Limitations to the design should be considered when interpreting the study findings. We tracked youth through one urban drop-in center, and no control group was used. Youth who access drop-in center services and agree to participate in treatment services may differ in levels of motivation, distress, and history of system involvement from youth who would not access services or participate in treatment. Findings may not be replicated in other areas of the United States, subject to different political, economic, and social pressures. While findings from this study cannot determine whether outcomes are attributable to the drop-in center alone, we evaluated outcomes over a 12-month period in street youth who received treatment through a drop-in center, which is currently absent in the literature. Improvements were observed among youth up to 12 months postbaseline in percent days being housed, psychological distress, and substance use.
Securing housing is an important goal for homeless youth and service providers. Our study showed that a decrease in substance use was associated with an increase in housing. This finding corroborates research which identifies homelessness as a risk factor for mortality, alcohol and drug use, victimization, and physical and mental health problems (e.g., Roy et al. 2000
). While substance abuse problems can precede homelessness (Caton et al. 2005
), some research suggests that homelessness leads to drug use (Roy et al. 2003
). Similarly, Wright (1990a)
noted that while 41 percent of the HCH sample of adults reported alcohol problems, 25 percent reported that drinking problems emerged after the onset of homelessness.
The finding that lower percent days of education at baseline was associated with a greater decrease in psychological distress is puzzling. Youth with less education may have had fewer connections with positive role models; the connection with positive role models offered through the drop-in center may be especially potent for ameliorating psychological distress.
No research was found identifying predictors of change in homelessness among youth. Predictors of exiting/change in homelessness are not well understood even among adults (Shinn et al. 1998
; Dworsky and Piliavin 2000
; Caton et al. 2005
). In this study, individual characteristics including age, education level, and ethnicity were not predictive of change in homelessness. This is similar to the findings of Shinn et al. (1998)
who found that individual characteristics were more important in predicting shelter requests than in predicting later stability among the adult homeless. However, females increased the percent days housed over time to a greater extent than males, which is consonant with findings indicating higher rates of homelessness among male youth (Yoder, Whitbeck, and Hoyt 2001
). Our finding that higher baseline substance use did not predict housing over time does not corroborate prior findings that substance abuse and mental illness reduce the likelihood of exiting homelessness (Dworsky and Piliavin 2000
; Caton et al. 2005
). However, those studies were not treatment evaluation studies, and without treatment, the impact of substance use on outcome is likely more negative.
Research examining the relationship between housing and substance use treatment among street living youth was also not found. Among adults, focus on meeting basic needs such as housing before addressing substance use and mental health issues is contrary to the continuum of care model, which first targets substance and mental health issues within a temporary housing setting and then transitions individuals to permanent housing (Tsemberis et al. 2003
). Whether to provide abstinence based housing (ABH), or non-ABH (NABH) is debatable. Tsemberis et al. (2003)
found that NABH housing led to greater housing stability at 24 months compared with ABH. However, Milby et al. (2005)
found no differences in housing outcomes among those assigned to ABH compared with NABH at 6 months. Neither study reported differences in substance use rates. However, Milby et al. (2005)
found that abstinence rates were higher in housed compared with nonhoused groups, highlighting the importance of housing in the treatment of homeless substance abusers and replicating earlier findings showing the importance of housing on abstinence (Milby et al. 1996
Even with the promising findings, there is need for improvement. While psychological distress and substance use significantly decreased and the percent days housed increased among youth, most youth did not acquire permanent housing. Moreover, education, employment, and medical care use did not increase over time. Drop-in centers and outreach programs are limited in acquiring housing for homeless youth. Homeless youth who are minors are not able to sign leases for apartments or independent living programs without a legal guardian's co-signature, limiting their ability to stabilize, work, and maintain attendance in school. While shelter programs are usually charged with improving the housing status of the homeless, street living youth often avoid shelters and the foster care system (Kipke et al. 1995
; De Rosa et al. 1999
Attention paid to reorganizing the system of care for homeless youth to ensure adequate housing is necessary in order to facilitate reintegration. A transitional housing program in Colorado offers housing, medical care, substance use, and mental health services to homeless youth (Van Leeuwen 2004
). In an evaluation of this program, it was estimated that it costs $5,887 to permanently move a homeless youth off of the streets while it costs Colorado $53,655 to maintain a youth in the criminal justice system for 1 year and $53,527 for residential treatment. This underscores the cost effectiveness of such service provision. Van Leeuwen notes that in 2003, 60 percent of the youth who entered the Colorado program permanently exited the streets. While this is impressive, it also suggests that housing alone may not be the sole panacea to exiting life on the streets.
Outside of the McKinney Vento Act devoting funds to outreach, group homes, and runaway shelters, little policy is available to guide intervention with homeless youth. State laws allowing access to mental health services and independent living programs would offer homeless minors an opportunity to access needed services without parental consent. The Good Samaritan Initiative did not impact the current project as Albuquerque, New Mexico had not yet begun to implement its 10-year plan. Even so, as of 2007, nearly 200 plans are completed or under development around the United States and the National Alliance to End Homelessness (2006)
notes that many communities have markedly reduced homelessness. However, the plan does not address the barriers to providing housing to minors without a guardian co-signature and who avoid the foster care system. Advocacy organizations, service providers, and researchers are beset with a challenge in which service provision, policies, laws, and funding must converge to successfully intervene in homelessness. Such convergence requires the collaborative efforts and consultation among many groups including those targeted by intervention efforts.
Conclusions and Implications
We showed that substance use and mental health services can be effectively integrated into drop-in services for homeless youth, and these youth can be engaged and maintained in treatment. Many barriers to more intensive treatment—including transportation, trust, and financial services—are addressed through offering substance use and mental health services as part of the menu of options at a drop-in center. The findings also indicate that follow-up with youth is important to enhance service provision. Housing is an important prerequisite for stabilization, yet for youth, acquiring housing is a barrier to successful reintegration.