Housing interventions for emerging adults experiencing homelessness: A scoping review

Tensions in Young Adult Housing Programs: Exploring Two Case Examples and Implications for Youth Housing

While young adult homelessness impacts nearly one in ten young adults in the United States, limited work has explored the implementation of housing programs which support young adults. In this paper, we describe research on two case examples of housing programs for young adults in the United States: systematic program observations from Marsha and Marian's Neighbors, a shared housing program in the Mid-Atlantic region, and resident interviews from Laurel House, a permanent supportive housing program in the Rocky Mountain West. While the program designs and methods for researching each program were distinct, we collectively identified tensions which largely impacted both programs: considerations around community, youth choice and voice, and impact and outcomes. Finally, we identify key decision points for young adult housing programs to consider when working to meaningfully support young peoples' needs.

Understanding Homelessness Among Young People to Improve Outcomes

In the United States, an estimated 4.2 million young people experience homelessness during critical stages in their development-adolescence and emerging adulthood. While research on youth homelessness often emphasizes risk and vulnerability, the field must situate these issues within the developmental trajectories of adolescence and emerging adulthood to effectively prevent and end youth homelessness. This review uses the Risk Amplification and Abatement Model (RAAM) as a conceptual framework for contextualizing the landscape of youth homelessness research in the United States since 2010. An extension of ecological models of risk-taking, RAAM emphasizes both risk and resilience, positing that negative as well as positive socialization processes across interactions with family, peers, social services, and formal institutions affect key housing, health, and behavioral outcomes for youth experiencing homelessness. This review applies RAAM to our understanding of the causes and consequences of youth homelessness, recent interventions, and recommendations for future directions.

Adverse Childhood Experiences (ACEs) in Unhoused Children Increase Odds of Psychiatric Illness, Physical Illness, and Psychiatric Admission

Unhoused children and adolescents have high rates of adverse childhood experiences (ACEs). The objective of this study was to characterize a large cohort of unhoused children and investigate rates of psychiatric diagnoses, medical diagnoses, and utilization of emergency department (ED) resources depending on the presence of additional documented ACEs. A retrospective cohort of all unhoused children who presented to the ED of a large Midwestern health system from January 2014 to July 2019 were included. Unhoused status was determined by address field or ICD-10 code for homelessness (Z59.0). Demographics and ED visits were extracted from the electronic health record. Past medical history, ACEs, chief complaint (CC), length of stay (LOS), imaging, and labs were extracted by chart review. T-tests, chi square tests, and Fisher's exact tests were completed for each sub-analysis. Unhoused children with at least one additional ACE had higher odds of the following psychiatric disorders: depression (OR = 5.2, 95% CI = 3.4- 7.9), anxiety (OR = 3.4, 95% CI = 32.1-5.5), behavioral disorder (OR = 7.2, 95% CI = 35.1- 10.4), psychoses (OR = 6.0, 1.9-18.4), bipolar disorder (OR = 19.8, 95% CI = 34.6-84.9), suicidal ideation (OR = 8.0, 95% CI = 34.8-13.4), post-traumatic stress disorder (OR = 10.1, 95% CI = 35.4-18.6), and attention deficit hyperactive disorder (OR = 4.1, 3.0-5.7). Patients with additional documented ACEs were also more likely to have a prior psychiatric admission (p < 0.001). Unhoused children and adolescents with exposure to additional documented ACEs are more likely to have some serious psychiatric and medical diagnoses compared to other unhoused children.

Longitudinal Associations between Homelessness and Substance Use: Investigating Demographic Differences for Young Adults in Treatment

Objective: To examine prospective, bidirectional associations between homelessness and substance use frequency among young adults receiving substance use treatment in the United States. We also investigated potential differences across demographic subgroups. Methods: Young adults (N = 3717, Mage = 20.1, 28% female, 7.3% sexual/gender minority, and 37% non-Hispanic White) receiving substance use treatment in the U.S. completed assessments at intake, 3 months, 6 months, and 12 months post-intake. Latent growth curve models with structured residuals (LGC-SR) were used to examine cross-lagged associations between homeless days and frequency of substance use and associated problems. Models were stratified by sex, race/ethnicity, and sexual and/or gender minority status. Results: Overall, days spent homeless (μ slope = -0.19, p = 0.046) and substance use frequency (μ slope 1 = -6.19, p < 0.001) significantly decreased during treatment, with no significant cross-lagged associations between homeless days and substance use frequency. However, results differed by race and ethnicity. For non-Hispanic White young adults, greater substance use at treatment entry was associated with steeper declines in homeless days between-persons (ϕ standardized = -0.14, p = 0.04). For African Americans, homeless days at treatment entry were associated with greater increases in substance use between-persons (ϕ standardized = 0.29, p = 0.04). No significant differences were found by sex or sexual/gender minority status. Conclusions: Despite overall declines in homelessness and substance use during treatment, these outcomes may unfold differently for non-Hispanic White and African American young adults. More support may be needed for African American young adults reporting homelessness at treatment entry.

Support Interventions for Young People in Housing Programs: A Rapid Literature Review

This rapid review synthesizes current original research studies concerning support interventions intended for young people who experienced homelessness and are housed through youth-focused housing programs. Peer-reviewed articles on interventions for young people between 13 and 25 years of age with experience of homelessness living in youth-focused housing published between January 2017 and May 2022 were search in Scopus, Web of Sciences, PubMed, and EBSCO. Ten articles were included in the review. Interventions examined in the reviewed literature included case management, psychosocial and mental health support interventions; social support through peer support, mentorship, and positive social networks; and socioeconomic inclusion through skill building. Evidence found in the current review provides directions for the development of promising practices.

Engaging stakeholders to inform national implementation of critical time intervention in a program serving homeless-experienced Veterans

The Veterans Affairs (VA) Grant and Per Diem Case Management "Aftercare" program provides 6 months of case management for homeless-experienced Veterans (HEVs) transitioning to permanent housing, with the aim of decreasing returns to homelessness. Implementing Critical Time Intervention (CTI)-an evidence-based case management practice-would standardize care across the 128 community-based agencies that provide Aftercare services. To prepare for national CTI implementation in Aftercare, guided by Replicating Effective Programs (REP), we conducted a four-site pilot in which we adapted a CTI implementation package (training, technical assistance, and external facilitation); characterized stakeholder perspectives regarding the acceptability and appropriateness of this package; and identified contextual factors that affected CTI implementation. We engaged a stakeholder workgroup to tailor existing CTI training and technical assistance materials for Aftercare. To provide tailored support for providers and leaders to adopt and incorporate evidence-based practices (EBPs) into routine care, we also developed external facilitation materials and processes. Over 9 months, we implemented this package at four sites. We conducted semi-structured interviews at pre-implementation, mid-implementation, and 6 months post-implementation, with HEVs (n = 37), case managers (n = 16), supervisors (n = 10), and VA leaders (n = 4); these data were integrated with templated reflection notes from the project facilitator. We used rapid qualitative analysis and targeted coding to assess the acceptability and appropriateness of CTI and our implementation package and identify factors influencing CTI implementation. Stakeholders generally found CTI acceptable and appropriate; there was consensus that components of CTI were useful and compatible for this setting. To adapt our implementation package for scale-up, this pilot highlighted the value of robust and tangible CTI training and technical assistance-grounded in real-world cases-that highlights the congruence of CTI with relevant performance metrics. Variations in agency-level contextual factors may necessitate more intense and tailored supports to implement and sustain complex EBPs like CTI. Processes used in this pilot are relevant for implementing other EBPs in organizations that serve vulnerable populations. EBP scale-up and sustainment can be enhanced by engaging stakeholders to tailor EBPs for specific contexts; pilot testing and refining implementation packages for scale-up; and using qualitative methods to characterize contextual factors that affect EBP implementation.

Adverse childhood experiences and perceived stress in early adulthood in the context of disadvantage

BACKGROUND

Adverse childhood experiences (ACEs) may sensitize individuals to view situations in adulthood as more stressful, which may contribute to poor health outcomes. In populations facing disadvantage, ACEs may lead to the accumulation of stressors (stress proliferation or mediation hypothesis) throughout the life course. ACEs could also heighten perceived stress later in life due to its enduring impact (stress sensitization or effect modification hypothesis).

OBJECTIVE

We examine the associations between ACEs and perceived stress in early adulthood, considering concurrent life stressors, in a longitudinal cohort of Puerto Rican youth exposed to a high degree of disadvantage.

PARTICIPANTS AND SETTING

A community-based sample of 1626 Puerto Rican children living in disadvantaged contexts was followed longitudinally in the Boricua Youth Study from 2000 to 2017.

METHODS

ACEs were measured prospectively during childhood (<18 yrs), and life stressors and past year perceived stress were measured in early adulthood (EA; mean age = 23.4, sd 2.22). Causal mediation analysis tested ACEs' effects on EA perceived stress indirectly through life stressors including potential effect modification.

RESULTS

ACEs influenced perceived stress in EA (standardized total effect = 0.13, p < .001) with 35% mediated by increased exposure to life stressors in EA due to ACEs. There was no evidence of increased sensitization to EA life stressors among those with higher ACEs exposure.

CONCLUSIONS

ACEs contribute to perceived stress in EA, albeit with small effect, partially through accumulating effects of ongoing stressors, supporting the stress proliferation hypothesis. Policies aimed at reducing exposure to adversity from childhood to EA are needed to reduce the experience of ACEs and negative sequelae.