 Unstructured and semi-structured interviews, and observations (n=11) Street youth age 13–16; 72.7% male; 100% from China Not applicable Youth felt trapped and imprisoned inside the highly restrictive shelter. Complaints about boredom and lack of freedom were also common. The “prison”-like environment discouraged youth from seeking shelter services. Only two youth expressed appreciation for the family reintegration policy of the center; most tried to escape from being forced back into abusive homes.
Taylor et al., 2007 Mental health service intervention (n=150) Homeless youth age 16–29, 53.3% male, 86.6% White British, 4% mixed, 1.3% Black Caribbean, 1.3% Black African, 2% Black British, 4.7% other Follow-up completed at discharge (45%) No change was found between the initial assessment and discharge for physical illness or disability problems, and living conditions. The risk of self harm significantly decreased at post-intervention. Youth who had previous mental health problems, were at risk of drug abuse, attended many sessions, had a planned discharge interview, and had attended a satisfactory number of sessions with their counselor were more likely to improve on the mental health measure.
Qualitative Studies
Darbyshire et al., 2006 Individual interviews (n=10) Homeless youth age 16–24, 70% female Not applicable Youth resented being labeled and further marginalized by service providers. Quick, impersonal assessments and vague medical explanations added to feelings of discomfort. Positive experiences with service providers resulted from trust, respect and kindness.
Ensign and Gittelsohn, 1998
  1. Individual interviews (n=6)
  2. Focus groups (n=31)
  3. Free listing and pile sorting activities (n=15)
Shelter youth age 12–17, 98% from Baltimore City, MD Not applicable The most frequently listed health problems for shelter youth were STD’s, HIV/AIDS, pregnancy, depression, drug use, and injuries. Youth were willing to seek medical assistance if care was confidential, teen-friendly, and non-judgmental.
French et al., 2003 Individual interviews (n=16) Homeless, or at-risk for homelessness youth age 14–21 Not applicable Four themes regarding successful program engagement emerged: personal characteristics, attractiveness of the services, accessibility of the services, and assertiveness of the follow-up procedure. Youth needed service providers to be understanding, trustworthy, and non-judgmental. Engagement strategies needed to be tailored to the individual because of the heterogeneity of at-risk youths’ situations.
Karabanow and Rains, 1997 Case study of residents (n=44) and staff (n=18) Street youth age 16–21, 30 current residents, 9 former residents, 5 street kids who were never residents of this shelter Not applicable Youth reported feeling alienated by the rigidly enforced structure of the shelter. Feeling cared for by staff and viewing the shelter as a safe, second home were the main reasons youth chose to remain and/or return to the shelter.
Kidd, 2003 Individual interviews (n=80) Street youth age 15–24, 61% male; 85% Caucasian, 9% Native Canadian, 6% other Not applicable Making friends on the street is essential for setting up a support system and learning the culture of the streets. Youth learn to value themselves in order to block out negative comments and actions from others. Surviving such hard times gives youth a sense of pride, and they were hopeful for a better future. Youth coped with stress by socializing with friends, using drugs or alcohol, doing a hobby, finding a place to think, and sleeping. Developing useful skills to produce self worth was also important.
Nebbitt et al., 2007 Focus groups and interviews with shelter providers (n=25) and former shelter youth (n=21) White and African American sample: 23% youth, 24% providers were African American; Female: 76% youth, 64% providers Not applicable Family support and outreach was associated with youth successfully returning home after a shelter stay. Youth who returned home were engaged in treatment at the shelter and developed caring relationships with staff.
Thompson et al., 2006 7 focus groups (n=60, average of 8 youth per group) Homeless youth age 16–24, 47% female; 65% Caucasian, 23.3% Latino/a, 9.7% African American Not applicable Youth utilized services in environments which they felt were safe and clean from service providers who were respectful, trustworthy, and kept information confidential. Although most youth had health problems, few used medical services. Youth sought independence and resented rigid rules and providers who treated them like children. Additionally, they did not want to be viewed as victims.
aCommunity Reinforcement Approach
bPatient-Delivered Partner Therapy
cBrief Motivational Intervention
dEmotion-Based Family Therapy
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