Youth Mental Health & Homelessness: Looking Upstream for Solutions
By Melissa A. Kull, PhD; Amanda M. Griffin, PhD; Alesha Alexcee; and Anne F. Farrell, PhD
Social Work Today
Vol. 22 No. 2 P. 16

An examination of the current situation laments missed opportunities but holds hope for the future.

The word “homeless” conjures a visual image, often a negative one. As educators and human service providers, we are not immune to such images. We might envision an adult living on the street, unsheltered, sometimes with unaddressed mental health or substance use issues. A shopping cart. A person who lacks connections. A mother evicted with her children. A veteran who completed his service and returned to a community without supports to reenter the workforce. Maybe the person is holding a sign. Communities often prioritize services for adults experiencing homelessness because they are visible.

Youth homelessness looks different. It is fluid and hidden. It is the culmination of missed opportunities in families, schools, health systems, and communities. However, it’s possible to turn those missed opportunities into new opportunities for young people to thrive.

Youth and young adults (YYA) rarely come to mind when we think of homelessness.1 “Unaccompanied youth” refers to an individual between the ages of 13 and 24, on their own, experiencing homelessness. Homelessness among young people is largely hidden; it may involve couch hopping with friends (couch hopping here refers to nonvoluntary forms, eg, a young person who goes from household to household without a choice, and is subject to dismissal or exploitation, as distinguished from intentional couch surfing as part of travel), staying in a shelter, or being unsheltered (sleeping in a place not fit for human habitation).2

Chapin Hall’s national study found homelessness in 1 out of 30 youth aged 13 to 17 and 1 out of 10 young adults aged 18 to 25 in a single year. Young people experiencing homelessness include parents with young children, youth met with rejection after disclosing their sexual orientation or gender identity, and youth who ran away from a foster home or “aged out” of foster care. The study found that around one-third had prior foster care involvement, almost one-half had prior justice system involvement, and about one-quarter had their first episode of homelessness as children.2

Annual point-in-time counts, which enumerate sheltered and unsheltered people experiencing homelessness on a single day, notoriously undercount YYA. Why? Because these young people look like their peers. They are not carrying signs. They don’t want to be homeless nor do they see themselves as homeless.

Chapin Hall’s Voices of Youth Count initiative revealed that young people who identified as Black, Hispanic, and Indigenous, as well as lesbian, gay, bisexual, queer, transgender, or gender nonconforming (LGBTQ+) were at a greater risk for homelessness.2,3 Young people with these identities, or those who are part of other marginalized groups, experience more threats to mental health and wellbeing than their counterparts from white, heterosexual, and cisgender (an individual whose gender identity corresponds to the sex assigned at birth) groups.

Youth homelessness may be less visible, but it occurs during an important developmental window, one in which precious energies should be committed to aspiration and growth rather than a struggle to meet basic needs for safety, food, clothing, and shelter.

Missed Opportunities
There is ample evidence that individuals who identify as Black, Indigenous, and People of Color (BIPOC) are at disproportionate risk of experiencing homelessness and mental health concerns. Likewise, there are disparities in child welfare and juvenile justice system involvement among these historically marginalized groups (eg, Black/African Americans, Native Americans, and sexual and gender minorities).4 Because of longstanding discrimination and systemic injustice, these young people may be reluctant to engage with systems they see as perpetuating inequity.

Aversive and disproportionate engagement with school discipline and legal systems among BIPOC and LGBTQ+ youth have a compounding effect. These young people are more likely to experience housing instability; barriers to high-quality, affirming health, education, and human services; mistrust in the health care system; and a lack of resources (including insurance) that prevent access to valuable supports.5,6

Mental Health Threats
The experiences that precede homelessness, and homelessness itself, are stressful and traumatic. It is unclear whether mental health challenges preexist or develop because of housing instability, but it’s likely both. Developmental science tells us that the onset of mental health disorders can be triggered by stressful events.7,8

Mental health problems are undoubtedly exacerbated by homelessness and housing instability, which may include exposure to violence, exploitation, and an inability to meet basic needs.9

According to the National Alliance on Mental Illness, 75% of lifetime mental illnesses develop by the age of 24, and 1 in 3 young adults between the ages of 18 and 25 has a diagnosable mental illness.10

These numbers are even more alarming for unhoused youth. A recent national study found that 69% reported mental health difficulties and 29% reported substance use problems.2 PTSD, depression, and anxiety are the most common difficulties in this population.11 Additionally, access to mental health services is inequitable: BIPOC youth are not only less likely to receive mental health services but also less likely to be offered evidence-based services.12 As a result, the intersectionality of predisposing contexts magnifies risk while diminishing access to timely, effective supports.

The Diverse and Common Characteristics of Homelessness
Each person’s pathway into homelessness is unique. At the same time, homelessness is preceded by common critical conditions that set the stage for housing instability. One-third of youth experiencing homelessness faced the death of a caregiver and many more experienced numerous adversities such as family homelessness, physical and/or sexual abuse, poverty, isolation, and exposure to family substance use and mental health problems.12,13

Absent resources to buffer young people from traumatic experiences, sustained stress can alter an individual’s neurobiology.7

One thing is clear: Young people likely interface with helping professionals and systems ahead of episodes of homelessness. That being the case, it’s likely those are missed opportunities to prevent homelessness and support YYA. We are failing to pick up on signs of anxiety and depression.

Because housing instability involves frequent moves, episodes of homelessness leave young people without access to the systems most likely to assist them: They are absent from school or work and lack access to health and behavioral health care. Commonalities in the pathways to homelessness show us the doorways to prevention, identification, and intervention.

Preventive Measures
There is a national public health goal of eliminating health disparities and achieving health equity. In addition, there is recognition that systems pay insufficient attention to screening for depression and that too few young people receive appropriate supports for trauma.14

Public health approaches to wellness reduce risk, ensure access to preventive services, identify and address problems before they solidify, and reduce their duration and chronicity. As a nation, we tend not to invest in proactive prevention efforts, particularly when it comes to mental health. This is analogous to envisioning the entire health care system as an emergency department. Reactive approaches have high financial and human costs and can disenfranchise young people.

Critical conditions combined with a dearth of affordable housing and a reactive approach to homelessness leave young people facing housing and mental health crises. One does not have to experience homelessness to understand that it presses hard; the energy and will required to attend to basic survival does not leave much room for vocation, education, or aspiration. It is no wonder that young people experiencing homelessness are less likely to graduate from high school, attend college, and succeed in higher education.15-17

We tend to view homelessness as an individual problem rather than a failure of systems to identify young people in need of support. Alternatively, we can go upstream to identify risks and early signs of mental health and housing problems. Early identification can bolster youth resources by building on their assets, positively changing their trajectories. Many young people demonstrate the “ordinary magic” of resilience in remarkable ways, surviving and succeeding despite challenges.18

To date, little research has addressed the prevention of homelessness and accompanying mental health problems. A recent systematic review revealed numerous promising and effective practices to improve mental health.19 Overall, evidence is lacking on how intervention effects vary by the subpopulations disproportionately impacted by homelessness. A small evidence base shows that youth homelessness is preventable by targeting youth at risk for homelessness and delivering tailored casework supports.

Going Upstream: Communities Promoting Positive Outcomes
Preventing homelessness is no easy feat, but screening and early identification are critical means of diversion. Children, youth, and families interact with various systems that can prevent risk from becoming crisis and crisis from becoming homelessness.

Recognizing that social determinants of health such as housing instability can have long-term mental health repercussions, some Connecticut Head Start programs use a screening tool to understand family housing circumstances, risks for homelessness, social support, and mental health among a population that is largely BIPOC.20 The tool enables prompt referrals for local supports, or connection with housing subsidies and other concrete supports.21 This approach may interrupt an intergenerational cycle of housing instability.

Going upstream in middle and high school means universal screening for factors that place students at risk for mental health problems, school disengagement, and housing instability and homelessness. Currently, two early adopter communities in Minnesota and California are implementing adaptations of a project that originated in Australia as The Geelong Project.22

Geelong demonstrated dramatic decreases in youth homelessness and school dropout. The US adaptation, the Upstream Project, is a multitiered system of support, including universal screening that identifies students at risk.23 Once children/families are identified, school staff offer to facilitate connections to resources, including mental health and housing supports. The two US pilots assist school staff to provide supports to students and families experiencing or at risk of homelessness, a disproportionate amount of whom are BIPOC and LGBTQ+.

What’s Next?
Although there are not always options, programs, or policies in place to prevent young people from becoming homeless, there is an array of promising solutions. One of these solutions is direct cash transfer programs, which entrust young people experiencing homelessness with agency over their resource expenditures. New York City is currently piloting the Trust Youth cash transfers initiative, which offers cash transfers and supportive services to young people.24 Although cash transfers are not currently a form of primary prevention, demonstration of their effectiveness may spur policymakers to move cash transfers upstream.

Effective programs ensure that historically marginalized groups benefit from tailored support services that are feasible and culturally relevant. Interventions focused on LGBTQ+ youth can strengthen family and peer communication, increase acceptance of sexual orientation, and support family reunification. Young people will disengage from providers who come across as judgmental or culturally unattuned. Several federal, state, and local programs require youth to participate as expert advisors, contributing their understanding of and experience with mental health and homeless systems, and advocating for change. YYA are also employed as peer counselors, case managers, and systems navigators.25

Facing provider shortages, some schools and communities create mental health service delivery frameworks that integrate paraprofessional mentors in the context of multitiered systems.26 For example, Massachusetts licenses programs in which therapeutic mentors work in the community as part of an interdisciplinary team.27

A recent systematic review reveals that peer and near-peer supports can be effective while noting several challenges, including ensuring that peer counselors are supported adequately as they negotiate difficult circumstances.28 There are unexplored avenues along these lines.

The federal Runaway and Homeless Youth Act authorizes community supports for unaccompanied youth. Administered by the Family and Youth Services Bureau, runaway and homeless youth projects provide temporary shelter and care to youth in need of temporary shelter, counseling, and aftercare.29 The bureau also funds the Runaway and Homeless Youth Training and Technical Assistance Center, which conducts an annual provider needs assessment and offers technical support to local programs to advance their efforts to serve youth experiencing homelessness, such as by building referral networks with mental health resources.30,31

Another promising path to mental health supports and policy solutions is the Youth Homelessness Demonstration Program, a community initiative funded by the Department of Housing and Urban Development that awards grants to communities committed to transforming their youth homelessness systems, prioritizing youth involvement and equitable service provision.32 The Youth Homelessness Demonstration Program can strengthen connections between youth service providers and mental health resources across the community to ensure that youth obtain needed supports. These programs can support local innovations, including upstream efforts and the involvement of YYA as advisors.

Among the landscape of systems and services, a recognition of the impact of youth homelessness, the critical conditions that precede it, the mental health challenges it provokes, and the services to reduce its impact are relatively young. Opportunities to shore up housing and mental health among our nation’s youth have been missed. However, evidence suggests both established and emerging programs can be effective. The time has come to transform this knowledge into innovations that interrupt pathways to homelessness and help the next generation enter adulthood on solid footing.

— Melissa A. Kull, PhD, is a developmental psychologist and policy researcher at Chapin Hall at the University of Chicago where her research focuses on improving the systems that address family and youth homelessness, particularly in the domains of screening and referral processes. Her postdoctoral training focused on epidemiology and public health, which involved working at the New York City Department of Health and Mental Hygiene to design, implement, and evaluate school- and community-based mental health programs for children and youth.

— Amanda M. Griffin, PhD, is a prevention researcher at Chapin Hall at the University of Chicago where she develops and evaluates resources and programs designed to address social disparities and inequities facing youth and families experiencing homelessness. Prior to joining Chapin Hall, Griffin was at the University of Oregon Prevention Science Institute as a postdoctoral fellow through a National Research Service Award grant from the National Institute of Child Health and Human Development.

— Alesha Alexcee is a researcher at Chapin Hall at the University of Chicago whose work informs and advances systemic change through collaboration with youth and community stakeholders, guided by values of antiracism and inclusion and driven by principles of positive youth development. Prior to joining Chapin Hall, she worked at the Reengagement Hub at Monroe Harding as a peer support worker providing direct services to youth and young adults.

— Anne F. Farrell, PhD, is a translational researcher and the director of research at Chapin Hall at the University of Chicago. Former faculty at the University of Connecticut, she is coeditor of the Journal of Child and Family Studies and leads a research agenda aimed informing policies and practices that inequitably affect individual, child, family, and community well-being.

References
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2. Chapin Hall at the University of Chicago; Voices of Youth Count. Missed opportunities: youth homelessness in America: national estimates. https://voicesofyouthcount.org/wp-content/uploads/2017/11/ChapinHall_VoYC_NationalReport_Final.pdf. Published 2017.

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21. Housing choice vouchers fact sheet. U.S. Department of Housing and Urban Development website. https://www.hud.gov/topics/housing_choice_voucher_program_section_8.

22. The Geelong Project. Barwon Child, Youth & Family website. https://www.bcyf.org.au/youth-services/the-geelong-project/

23. The Upstream Project. Chapin Hall at the University of Chicago website. https://www.chapinhall.org/project/leading-on-youth-homelessness-prevention/

24. Public-private partnership launches the first direct cash transfer study for addressing young adult homelessness. Chapin Hall at the University of Chicago website. https://www.chapinhall.org/news/public-private-partnership-launches-the-first-direct-cash-transfer-study-for-addressing-young-adult-homelessness/. Published June 17, 2021.

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32. Youth Homelessness Demonstration Program. HUD Exchange website. https://www.hudexchange.info/programs/yhdp/