Doctors underprepared for challenges homeless teens face

Adolescents who experience homelessness are more likely to face a barrage of mental and emotional problems-moreso than their nonhomeless peers-but there is little scientific direction for clinicians on how to help them.

In a new study, published in Pediatrics, Andrew J. Barnes, MD, MPH, assistant professor and fellowship director, Developmental-Behavioral Pediatrics, University of Minnesota, Minneapolis, compared factors such as suicidality, self-esteem, school and parent connectedness, academics, and more among more than 62,000 8th- though 12th-graders-some who had experienced homelessness and those who had not.

In total, about 4500 of the students had experienced homelessness at some point, and 42% endorsed high levels of emotional distress. Another nearly 30% reported self-injury, 21% reported suicidal ideation, and 9.3% revealed that they had attempted suicide in the past year.

“Teens who have experienced family homelessness in the past year are at over twice the risk for suicide attempts and related emotional health problems, above and beyond their race or poverty status or whether they live in an urban or rural area,” Barnes says. “Furthermore, although developmental factors such as self-esteem do reduce this risk, these positive factors are both less common and less protective than for youth with stable housing.”

Children who had been homeless also had fewer positives to fall back on, including positive teacher relationships, empowerment, and academics, the study adds. Positive development assets and identities were 10% less likely to reduce suicide risks in children who had been homeless compared with their nonhomeless peers, according to the report. The study also notes that girls who had been homeless who were closely connected with their parents were less likely to self-harm or have suicidal thoughts than homeless boys who were close to their parents.

A growing homeless population

Children who are homeless along with an adult family member make up about 40% of the homeless population in the United States, Barnes says, and also represents the fastest-growing proportion of homeless individuals.

Most pediatricians have been touched by children who have experienced homelessness, but Barnes notes that there is a lack of scientific knowledge and evidence-based practice guidelines to assist clinicians in helping this population.

“The American Academy of Pediatrics (AAP) noted in a 2013 Policy Statement that pediatricians should remember that homeless youth are at high risk of physical and mental health problems, but up until now, most of what we knew about this was based on research without a comparison group of housed youth, and was based on youth who were homeless without a family member,” Barnes says. “Our research highlights that these risks remain elevated even for youth who are homeless with their families and living temporarily in emergency shelters or even living ‘doubled up’ with another family-and being homeless with a family member is much more common for youth than being homeless alone, actually.”

Homelessness and mental health

Both the AAP and the US Preventive Services Task Force recently updated guidance about screening all adolescents for depression on a regular basis, and beginning treatment early with evidence-based methods including therapy.

“That remains even more true for youth who’ve been homeless, and it seems to me it would make sense to do that screening with an instrument that includes questions about suicide such as the PHQ-9A or the Children’s Depression Inventory,” Barnes says. “Furthermore, youth who’ve been homeless are likely to have been exposed to trauma, violence, or maltreatment and thus would likely benefit from a trauma-informed approach both to their primary care and to any therapy they might be referred to as an intervention for emotional health problems.”

Barnes says the recently revised GLAD-PC guidelines and the AAP’s Bright Futures materials both offer helpful tools for pediatricians to tackle mental health issues for teenagers in primary care. Pediatricians also should work to advocate for fair and equitable housing policies for families in their area, to partner with local social service agencies, to have trauma-informed practices in their clinics, and to integrate social workers into their clinical practices.

“In areas where mental health care for youth is lacking, pediatricians might, first of all, make sure that the family understands that homeless students have certain rights in their schools thanks to an act of Congress several years ago called the McKinney-Vento [Homeless Assistance] Act, including staying in the school they are enrolled in if they lose their housing,” Barnes says. “As clinicians, we need to keep housing, and other social determinants of health, such as hunger, on our radars as we talk with our patients and their families about stressors and changes in their lives over time.”