Dina Wilderson, Director of Research and Evaluation at Larkin Street Youth Services, oversees agency-wide data management, conducts internal program evaluations, leads the agency's research initiatives, and coordinates dissemination activities. She has over ten years of experience in the social services field in both direct service and administration and holds a Ph.D. in Child and Family Studies from Syracuse University.
JoAnn Lee, Manager of Research and Evaluation at Larkin Street Youth Services, has experience in program evaluation and data analysis in both the public and non-profit sectors. She holds dual Master's degrees in Social Work and Public Policy from Columbia University.
Eliza Gibson, Chief of Programs at Larkin Street Youth Services supervises Program Directors and coordinates services across all programs. She is a licensed clinical social worker with over ten years of experience in program development, management, direct services, and psychotherapy.
The transition into adulthood can be a challenging period for anyone. Youth entering adulthood must develop the skills needed to become responsible for their own well-being and care. Most people believe that age 18 is too early to expect youth to be independent and able to live on their own. In fact, most believe that youth should not be considered independent until they reach age 23 (Lake, Snell, Perry, & Associates, 2003). Approximately 40% of youth return to their parental home after leaving to live independently (Osgood, 2006).
Adolescence is a time when we develop the crucial relationships and networks that will stay with us and assist us throughout life. Many youth, especially those who attend a four-year college, receive a considerable amount of family and institutional support as they gradually learn to manage their own schedules, finances, and other life events. Other youth are forced to transition into adulthood with little preparation, guidance, or support. There is no system focused on meeting the needs of transition aged youth, therefore they are likely to remain unnoticed until they become adults dependent on the system. It is estimated that 5% to 7% of American youth will not successfully transition from adolescence into adulthood by the time they have reached age 25 (Wald & Martinez, 2003). These are the youth who reach adulthood without employment, independent living skills, or social support systems.
An often overlooked segment of the transition aged youth population are homeless youth, a group with a distinct set of issues and challenges. For the purpose of this article we will use the term homeless youth to include both youth who are without housing altogether, as well as youth in unstable living arrangements. The unstably, or marginally housed, group include youth who bounce from one transitory housing situation to another, staying temporarily with relatives or crashing on friends' couches. Homeless youth often fall into at least one additional group identified as being high risk for failing to make the transition into self-sufficient adulthood: previous involvement in the foster care system, previous involvement with the juvenile justice system, or high school dropout (Wald & Martinez, 2003).
Homeless transition age youth have complex issues that need to be addressed if they are to reconnect into mainstream society. The first step is to move youth beyond survival mode. After their basic needs have been met it becomes possible to engage them at the next level of services. This article will discuss the issues impacting homeless youth, their service needs, and the Larkin Street Youth Services model of care to address these issues and needs.
Youth Homelessness
Homelessness is believed to affect between 1 and 1.7 million youth in the United States, an estimated 5% to 7.7% of all youth (Moore, 2006; National Alliance to End Homelessness, 2006). California is one the most popular destinations of homeless youth due to its large population, mild climate, and liberal reputation. There are as many as 4,000 homeless youth living on the streets each year in San Francisco (San Francisco Workgroup on Homeless and Runaway Youth, 2005).
Homeless youth are a diverse group with a combination of risks and challenges for a successful transition into adulthood. However, there are common paths into homelessness. Homeless youth often fall into at least one of the following categories: runaway youth, foster care youth, high school drop out, or low-income household. It is important to note that these groups are not discrete and often overlap.
Runaway Youth
It is estimated that between 500,000 to 1.5 million young people run away or are forced out of their homes every year (Moon et al., 2000). Family conflict or dysfunction is the primary reason that youth under the age of 18 leave home (Family and Youth Services Bureau, 2004). About half of youth surveyed in shelters said that their parents or caretakers either asked them to leave home, or knew that they were leaving and did not care (Family and Youth Services Bureau, 1998). Youth who are homeless as a result of family dysfunction have often experienced some form of neglect or abuse. Neglect is the most commonly reported experience (57%), followed by physical (40%) and sexual (31%) abuse (Robertson & Toro, 1999). These problems are longstanding, a one-time event is not the catalyst for the youth's departure from their family home (Smollar, 2001).
Family problems often permeate beyond the parent-child dyad, with these families reporting higher rates of substance abuse and family violence (MacLean, Embry, & Cauce, 1999). In one study, almost 50% of runaway youth reported that their caretaker had participated in either alcohol or substance use treatment (Johnson, Whitbeck, & Hoyt, 2005). The magnitude of substance abuse issues in the home environment is likely to be more prevalent than the number of youth reporting parental treatment.
Youth leave untenable home environments without money, clothing, or a safe place to stay. Once on the streets, their lives are often no better than the ones they left behind. They sleep where they can find minimal shelter and scrounge for food. Having broken ties with their families of origin, they often develop into family-like groups with other street youth, which serves as a support system.
Foster Care Youth
Former foster care youth are disproportionately represented among the homeless population. Estimates are that between 38% and 70% of homeless youth have previously spent time in an out-of-home placement (Moore, 2006). A large number of youth, between 12% and 45%, emancipate from the foster care system directly into homelessness (HomeBase, 2001). In addition, youth who have been in the foster care system are homeless for a longer period of time than youth who have not been in the system (HomeBase, 2001). Youth leave the system without the requisite skills to live independently, making their transition to self-sufficiency particularly challenging, and with the end result being homelessness.
High School Dropout
There is often a history of school failure among youth prior to their homelessness. One study found that only 44% of homeless youth had attended school regularly before leaving home, 43% had failed or repeated a grade in school, and 11% had failed a grade more than once (Smollar, 2001). Up to 75% of older homeless youth have dropped out of high school (Cauce et al., 2000). Research has shown that high school dropout status is linked to periods of unemployment, 50% of youth without a high school diploma were out of the labor force for three years or more between the ages of 18 and 25 (Wald & Martinez, 2003). Lack of educational attainment limits employment options for youth and impacts their ability to attain self-sufficiency.
Low Income Households
Many youth find themselves homeless due to their families' low economic status and/or residential instability. One study found that 40% of youth had parents who received public assistance or lived in public housing (Moore, 2006). Most young adults depend on their parents for financial support until at least the age of 21. In the general population parents continue to provide financially for their children into adulthood, providing as much as a third of the annual amount paid to support them before age 18 to them later in life, up to the age of 34 (Osgood, 2006). For youth without this financial safety net homelessness is sometimes the result. Some youth are originally homeless as part of their family, and then set off on their own. Others are forced to leave their home environments when they become older because their families are not able to provide for them due to a lack of financial resources.
Issues Facing Homeless Youth
The time between ages 18 and 24 is challenging even for those with the financial and emotional support of their family. Homeless transitional youth lack the safety and support of family and home. They lack educational attainment and possess few job skills. Their ability to take steps toward long-term independent living is severely hindered by the demands of day-to-day survival. These transitional homeless youth are in need of services that will help them stabilize and begin the shift into independent adulthood.
Basic Needs
The most pressing issue for homeless youth is ensuring that their basic needs get met. They are constantly struggling to secure food, clothing, and shelter. Two-thirds of street youth reported having problems meeting their basic needs (Family and Youth Services Bureau, 1998). Safety is also a paramount concern. Street youth face high rates of victimization, including robbery and rape (Cauce et al., 2000). Between 30% and 50% are physically assaulted, and one in four reports being seriously hurt by a violent attack while on the streets (Kipke, Simon, Montgomery, Unger, & Iversen, 1997). Homeless youth live in the day-to-day. Forced to focus on their basic needs and short-term survival, they have little energy or capacity to plan for their future.
Education and Employment
Homeless youth lack the education and employment skills necessary to connect to the job market. Most have not completed high school or acquired the basic work skills and experience required for entry level jobs. The lack of educational attainment has serious implications for future earnings. On average, an individual with a high school diploma earns $6,000 more a year than an individual with 11 years of schooling, and those with a college degree earn more than twice annually that of those with only a high school diploma (Rouse & Barrow, 2006). Not only do these youth lack education, but they also do not have the career guidance that high schools and colleges often provide for their students. These youth have very few options, and limited opportunities to educate or train themselves when they must provide for their most immediate needs.
Physical Health
Among the range of problems that impact homeless youth are poor nutrition, exposure to the elements, irregular sleep, and overall poor health (Moore, 2006). They are at high risk for a number of health problems including hepatitis, asthma, pneumonia, nutritional disorders, and skin infections (Robertson & Toro, 1999; Smollar, 2001). Their survival techniques put their health in jeopardy. In the Bay Area 42% of homeless youth exchange sex for money or shelter (HomeBase, 2001). Due to their participation in survival sex and other high-risk behaviors homeless youth are at high risk for STIs and HIV (Auerswald, Sugano, Ellen, & Klausner, 2006). Moreover, the health of these youth deteriorates the longer they have lived on the streets.
Behavioral Health
With the majority of homeless youth reporting a history of family substance abuse, it is not surprising that rates are high among this group. In a study on the prevalence of substance abuse issues, 61% of runaways met the DSM-IV lifetime criteria for alcohol abuse, alcohol dependence, or drug abuse (Johnson, Whitbeck, Hoyt, 2005). Of those, 93% also met criteria for another mental health disorder, such as PTSD, depression, anxiety, thought disorders or conduct problems (Johnson, Whitbeck, Hoyt, 2005). The causal direction and relationship between substance use, mental health, and homelessness is unclear. However in order to assist these youth to make a successful transition into adulthood attention must be paid to behavioral health issues.
Mental Health
Homeless youth have disproportionate rates of mental health issues and disorders. The majority of these youth report histories of family dysfunction, experiences that often translate into mental health issues. In a study of the mental health of homeless adolescents, ages 13-21, Cauce et al. (2000) found that two-thirds of their sample met criteria for at least one of a handful of disorders: conduct disorder, oppositional defiance disorder, attention deficit disorder, major depressive disorder, mania/hypomania, post traumatic stress disorder (PTSD), or schizophrenia. Comparatively, 26% of the U.S. adult population meets criteria for at least one mental disorder (National Institute of Mental Health, 2006).
Homeless youth have had traumatic experiences, either in their home environment, on the streets, or both. This trauma can produce a state of psychological distress and exacerbate any existing conditions (Whitbeck, Chen, Hoyt, Tyler, & Johnson, 2004). In a sample of San Francisco street youth, two-thirds met the criteria for post-traumatic stress disorder (Robertson & Toro, 1999). There are also high levels of suicidality and suicide attempts; 26% of youth in shelters and 32% of youth on the street have attempted suicide (Family and Youth Services Bureau, 1998; Smollar, 2001).
Substance Use
Adolescence is a time of experimentation, and it is not uncommon for youth to experiment with substance use, regardless of their living conditions. However, research shows there is a higher prevalence of substance use among homeless youth than among housed youth. Substance use often becomes a coping strategy for dealing with the additional stresses of homelessness and trauma, trying to dull the pain of life on the streets or looking for relief from a psychiatric condition (Baron, 1999). Street youth may also use amphetamines to stay alert at night. The level of drug use among runaway and homeless youth is higher than that of mainstream youth. Runaway youth are three times more likely than non-runaways to use marijuana, seven times more likely to use crack cocaine, five times more likely to use hallucinogens, and four times more likely to use heroin (Koopman, Rosario, & Rotheram-Borus, 1994). One study found that 25.8% of homeless youth use crack cocaine, 23.5% use other forms of cocaine, and 54.7% use other drugs (HomeBase, 2001). Another study of San Francisco street youth found even higher rates with 80% reporting use of crystal methamphetamine or some other form of speed and another 30% reporting heroin use (Denizet-Lewis, 2000).
Research reports clearly demonstrate that homeless youth are impacted to a high degree by behavioral health issues. Mental health issues, substance use, or a combination of both create additional barriers to exiting street life and making successful transitions.
Service Issues
Homeless youth face any combination of the following factors: ongoing trauma from living on the streets, a lack of educational and employment preparation, greater medical needs, emotional and mental health issues, and substance use issues. In order for these youth to transition from the streets and into a self-sufficient adulthood, they need to have their basic needs met and to receive stabilization services.
Homeless youth are forced to develop survival skills that, for the most part, are considered maladaptive in mainstream society. This is usually coupled with a lack of future orientation, due to an inability to see beyond today and a perceived lack of opportunity. Feeling helpless or hopeless was the feeling most reported by a group of homeless youth interviewed about life skill needs (Aviles & Helfrich, 2004). In addition, low self-esteem is a common problem (Moore, 2006). Many of these youth have given up on participating positively in society, often because they do not believe they are able.
Since homeless youth lack mainstream skills and are plagued with feelings of hopelessness, it usually takes time and multiple attempts before youth engage with services and consequently make the transition into mainstream culture. Wald and Martinez (2003) discuss the "transformation" that must occur for disconnected transition aged youth before they will actively seek to change their situation. This is the moment in which disconnected youth commit, emotionally and mentally, to get their lives back on track, regardless of the difficulty (Wald & Martinez, 2003). A comprehensive range of services, with multiple entry points and opportunities for engagement, ensures that when this transformational moment arrives providers are there to seize the opportunity to help these youth change their course.
Model of Care: Larkin Street Youth Services
One model for meeting the unique needs of transition aged youth has been developed and implemented in San Francisco, California by the non-profit organization Larkin Street Youth Services. Larkin Street offers a comprehensive continuum of services to assist youth transition from homelessness to stable living. The central tenet is that housing is the key to stabilization. To that end the agency provides a range of housing options to reach youth at various stages of stability and with various levels of need. Intensive case management is a vital component that runs through all levels of the housing continuum. In addition, the agency provides support services including education, employment, behavioral health services, and medical care.
Philosophy of Service Provision
Housing as a Treatment Modality
Central to Larkin Street's philosophy of service provision is that housing is in itself an intervention, and is crucial to stabilizing the lives of homeless youth. The continuum of housing options is provided to meet the diverse needs of homeless youth. This ensures that youth at various levels of need and self-sufficiency are provided with shelter. It also provides housing at a level that is aligned with the youth's readiness to transition from the streets. Multiple entry points allow youth to be placed in the housing type that is most appropriate for them rather than requiring youth to move through the various levels of housing. Housing provides stabilization for youth and increases their ability to participate in support services.
Focus on Life Skills
For transition aged youth there must be a focus on providing skills needed to live independently. Key areas of skills development for youth that have been linked to later positive outcomes include education, employment, and money management (Youth Transition Funders Group Foster Care Work Group with The Finance Project, 2004). Development of life skills is stressed in the transitional living programs and includes work with participants to develop individualized training in skills such as opening and maintaining a bank account, budgeting, conducting a housing search, landlord relationships, cooking, grocery shopping, paying household bills, and household maintenance. Individual and group life skills interventions occur in each program.
Harm Reduction
Larkin Street services are provided within the context of a harm reduction approach. Harm reduction is a client centered approach that addresses where the youth is in terms of desire to change behavior. Inherent in the approach is the acknowledgment that youth engage in high-risk behaviors. Rather than requiring that they quit participating in these behaviors to receive services, staff members instead work with youth to minimize the harmful effects. Youth are viewed as the primary agents of reducing their risk, and are empowered to share information with peers and support each other in a non-judgmental way.
Housing
Emergency Housing
Emergency housing is the first step in the stabilization process. Youth are able to stay in emergency housing for up to four months. The main focus of this housing type is to provide safety and stability for the youth while simultaneously engaging them in case management to address the additional issues that may be impacting their ability to become self-sufficient. The goal is to connect youth to other internal support services such as education, employment, mental health, and substance abuse services. The development of a housing plan that extends beyond the shelter is one of the important steps for youth engaged at this level.
Transitional Housing
Transitional housing is intended for youth who have achieved a level of stability and demonstrated their ability to follow-through with their case plans. There are three types of transitional housing options offered by the agency: congregate, scattered-site, and supportive housing. The three types differ from each other in terms of supervision level, expectations, and rent payment. Youth in all types of transitional housing are actively engaged in case management and other support services.
Congregate housing. Congregate housing is the traditional group home model of transitional housing. Youth in this program are housed for up to 18 months. There is on-site staff support around the clock, and residents' whereabouts are monitored. Intensive case management is a central component, as well as participation in employment, education, and life skills development. Youth are required to hold employment and 30% of their income is paid as rent, which is put into an interest-earning savings account for the youth. Upon exit from the program, youth utilize these savings as a resource to finance security deposit, move-in costs, and other unexpected future expenses. Another focus is on community participation, both within and outside of the program, and increasing independent access to community resources. Youth in congregate housing need on-site support to assist in their transition but the expectation is that they will be able to live independently upon completion of the program.
Scattered site housing. Scattered site housing provides a reduced level of staff supervision and greater opportunity for youth to practice independent living within a supportive safety net. Youth are housed in apartments in the community for up to two years. Youth receive intensive, outreach case management services in addition to access to support services. Case managers meet with youth as often as needed (one to five times per week) in order to support the youth in maintaining housing and in gaining a greater level of independence. Youth are also expected to meet with an education/employment specialist on at least a weekly basis. Larkin Street holds the master lease on the apartments and provides a shallow rent subsidy to youth. Youth are required to pay 30% of their income as rent, which is again put into an interest earning savings account for the youth. Overtime, the percentage of income towards rent is increased (and the subsidy decreased) to a level as close as possible to the market value of the apartment. Upon exit, if feasible, youth are given the option to take over the lease themselves. Therefore there is essentially a built-in permanent housing component. The focus of the program is on employment, education, and the development of life skills. Youth negotiate real life situations and consequences with guidance from staff members and the safety net of being part of a program.
Supportive housing. Supportive housing is provided in multiple Single Room Occupancy units located in one building. This model provides more intensive support for youth stabilizing from the streets, working towards living more independently. Youth have access to a higher amount of peer support because they all live in the same building. Weekly "house" meetings take place to address and support independent life skills development. Youth in this program also receive intensive outreach case management. Youth can remain in the program for up to two years. Larkin Street holds the master lease and youth pay 50% of their income in rent. The program expectation is that youth are employed, involved in education, and/or involved in treatment. For youth who are unable to work, rent may be paid through GA or SSI. Connection to community treatment providers is central for most youth participating in this housing model. For those who are unable to transition to independence, referral and linkage to adult supportive housing programs takes place.
Specialized Housing
The agency also provides housing for populations with specialized needs. There are two housing programs to address the unique needs of HIV-positive youth. The Licensed Residential Care Facility provides on-site housing, on-site medical care, and 24 hour staffing. Youth participate in intensive case management and there is an expectation that youth are involved on a weekly basis in a minimum of 20 hours of structured activity such as school, job training, or volunteer activities. The second program provides scattered site housing, intensive case management, medical care, and support services. A third program was designed to address the needs of youth with more intensive behavioral health needs. The program is a scattered-site model with enhanced behavioral health services and an expectation that youth are involved with community behavioral health services.
Permanent Housing
Permanent affordable housing is provided to youth who are in need of longer-term housing support. The program provides Section 8 housing with supportive, on-site case management. Larkin Street has a property management partnership for this program.
Support Services
Education and Employment
Larkin Street provides a range of education and employment services aimed at developing the skills and resources transitional youth need to attain long-term self-sufficiency. Educational services include GED assistance, adult basic education, and college counseling. The Day Labor program provides immediate employment and job skills development for youth with minimal job skills and/or work histories. Additional employment services include job readiness services, workforce placement, and career development services. The unique combination of education and employment services connected to housing increases program retention and provides youth with an environment that is conducive to skill-building.
Behavioral Health
Larkin Street's support services include youth-focused mental health and substance use services integrated throughout the agency's housing programs. Youth receive assessments, individual level interventions, and group interventions. Each program site has a designated mental health and substance use specialist. These specialists participate in weekly team meetings where client care related to behavioral health issues is discussed and coordinated. These meeting also provide a forum for staff to receive additional clinical support to deal with these issues. Youth receive referrals for more intensive or longer-term care as appropriate. In addition, a psychiatric consultant provides evaluations, medication monitoring, and limited psychotherapy.
HIV Prevention Services
HIV prevention services are integrated throughout the agency's continuum. Youth receive HIV risk behavior assessments, individual risk reduction counseling, and group interventions. HIV counseling and testing is provided at the medical clinic, in community settings, and through street outreach.
Medical Care
The agency operates a health clinic for homeless youth in collaboration with San Francisco's Department of Public Health. The clinic provides primary care for youth as well as family planning and HIV testing.
Community Partnerships
Community partnerships are critical to the success of programs that serve transition aged youth. Larkin Street has worked with numerous community partners to develop new programs and support on-going service provision. The Larkin Extended Aftercare for Supported Emancipation (LEASE) program is a collaborative project with the San Francisco Independent Living Skills Program (ILSP) to provide housing for emancipating foster youth. The program was initially funded through a grant from the Transitional Housing Program Plus fund through the State of California and a matched grant from the City and County San Francisco. The aim was to provide longer-term assistance, which would lead to independent living and self-sufficiency among youth exiting the foster care system. Legislative changes in the last year have resulted in a growth of this partnership. The program is now fully funded by the State of California and is able to serve emancipated foster care youth up to the age of 24. All referrals to the program come through ILSP. There are formal meetings on a monthly basis between Larkin Street and ILSP staff to review referrals and discuss current cases.
Castro Youth Housing Initiative (CYHI) is a program that came out of a community collaborative of public and nonprofit service providers to address the needs of homeless LGBTQQ youth in the Castro District. It is a formalized partnership that successfully advocated receiving additional funds from the City and County of San Francisco to expand the housing program and increase support services (case management, paid internships, expanded meal nights, and an additional queer youth medical clinic shift). This collaborative meets regularly to ensure coordinated service delivery.
The Routz program targets youth with significant behavioral health needs. Funding was made available through Prop 63, a California initiative that increased funding for mental health services for targeted populations. This is part of a new system-of-care in partnership with San Francisco's Department of Public Health, Community Behavioral Health Services (CBHS). Larkin Street works closely with the Transitional Aged Youth Access Team of CBHS to identify and authorize eligible youth, as well as to provide on-going support services including intensive case management, psychiatric care, independent living skills development, education, and employment.
Conclusion
The time between ages 18 and 24 is challenging for all youth, but even more so for homeless youth who lack shelter and familial support. Homeless youth face multiple challenges when making the transition to independent adulthood. Their homelessness results from family instability, systems failure, or financial instability. They exhibit high levels of trauma, mental health issues, and substance use issues. They lack the educational attainment and employment experience that results in living wage jobs. They are forced to focus on their day-to-day survival and many give up hope on their future.
Larkin Street Youth Services has developed a housing based service model that addresses the needs of homeless transition aged youth. The central tenet is that housing is essential as it provides initial stabilization and allows youth to focus their attention on developing skills and longer term goals. Intensive case management across the continuum of housing options provides the support and guidance needed to overcome additional barriers to self-sufficiency. Education and employment services address deficiencies which are linked to later economic stability. There is an inclusion of harm reduction principles which provides youth with the skills to make informed decisions about activities they participate in, acknowledging the potential impact it may have on their stability. Finally, there is a focus on life skills development to counter the lack of deficit in this area and support youth in their journey to becoming successful adults.
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