Substance Abuse and Mental Health Correlates of Victimization Classes among Homeless Youth

Background

Literature demonstrates that street victimization is a common occurrence among homeless youth.¹ Street victimization is correlated with poorer mental health, including substance abuse,^2,3 depressive symptoms,³ and posttraumatic stress disorder (PTSD).⁴ Despite much research on street youth victimization, few studies have examined victimization classes and how those classes differ by type and frequency of victimization. In two separate studies, authors Bender, Thompson, Ferguson, and Langenderfer relied on latent class analysis to determine subgroups of homeless youth based on the youths’ self-reported victimization experiences. The authors then ran analyses to determine which of several variables predict subgroup membership. Study One focused on substance abuse, whereas Study Two focused on mental health.

The Sample

Purposive sampling between March 2010 and July 2011 resulted in a sample of 601 street youth, each served by a homeless youth agency in Los Angeles (n=200), Austin (n=200), or Denver (n=201). The three eligibility criteria were that the youth had to 1) be 18 to 24 years old, 2) have spent at least two weeks away from home prior to the interview, and 3) provide written informed consent. Researchers conducted quantitative retrospective interviews with the youth to assess demographics, victimization experiences, substance use symptoms, and mental health symptoms. Researchers assessed victimization experiences using a revised version of the Traumatic Life Events Questionnaire,⁵ retaining items only if they were relevant to homeless youth. Substance use and mental health variables were assessed by the Mini International Neuropsychiatry Interview (MINI).⁶ Specifically, Study One examined substance abuse and substance dependence correlates of victimization class while Study Two examined depression and PTSD correlates.

Demographics for the total sample are as follows:

• Age: M=20.5 years (SD=1.6)
• Gender: 64% male, 36% female
• Race/Ethnicity: 40% White, 25% Black, 18% Latino, 17% Other
• Primary living arrangement: 50% homeless, 50% temporarily housed
• Met diagnostic criteria for:
• Alcohol Addiction: 49.8%
• Drug Addiction: 59.7%
• Substance Abuse: 36.6.%
• Substance Dependence: 48.5%
• Depression: 31%
• PTSD: 23%
• Number of moves: M=3.5 (SD=3.7)
• Months homeless: M=32.4 (SD=31) = 2.7 years

The Results

Identifying Victimization Classes

In Study One, researchers identified victimization classes using exploratory latent class analysis, grouping youth based on type and frequency of victimization. Researchers ran multiple models, from one to six classes, and used best-fit indices and their abilities to describe distinct patterns in classes to decide on a three-class model: low-victimization, high victimization, and witness classes.

Among youth in the low-victimization class (n=215, 36%) more than 85% never experienced robbery, experienced physical or sexual assault by a stranger, experienced threat of bodily harm, witnessed an assault, or personally overdosed on drugs. Typically, youth in this class experienced lower rates of all types of victimization than both the high-victimization and witness classes.

The high-victimization class (n=136, 23%) reported high rates of both indirect (e.g., witnessing a severe assault) and direct (e.g., physical assault by a stranger) victimization. This class also reported experiencing victimization types rarely reported by either the low-victimization or witness classes, such as physical or sexual assault by an intimate partner and personally overdosing on drugs.

The witness class (n=250, 42%) reported high rates of indirect victimization, such as witnessing severe assault, witnessing a drug overdose, or experiencing the sudden death of a close friend or loved one. Typically, these indirect forms of victimization were experienced only once.

Study One: Substance Abuse

Results of a first multinomial regression model indicate that, compared to low-victims, witnesses are approximately twice as likely to meet criteria for both substance abuse and dependence. Moreover, both substance abuse and substance dependence increased the odds of being classified as a high-victim versus a low-victim. Results of a second multinomial regression model indicate that although alcohol and drug addiction both increase the risk of being classified as a witness or high-victim as opposed to a low-victim, the odds ratios were higher for alcohol than for drugs.

Study Two: Mental Health

Again using multinomial regression, results indicate that youth in the high-victimization and witness classes were nearly twice as likely to experience depression symptoms and nearly three times as likely to experience PTSD compared to youth in the low-victimization class. Researchers found no significant differences in mental health risks between high-victims and witnesses.

The Implications

Street youth classified as witnesses or high-victims demonstrated higher rates of substance abuse, substance dependence, depression, and PTSD than low-victims. Given the distinct experiences of youth in the three classes, it is important that providers screening for victimization among homeless youth assess not only types of victimization, but potential consequences as well, such as substance abuse and mental health problems. Moreover, prevention efforts targeting homeless youth should include victimization prevention education.

For More Information

For more details on how latent classes were determined; how time homeless, primary living situation, and transience impact classification; and expanded implications, refer to the full articles in Child Abuse & Neglect and Journal of Adolescence. Click the links below to learn more about the authors’ work.

Dr. Kimberly Bender

Lisa Langenderfer-Magruder

Citations

Bender, K., Ferguson, K., Thompson, S., & Langenderfer, L. (in press). Mental health correlates of victimization classes among homeless youth. Child Abuse & Neglect.

Bender, K., Thompson, S.J., Ferguson, K., & Langenderfer, L. (2014). Substance use predictors of victimization profiles among homeless youth: A latent class analysis. Journal of Adolescence, 37(2), 155-164. doi: 10.1016/j.adolescence.2013.11.007

References

1 Stewart, A.J., Steiman, M., Cauce, A.M., Cochran, B.N., Whitbeck, L.B., & Hoyt, D.R. (2004). Victimization and posttraumatic stress disorder among homeless adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 43(3), 325-331.

2 Hoyt, D.R., Ryan, K.D., & Cauce, A.M. (1999). Personal victimization in a high-risk environment: Homeless and runaway adolescents. Journal of Research in Crime and Delinquency, 36(4), 371-392

3 Whitbeck, L.B., Hoyt, D.R., & Bao, W. (2000). Depressive symptoms and co-occurring depressive symptoms, substance abuse, and conduct problems among runaway and homeless adolescents. Child Development, 71(3), 721-732.

4 Whitbeck, L.B., Hoyt, D.R., Johnson, K.D., & Chen, X. (2007). Victimization and posttraumatic stress disorder among runaway and homeless adolescents. Violence and Victims, 22(6), 721-734.

5 Kubany, E. S., Leisen, M. B., Kaplan, A. S., Watson, S. B., Haynes, S. N., Owens, J. A., Burns, K. (2000). Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The Traumatic Life Events Questionnaire. Psychological Assessment, 12(2), 210-224. doi: 10.1037/1040-3590.12.2.210

6 Sheehan, D., Lecrubier, Y., Sheehan, K., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22-33.

Does Identification of Depression Affect Community Long-Term Care Services Ordered for Older Adults

Background

Community long-term care (CLTC), available in every state, provides funding for services (e.g., personal care, meal delivery, relief for caregivers) for low-income older adults at risk for nursing home placement. Previous research has found that nearly 25% of CLTC clients suffer depression and typically demonstrate low use of mental health services.¹ Moreover, when depression goes undetected, there is an increased risk for disability and mortality, particularly among older adults.^2,3 In the present study, Hasche and her colleagues examine whether or not the identification of depression influences service authorization in public CLTCs. Authors paid particular attention to competing demands (i.e., total number of health problems, overall level of care needed, cognitive impairment, and number of medications) that had the potential to influence a CLTC worker’s decision to authorize services.

Methods & Sample

CLTC workers approached eligible clients (over 60 years old, English-speaking, were their own  legal guardians), of which 1,508 agreed to participate. Phone interviews were conducted with all clients who met depression criteria (n=299) and a random sample of non-depressed older adults (n=315); several participants were excluded for not returning client-release forms, leaving a final analytic sample of 533. Using self-report interview data and case files for CLTC clients between October 2000 and May 2003, researchers determined 1) whether or not the participant’s CLTC worker noted client depression; 2) type and amount of services authorized; 3) competing demands; and 4) sociodemographic variables. Selected sample characteristics are as follows:

• Age Range: 59-95 years (M=72.51, SD=7.98)
• Gender: 75.42% female
• Race/Ethnicity: 26.08% not White
• Marital Status: 24.39% married
• Monthly Income (in dollars): M=738.41 (SD-338.45)
• Depression noted by CLTC in case record: 15.38%
• Competing Demands:
• Number of Health Problems (0-5): M=1.30 (SD=1.21)*
• Overall Level of Care (4-12): M=8.57 (SD=1.28)*
• Cognitive Impairment (0-12): M=2.88 (SD=2.72)*
• Number of Medications (0-22): M=8.44 (SD=4.18)*

*Higher means (M) indicate higher numbers/levels

Results

Researchers ran three multivariate logistic regressions to determine whether CLTC workers’ depression notation increased the likelihood of service authorization. Each model examined specific services ordered: personal care, homemaker services, and nursing services.

Personal Care

Race, physical health problems, and cognitive impairments were significantly associated with clients being ordered personal care services. Specifically, services were more likely to be ordered for clients who do not identify as White, had more physical health problems, and had fewer cognitive impairments. CLTC workers’ notations of depression were not associated with ordering personal care.

Homemaker Services

Increased age and rural residency were associated with clients being ordered homemaker services. Services were more likely to be ordered for clients who demonstrated less cognitive impairment and took more medications. CLTC workers’ notations of depression were not associated with ordering homemaker services.

Nursing Services

Contrary to the authorization of personal care and homemaker services, notation of depression, as well as number of medications, was significantly associated with the authorization of nursing services. Specifically, CLTC workers were more likely to authorize nursing services for clients who were taking more medications and for whom the worker noted depression.

Implications

Though this study focuses on services ordered, as opposed to service utilization, findings indicate that, even when CLTC workers note depression, older adult clients may still have unmet needs (i.e. personal care, homemaker services). The authors suggest implementing standardized depression screenings for CLTC clients to identify depressed older adults and connect them with appropriate services. Moreover, social workers in non-mental health settings may benefit from additional training in identifying depression and familiarizing themselves with relevant community resources.

For More Information

For more information on CLTC and depression among older adults, you can find this full-text article in Social Work Research, Volume 37. For more on Dr. Hasche’s work, visit her GSSW faculty page or DU portfolio.

Citation

Hasche, L. K., Lee, M. J., Proctor, E. K., & Morrow-Howell, N. (2013). Does identification of depression affect community long-term care services ordered for older adults? Social Work Research, 37(3), 255-262. doi: 10.1093/swr/svt020

References

¹ Morrow-Howell, N., Proctor, E. K., Choi, S., Lawrence, L., Brooks, A., Hasche, L., et al. (2008). Depression in community long-term care: Implications for intervention development. Journal of Behavioral Health Services and Research, 35, 37-51.

² Adamson, J. A., Price, G. M., Breeze, E., Bulpitt, C. J., & Fletcher, A. E. (2005). Are older people dying of depression? Findings from the medical research council trial of the assessment and management of older people in the community. Journal of the American Geriatric Society, 53, 1128-1132.

³ Murray, C. J., & Lopez, A. D. (Eds.). (1996). The global burden of disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 (Vol. 1). Cambridge, MA: Harvard School of Public Health and the World Health Organization.