Comorbidity in Youth Experiencing Homelessness

Find information on working with youth who are experiencing homelessness and suffering from both mental and substance use disorders.

Many youth experiencing homelessness make an effort to blend in with their surroundings while remaining service averse. Some young people may think they are invincible, while others are not interested in interacting with authority figures. Others may refuse to take medical health issues seriously or are afraid of being revealed as in need and put in foster care. Yet young people who live on the streets are exceptionally vulnerable to victimization.

“Youth is a unique time of life,” says Harmony Rhoades, Ph.D., a research assistant professor at the University of Southern California’s School of Social Work. “Sometimes it may not seem that youth are as ready for treatment as older adults who maybe have been dealing with addiction and chronic health issues for many years. Young people may appear healthier, and they may just be a little more difficult to deal with,” Dr. Rhoades says. That difficulty extends to resisting treatment specifically, as well as rebelling against authority and service providers in general. She has found significant comorbidity with post-traumatic stress disorder (PTSD) and depression among youth experiencing homelessness—something she thinks must be acknowledged.

“Providers need to recognize that the youth they’re seeing that have symptoms and are disruptive in many ways—it may be because they have these comorbid issues,” says Dr. Rhoades. “That may be making it difficult for them to interact with providers.”

Homelessness, Mental Health, and Substance Use: The "Triangle"

A useful visual to explain homelessness, mental health, and substance as a comorbidity is a triangle. The three sides are made up of arrows that go in all directions. It does not work to treat just one of those aspects, says Dr. Rhoades, although beginning with a roof and four walls is key.

“Providing safe and secure housing for young adults has to be the cornerstone for addressing treatment,” she says. “Both mental health treatment and substance use recovery need to be done in conjunction with one another—or at least assessed. These things are potentially reinforcing each other—just dealing with one is not going to get at the root of the issue.”

In a study published in the May issue of Drug and Alcohol Dependence, Dr. Rhoades and two colleagues looked at prescription drug misuse among youth experiencing homelessness, ages 17 to 25, in Los Angeles drop-in centers. Half reported lifetime prescription drug misuse; 22% said they had misused prescription drugs within the past month. Most of that misuse included opioids and sedatives, which youth acquired from friends and family members, largely for free (only 5% reported having stolen the drugs). Much of it came about through trading—Dr. Rhoades says she has heard anecdotally that among youth on the street, there is an “ethos of helping out when you’ve got something, and sharing.”

Prescription Drug Misuse Among Youth

One surprising finding: youth experiencing homelessness were less likely to be engaged in prescription drug misuse if they had been in foster care. At the same time, Dr. Rhoades says other studies have found that having been in foster care is more predictive of an individual’s methamphetamine use.

Dr. Rhoades is looking next at the issues of comorbidity; specifically, whether youth living on the streets in L.A. are self-medicating for mental illness symptoms. She is also conducting a pilot study of the experiences of youth who have been placed in permanent supportive housing to more fully assess the possibilities of the Housing First model.

Dr. Rhoades encourages providers who work with youth to recognize the types of resistance they may encounter, reiterating that this is a population that has routinely been let down by people in positions of authority who are supposed to be taking care of them. It is only natural that there might be some pushback, against both the treatment and its providers. Yet it is essential that providers remember just how vulnerable this population is, she says, and that they really do need care—even if that means working through a little attitude.

This article was originally published to highlight the March 2015 theme of Youth Homelessness.

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Sarah Zobel
Last Updated: 04/19/2016