Suicide prevention for substance using youth experiencing homelessness: study protocol for a randomized controlled trial.

BACKGROUND: While research on substance using youth experiencing homelessness (YEH) is increasing, there is a dearth of information regarding effective prevention interventions for these youth. Suicide is the leading cause of death among YEH and most youth do not access services that may be available to them. Therefore, this study seeks to address this gap in the research literature with the goal to identify an effective suicide prevention intervention that can be readily adopted by communities that serve these youth. METHODS: Three hundred (N = 300) YEH with recent substance use and suicidal ideation or a recent suicide attempt will be recruited from the streets as well as a drop-in center serving YEH. After the baseline assessment, all youth will be randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Services as Usual (SAU) (N = 150) or to SAU alone (N = 150). SAU includes outreach, advocacy, and service linkage whereas YEH who receive CTSP will also receive ten CTSP sessions and an optional nine booster sessions. Follow-up assessments will be conducted at 3, 6, 9, and 12 months post-baseline. Theoretically derived mediators (e.g., cognitive distortions) will be tested to shed light on mechanisms associated with change, and the moderating effects of sex, race, sexual orientation, and baseline service connection will be examined. In order to ease future dissemination of the intervention to agencies serving YEH, we will rigorously assess acceptability, feasibility, fidelity, and cost associated with the delivery of our intervention approach using a mixed-methods approach. DISCUSSION: This study adds to a very small number of clinical trials seeking to prevent lethal suicide among a very high-risk group by addressing suicidal ideation directly rather than underlying conditions. It is hypothesized that youth receiving CTSP + SAU will show greater reductions in suicidal ideation (primary outcome), substance use, and depressive symptoms (secondary outcomes) over time compared to SAU alone, as well as improved risk and protective factors. TRIAL REGISTRATION: NCT05994612. Date of Registration: August 16, 2023.

Lessons learned from housing first, rapid rehousing trials with youth experiencing homelessness.

BACKGROUND: Youth, 18 to 24 years, experiencing homelessness (YEH) are recognized as having developmental challenges dissimilar to older adults. Yet, research on efforts to end homelessness and prevent or intervene in drug use and mental health problems among youth have lagged behind that of adults. The Housing First (HF) Model which underlies Permanent Supportive Housing (PSH) and Rapid Re-Housing (RRH) has become preferred over treatment-first models. METHODS AND RESULTS: We provide an overview of PSH and RRH studies to date and summarize our current understanding of their utility for use with YEH. Finally, we review our team's current and past randomized trials testing RRH with YEH, providing lessons learned and recommendations. CONCLUSION: Current research efforts to guide best practices are hampered by a lack of fidelity to HF principles, lack of randomized design, and lack of focus on youth. Lessons learned and recommendations from our work are offered to facilitate the future work of those who seek to end homelessness and address drug use and mental health problems among youth.

Hair Collection for Cortisol Among Youth Experiencing Homelessness.

BACKGROUND: Investigations of chronic physiological stress measured by hair cortisol are rapidly expanding among community samples of adolescents and adults. However, research examining physiological stress among youth experiencing homelessness is nascent despite the youth's increased risk for adverse exposures and subsequent impaired mental health. OBJECTIVE: This article aimed to examine the feasibility of collecting hair for measuring cortisol among diverse youth experiencing homelessness and gain an understanding of variation in participation. METHODS: Analysis of survey and hair participation data from three pilot studies among youth experiencing homelessness was conducted. Survey measures included sociodemographic characteristics (age, race and ethnicity, sex assigned at birth, and sexual orientation) and reasons for nonparticipation. Descriptive analysis examined participation rates in hair collection for cortisol measurement, including sociodemographic differences in participation. RESULTS: Participation in the hair sampling for cortisol was high for the combined sample (88.4%), with some variation across the three pilot studies. Insufficient hair for cutting was the most common reason for not participating; Black and multiracial youth, as well as male youth, had a higher prevalence of nonparticipation. DISCUSSION: The collection of hair for cortisol research among youth experiencing homelessness is feasible, and integration of physiological measures of stress into research with this vulnerable population should be considered, given their high risk for adversity and death by suicide and drug overdose. Methodological considerations and avenues for potential research are discussed.

Housing and supportive services for substance use and self-efficacy among young mothers experiencing homelessness: A randomized controlled trial.

AIMS: Homeless mothers with young children in their care contend with high rates of substance use and low self-efficacy. However, a limited number of studies have examined these outcomes associated with housing and supportive services. DESIGN: Participants were randomly assigned to: (1) housing + support services (n = 80), (2) housing-only (n = 80), or (3) services as usual (SAU) (n = 80) and were re-assessed at 3-, 6-, 9- and 12-months postbaseline. SETTINGS: The study recruited a community-based sample from homeless service agencies and advertisements in a large Midwestern city. PARTICIPANTS: The study recruited two hundred forty (N = 240) women between the ages of 18 to 24 years, experiencing homelessness and with a substance use disorder (SUD) who also had a biological child under the age of 6 years in their care. MEASUREMENTS: We measured frequency of alcohol and drug use using the Form 90 semi-structured interview, and self-efficacy using Pearlin and Schooler's (1978) 7-item Mastery Scale. FINDINGS: Overall, mothers showed significant improvement in substance use and self-efficacy over time in each condition. However, as expected, patterns of change differentiated intervention groups with more mothers showing better substance use and self-efficacy outcomes in housing + supportive services than in SAU. Unexpectedly, more mothers in SAU showed better outcomes than those in housing-only. CONCLUSIONS: Substance use decreased and self-efficacy increased over time, but patterns of change characterized the intervention groups. In particular, findings suggest that when providing housing to this population, supportive services should also be offered.

Personal Control and Service Connection as Paths to Improved Mental Health and Exiting Homelessness among Severely Marginalized Homeless Youth.

OBJECTIVE: Non-service connected, continuously homeless youth are arguably one of the most vulnerable populations in the U.S. These youth reside at society's margins experiencing an accumulation of risks over time. Research concludes that as vulnerabilities increase so do poor long-term outcomes. This study tested the mediating effects of service connection and personal control as mediators of cumulative risk and housing, health and mental health outcomes. By understanding the processes associated with therapeutic change among those with the most vulnerabilities, service providers and researchers can target those factors to enhance positive outcomes. METHOD: Seventy-nine, non-service connected, substance using homeless youth were offered a strengths-based outreach and engagement intervention and were assessed at baseline 3, 6 and 9 months post-baseline. RESULTS: Personal control mediated the effects of cumulative risk on housing stability, and service utilization mediated the effects of cumulative risk on mental health. CONCLUSIONS: This study specifies important targets of intervention for a population at high risk for continuing homelessness. In particular, service providers should target youths' sense of personal control and link them to needed community-based services in order to help them exit street life and improve mental health outcomes.

Predictors of Outreach Meetings Among Substance Using Homeless Youth.

Homeless youth have high rates of substance use and often lack connection to social services. Outreach is critical for connecting youth to services, but factors influencing their outreach engagement are unknown. This study examined predictors of meetings with outreach workers among 79 non-service connected, substance using homeless youth between 14 and 24 years of age. Results provide direction to service providers in that older age, higher levels of depressive symptoms, fewer drug-related problems, and no use of hard drugs within the prior 30 days predicted higher meeting attendance. Future research is needed testing strategies that overcome barriers to outreach engagement.

Homeless Youths' Caretakers: The Mediating Role of Childhood Abuse on Street Victimization and Housing Instability.

Homeless youths who live on the streets are particularly vulnerable to victimization and continued homelessness. Identifying factors associated with housing stability and victimization while homeless can offer useful guidance for those who serve these youths. The current study examined the relationship between multiple caretakers and the unique effect of childhood abuse (physical, sexual, neglect) on past-year housing and victimization experiences. Seventy-nine substance-using, street-living youths ages 14 to 24 years completed the survey. Findings confirmed a relationship between multiple caretaker transitions and childhood sexual abuse and neglect, but not physical abuse. Sexual abuse was further associated with higher street victimization and reduced housing stability. In addition, sexual abuse mediated the relationship between multiple caretakers and past-year victimization and housing instability. These findings suggest that sexually abused homeless youths are at particular risk for future victimization and housing instability compared with other youths, and specialized intervention for these youths is indicated.

A Test of Outreach and Drop-in Linkage Versus Shelter Linkage for Connecting Homeless Youth to Services.

Outreach and service linkage are key for engaging marginalized populations, such as homeless youth, in services. Research to date has focused primarily on engaging individuals already receiving some services through emergency shelters, clinics, or other programs. Less is known about those who are not connected to services and, thus, likely the most vulnerable and in need of assistance. The current study sought to engage non-service-connected homeless youth (N = 79) into a strengths-based outreach and advocacy intervention. Youth were randomly assigned to receive 6 months of advocacy that focused on linking youth to a drop-in center (n = 40) or to a crisis shelter (n = 39). All youth were assessed at baseline and 3, 6, and 9 months post-baseline. Findings indicated that youth prefer drop-in center services to the shelter. Also, the drop-in center linkage condition was associated with more service linkage overall (B = 0.34, SE = 0.04, p < 0.01) and better alcohol-l [B = -0.39, SE = 0.09, t(75) = -4.48, p < 0.001] and HIV-related outcomes [B = 0.62, SE = 0.10, t(78) = 6.34, p < 0.001] compared to the shelter linkage condition. Findings highlight the importance of outreach and service linkage for reconnecting service-marginalized youth, and drop-in centers as a primary service option for homeless youth.

"The Whole Family Suffered, so the Whole Family Needs to Recover": Thematic Analysis of Substance-Abusing Mothers' Family Therapy Sessions.

Substance abusing mothers and their children are more likely to experience a range of social, behavioral, and psychological difficulties. Despite the significant challenges faced by these families, little is known about their experiences in treatment. The current study analyzed 12 sessions of family therapy using thematic analysis to identify common themes that arose during substance abusing mothers and their children's discussion during family therapy. Mothers' ages ranged from 28 to 35 years and the children's ages ranged from 12 to 14 years. Four therapy sessions from three families were coded for a total of 12 therapy sessions. An ecological framework was used to classify themes, in which themes related to each level of the families' ecological systems were identified. Thematic analysis of the therapy sessions indicated that mothers and their children primarily discussed topics related to their relational and emotional needs. The findings indicated that substance use disordered mothers and their children have unique treatment needs that should be addressed when the mother seeks treatment. More research is needed to further clarify and confirm the observations in this study. In particular, future research should include a larger sample and quantitative methodology.

A comparison of three interventions for homeless youth evidencing substance use disorders: results of a randomized clinical trial.

While research on homeless adolescents and young adults evidencing substance use disorder is increasing, there is a dearth of information regarding effective interventions, and more research is needed to guide those who serve this population. The current study builds upon prior research showing promising findings of the community reinforcement approach (CRA) (Slesnick, Prestopnik, Meyers, & Glassman, 2007). Homeless adolescents and young adults between the ages of 14 to 20 years were randomized to one of three theoretically distinct interventions: (1) CRA (n = 93), (2) motivational enhancement therapy (MET, n = 86), or (3) case management (CM, n = 91). The relative effectiveness of these interventions was evaluated at 3, 6, and 12 months post-baseline. Findings indicated that substance use and associated problems were significantly reduced in all three interventions across time. Several moderating effects were found, especially for sex and history of childhood abuse. Findings show little evidence of superiority or inferiority of the three interventions and suggest that drop-in centers have choices for addressing the range of problems that these adolescents and young adults face.

Parenting under the influence: the effects of opioids, alcohol and cocaine on mother-child interaction.

Nearly 20% of adults receiving treatment for a substance use disorder live with their minor children (Stanger et al., 1999) and women in drug use treatment are twice as likely as men to have children in their household (Wechsberg et al., 1998). Parental drug use impacts the family through reduced family resources such as money and food, and researchers consistently note parenting deficits among substance users (Solis, Shadur, Burns, & Hussong, 2012). Little is known about differences in parenting and mother-child interaction among mothers with different drugs of choice or among mothers of older children, between 8 and 16 years. This study reports the findings from a sample of treatment seeking opioid, alcohol and cocaine using mothers and their 8-16-year-old child. Findings from a mother-child observational task and self-reported parenting measure indicated less undermining autonomy and higher mother maternal acceptance among opioid compared to alcohol addicted mothers. African American mothers were observed to have fewer negative interactional behaviors than Whites and both African American mothers and children self-reported higher firm control and maternal acceptance. Overall, mothers appeared to struggle with effective discipline with older versus younger children. Findings offer useful information to clinicians seeking to effectively tailor their interventions to women and children who present with different drugs of abuse, race/culture and developmental stage of child.

Two-year predictors of runaway and homeless episodes following shelter services among substance abusing adolescents.

Given high levels of health and psychological costs associated with the family disruption of homelessness, identifying predictors of runaway and homeless episodes is an important goal. The current study followed 179 substance abusing, shelter-recruited adolescents who participated in a randomized clinical trial. Predictors of runaway and homeless episodes were examined over a two year period. Results from the hierarchical linear modeling analysis showed that family cohesion and substance use, but not family conflict or depressive symptoms, delinquency, or school enrollment predicted future runaway and homeless episodes. Findings suggest that increasing family support, care and connection and reducing substance use are important targets of intervention efforts in preventing future runaway and homeless episodes amongst a high risk sample of adolescents.