Addressing Trauma in Homeless Children & Youth

1. Addressing Trauma in Homeless Children & Youth Presented by: Shelley Johnson, Executive Director, Partners to End Homelessness Eric Wood, LPC, MS State Hospital, Rise Above for Youth

2. Partners to end homelessness • Collaboration of 40+ homeless service agencies, advocates, and for-profit entities with a mission of preventing and ending homelessness in central Mississippi. • Monthly membership meetings • Annual Point-In-Time Count (homeless census) • Service Gap Analysis and Best Practice Implementations • One of 3 Continuums of Care recognized in Mississippi serving Hinds, Madison, Rankin, Warren & Copiah Counties • Oversees $1.7 million in HUD funding to area shelters for supportive housing services • Provides access and administration of the Homeless Management Information System (HMIS) for the community • Evaluates the integrity and efficacy of funded programs • Operates a 15 bed women & children’s shelter in Jackson • Rental & Utility Assistance to Prevent Homelessness and Re-house homeless individuals • Hotel Vouchers, Transportation and Mental Health Service support • Transportation for Homeless individuals – beginning in January 2015 through Wellsfest funding

3. Contributing factors to homelessness • Evaluating the economic factors contributing to homelessness and supports in place for those who need them helps us to better understand issues facing those we serve. • Traumatic events occur within our community members prior to homelessness including food insecurity, housing instability, community and domestic violence, developmental disabilities, substance abuse and child abuse/neglect • Homeless episodes only serve to exacerbate existing issues that preceded them.

4. Health and family living • Teen birth rate per 1,000: 55 • Children living in single parent families: 46% • Children in foster care: 3,582 • Percent of children in immigrant families: 3% • Number of grandparents raising grandchildren: 87,717

5. Kids count data hinds county

6. Poverty in Mississippi • Child poverty rate: 35% • Senior poverty rate: 18% • Women in poverty: 23.9% • Percent of single-parent families with related children that are below poverty: 47% • Economic well-being • Poverty rate: 24.2% • Extreme poverty rate: 10.2% • Unemployment rate: 9% • Food insecurity: 20.9% • Low-income families that work: 43.6% • Minimum Wage: N/A • Percent of jobs that are low-wage: 35.5% • Percent of individuals who are uninsured: 19%

7. EDUCATION • Education • Individuals with a high school diploma/equivalent: 81% • Individuals with a four year college degree: 20.7% • Teens ages 16 to 19 not attending school and not working: 13% • Percent of college students with debt: 57% • High school graduation rate: 63.8%

8. Families accessing federal programs • Adults and children receiving welfare (TANF): 23,290 • Children receiving food stamps (SNAP): 284,000 • Households receiving federal rental assistance: 62,074 • Families receiving child care subsidies: 10,400 • Participants in all Head Start programs: 30,329 • Number of children enrolled in Medicaid and CHIP: 550,703 • Number of women and children receiving WIC (Women, Infants and Children supplemental nutrition program): 91,652 • Households receiving LIHEAP (Low Income Home Energy Assistance Program): 65,526

9. Mental Health

10. Substance abuse

11. housing • Housing • Total households: 1,085,062 • Renters: 29% • Households paying more than 30% of income on housing: 142,518 • Homeless people: 2,413 • Home foreclosure rate: 2.33% • Justice System • Number of youth residing in juvenile justice and correctional facilities: 413 • Total incarcerated (prison and jail): 22,319

12. “Homelessness is severe trauma. It stays with you the rest of your life. In the two years I was homeless, the main thing that was reinforced within me was that I was not worthwhile, that I did not belong, not only to the community, but maybe even to humankind.” -Zenobia Embry-Nimmer Parenting and Public, 2000

13. Homeless families • Families are the fastest growing segment of the homeless population, now accounting for almost 40 percent of the nation’s homeless. • Typical Homeless Family: Single mother in her late 20s with two-three young children – usually preschoolers. • More than 90% of sheltered and low-income mothers have experienced physical and sexual assault over their lifespan. • At least 1.35 million children are homeless during a year’s time. • 42 percent of children living with homeless parents are under the age of 6. • Homeless babies show significantly slower development than other children do. • More than one-fourth of children under age 5 suffer from depression, anxiety, or aggression after becoming homeless.2 • Less than one-third of homeless children who need help for their emotional problems are receiving it. Unless otherwise specified, statistics were derived from the National Center on Family Homelessness.

14. Effects of homelessness • FOR THE FAMILY • Loss of community, routines possessions, privacy and security • Feeling more vulnerable to other forms of trauma such as physical and sexual assault, witnessing violence, or abrupt separation. • Exacerbates other trauma-related difficulties and interfere with recovery due to ongoing traumatic reminders and challenges. • HOMELESS CHILDREN • Are sick at twice the rate of other children • Go hungry twice as often as non-homeless children • More than 1/5 of preschoolers have emotional problems serious enough to require professional care, but less than 1/3 receive any treatment • Are twice as likely to repeat a grade • Twice the rate of learning disabilities and three times the rate of emotional and behavioral problems • Half experience anxiety, depression, or withdrawal compared to 18% for their peers • By the time they are 8 years old, 1 in 3 has a major mental disorder

15. Homeless youth in America – the data • Between 6% and 22% of homeless girls are estimated to be pregnant [Health Resources and Services Administration, 2001] • 46% of runaway and homeless youth reported being physically abused; 38% reported being emotionally abused; 17% reported being forced into unwanted sexual activity by a family or household member [Department of HHS, 1997]. • 75% of homeless or runaway youth have dropped out or will drop out of school • Between 20% and 40% of homeless youth identify as LGBT.

16. Homeless youth in America – the data • Between 1.6 and 2.8 million youth runaway and/or are homeless in a year [Office of Juvenile Justice and Delinquency Prevention, 2002; Research Triangle Institute, 1995]. • 5% to 7% of American youths become homeless in any given year [NAEH, 2007]. • Unaccompanied youth account for 1% of the urban homeless population[U.S. Conference of Mayors, 2007]. • Youth age 12-17 are more at risk of homelessness than adults[The Prevalence of Homelessness Among Adolescents in the United States, 1998] • Homeless youth are evenly male-female, although females are more likely to seek help through shelters and hotlines.

17. LGBT Youth

18. Mental health and homelessness • 20 to 25% of the homeless population in the United States suffers from some form of severe mental illness • Whereas only 6% of all Americans suffer from a severe mental illness • Men tend to be at a greater risk for homelessness than women • African American’s are at greater risk for homelessness than other ethnic groups

19. Barriers to treatment • Poverty. Basic needs such a food, clothing, shelter, or transportation supersede the need for treatment • May lack proper documents to obtain government assistance (address, ID, birth cert. etc. ) • Face double stigma of being Homeless and having a Psychological Disorder • Their disorder may impede their ability to ask for help or connect with local resources

20. Mental health issues for homeless children/youth

21. A service provider’s perspective of issues within our CURENT community system • School district responsibilities to maintain school district designation regardless of shelter site. • The role of homeless liaisons within school districts • Splitting families • Women & Children or Men’s Shelters (no options for in-tact families) • Men with Children • Shelter policies • Focus on Mom/Parent – not attending to issues facing children affected by homelessness • Requirement to vacate shelter during daytime hours (emergency/transitional) • Inability to obtain employment beyond 5pm • Lack of mental health resources for children/youth • Lack of childcare resources • Few safe places for homeless youth • Mandated Reporting/Child Welfare involvement • Returning youth to abusive households • Lack of substance abuse treatment options for homeless individuals

22. System based solutions • Transportation to maintain school district – offering stability for students who experience homelessness • The use of Rapid Re-housing for families experiencing homelessness • Modified policies for shelters (flexibility for jobs outside standard business hours and options to stay on-site during the day) • Prioritize child care vouchers/placements for homeless families – increase available resources. • Develop additional resources for runaway/homeless youth • Emergency Shelter • Long-term transition • Improve access to transitional programs out of foster care • Focus on both the parents and children and evaluating the needs for mental/physical health and wellbeing. • Shelters partner with treatment centers for partial/outpatient programming – providing housing at shelter sites, but attending treatment based programming during the day. • Long term planning and support to reduce/eliminate homelessness recidivism. • Proactive homeless prevention through service providers, schools, and counselors.

24. Becoming Trauma Informed This means all staff are aware of the high incidence rate of traumatic exposure that patients have experienced, that we understand the impact of trauma, and that we understand the importance of avoiding re-traumatization What Happened to you? vs What’s Wrong With You?

25. Complex Trauma “The term complex trauma describes both children’s exposure to multiple traumatic events, often of an invasive interpersonal nature, and the wide-ranging, long term impact of this exposure. These events are severe and pervasive, such as abuse or profound neglect. They usually begin early in life and can disrupt many aspects of the child’s development and the very formation of self. Since they often occur in the context of the child’s relationship with a caregiver, they interfere with the child’s ability to form a secure attachment bond.” - Complex Trauma: Facts for Service Providers working with Homeless Youth and Young Adults, June 2014

26. Common trauma experienced by homeless children and youth • Child physical and sexual abuse and neglect • Witnessing violence at home between parents or caregivers • Removal from home by child protective services • Incapacitation of parents due to mental illness, substance abuse, or incarceration • Witnessing community violence • Experiencing violence in their own relationships • Harassment or violence due to homelessness, sexual orientation, and/or gender identity • Physical and sexual assault on the street • Incarceration • Engaging in survival sex or prostitution.

27. Common Responses to trauma • Difficulties sleeping and/or eating • Inability to concentrate or complete everyday tasks • Feelings of inadequacy and guilt • Preoccupation with their bodies • Stomach aches, headaches, and other multiple health complaints • Acting out or impulsive behaviors, including unsafe sex, multiple sexual partners, substance abuse, or illegal activities • Bullying or intimidation of peers or staff • Behaving as if they were younger than they actually are • Impulsive and aggressive behaviors • Heightened moodiness and irritability • Pushing away caregivers

28. Infant mental health “Infant mental health is the developing capacity of the child from birth to three to: experience, regulate, and express emotions; form close and secure interpersonal relationships; and explore the environment and learn—all in the context of family, community, and cultural expectations for young children. Infant mental health is synonymous with healthy social and emotional development.” Healing Hands, June 2005

29. The effects of trauma on the brain

30. The effects of trauma on the brain “Brain development can literally be altered by toxic stress, resulting in negative impacts on the child’s physical, cognitive, emotional and social growth.” Child Welfare Information Gateway, November 2009 “[In] Babies who do not get responses to their cries, and babies whose cries are met with abuse…the neuronal pathways that are developed and strengthened under negative conditions prepare them to cope in the negative environment and impair their ability to respond to nurturing and kindness.” Shonkoff & Phillips, 2000 “Maltreatment may permanently alter the brains ability to use serotonin, which helps produce feelings of well-being and emotional stability.” Healy, 2004

31. The effects of trauma on the brain

32. Long term effects of abuse and neglect • Diminished growth in the left hemisphere, which may increase the risk for depression • Irritability in the limbic system, setting the state for the emergence of panic disorder and posttraumatic stress disorder • Smaller growth in the hippocampus and limbic abnormalities, which can increase the risk for dissociative disorders and memory impairments • Impairment in the connection between the two brain hemispheres, which has been linked to symptoms of attention-deficit/hyperactivity disorder. Teicher M.D., 2000

34. The effects of trauma on the brain

35. Characteristics of individuals that thrive after homelessness and trauma • Resiliency • Determination • Having meaning and purpose to life • Self - Care • Accepting help from others

36. Characteristics of resiliency • Ability to adopt new behaviors • Developing a sense of self esteem and self efficacy • Using painful experiences as a learning platform for transformation • Attitudinal and Behavioral Shifts from negative to positive life trajectory • Less engagement in high risk behaviors • Learning to recognize ones own needs and how to meet them constructively

37. Determination • Determination – Building Self Confidence and Self Sufficiency • Tenacity and Persistence in attaining goals • Inner Strength • Pride in making it through adversity • Service providers can foster determination by providing opportunities for youth to demonstrate this characteristic. Exerting determination to turn their life around, an individual’s life experiences reinforce their own efforts. The process of becoming more resilient is self reinforcing.

38. Having a meaning and purpose to life • Seeing how an individual fits into the bigger picture • Commitment to serve the community vs. what one can get or what is “owed” to them. • Hope coupled with gratitude as indication of resilience • Gratitude for opportunities to learn and grow from adversity can foster a sense of optimism which is indicated by interest in further education and assisting those who have suffered from similar fates

39. Self Care • Learning specific behaviors and adopting attitudes that enhance self care • Taking care of oneself physically, emotionally, mentally and spiritually • Finding constructive ways to get ones needs met • Assertively protecting oneself when needs are being blocked • Decision making becomes a source of pride • Acknowledging ones own needs can lead to a deeper sense of self acceptance • Realizing Self Care can be a gradual process • Keeping a journal • Learning to speak up for oneself • Self protection including • Setting personal boundaries • Distancing self from unhealthy relationships • Developing effective problem solving skills greatly contributes to development of resiliency • Weighing pros and cons • Looking at things in more than one way • Listing options out

40. Accepting help from others • Readiness for help • Openness to allowing helping individuals into their life • Reaching a point of receptivity • Actively seeking help • Beginning to trust safe people over time • How professionals can foster readiness • Acknowledge the need to transition from street homelessness into housing • Seeking and utilizing shelter and other services is a CHOICE to be anticipated, rather than a immediate outcome. • Acknowledge the strength, courage, skill and determination it takes to survive as a homeless youth. • Offer tailored, less restrictive, minimally invasive and strength based services

41. Program vs. person centered treatment • Program Centered: used to be the norm – in this format patients were expected to conform to program expectations and patient failures were viewed as indications that the patient was not “ready” for treatment (i.e., car assembly line) • Person-centered treatment: accepts the patient’s own goals as the basis for the treatment contract and builds on the patient’s strengths and preferences to advance treatment objectives (e.g., build a hot rod). (Sharp, Traunstein & Redditt, 2012) Van Dyke ATC Training

42. Person centered programs • Autonomy vs. Dependence • Meeting basic needs before therapeutic needs (Housing First) • Crisis Remediation • Safe Shelter • Food • Clothing • Medical Care (*Kidd 2003)

43. Outcomes from highlighted practices • Being able to model healthy relationships with peers • Addresses isolation • Can contrast from previous negative experiences and destructive patterns. • Identifying, engaging and sustaining healthy personal boundaries • Transformed self image

44. Quality Professionals/Programs • Nature of the Program – addressing comprehensive needs of the individual • Caring Consistently over time and in a variety of ways • Developing a level of trust in relationships • Sustained commitment to the individual and outcomes • Access to experiences that allow one to develop self esteem and self efficacy • Quality Professionals • Fidelity to the Nature of the Program (3 points above) • A source for comfort as well as guidance • Developing a model for healthy relationships that can be employed with peers • Respectful confrontation • Strength based perspective and knowing progress is often not a linear pattern • BELIEVE in the promise of change and potential in the population • UNDERSTAND that life is a developmental process • DEEPEN your understanding of the healing power of relationships

45. Effective interventions for homeless youth • Recognition of the unique culture of homeless youth • Must be culturally competent • Recognizing trust, power and control struggles • Shame – diminished understanding of self-care • Empowering Treatment Model • Goals • Restoration of safety and control – first goal of treatment • Assist to develop trust • Exercise control of ones own life • Decrease Shame • Increase self care self esteem “The greatest need of any traumatized individual is to feel safe, and this often requires attention to various practical dimensions” Wilson,Freeman, Lindy 2001 p. 247.

46. Steps for Pre-engagement with homeless youth • Pre-engagement (Outreach) • Establishing communication and trust between youth and provider • Make the first contact warm, respectful, and non-threatening • Attending to the immediate needs of youth by offering basic items such as food, clothing and hygiene • Convey respect of boundaries, empathy and genuine desire to be of assistance • Identify and introduce service options that convey an understanding of needs relevant to the youth homeless population • Building of rapport assists in the transition to full service engagement

47. Engaging homeless youth • Engagement - The worker collaborates with the youth to identify strengths, goals, and solutions. • Rapport can be established and maintained by: • Allowing youth to choose the subject and direction of the conversation • Focusing on Strengths • Not rushing the client to make change or long term plans. • Emphasis should be on fostering a sense of control, autonomy, and self efficacy. • Be prepared to repeat this introductory information to youth many times. As they feel safer, they may be able to hear more of what you have to offer. • Be prepared for them to challenge you or the rules. • May lead to implementing contract and goal setting

48. training • All providers should all receive training including: • Homeless youth culture • LGBTQ cultural competency • Crisis intervention model • Trauma informed care • Motivational Interviewing

49. Self care for provider – compassion fatigue “There is a cost to caring” – Charles Figley • Be Aware of the Signs: • Increased irritability or impatience • Decreased concentration • Denying that traumatic events effect clients or feeling numb or detached • Intense feelings and intrusive thoughts, that don’t lessen over time, about a client’s trauma • Dreams about client trauma • Guard against isolation • Get support by working in teams • Ask for support from administrators and colleagues • Recognize compassion fatigue as an occupational hazard – not a weakness or incompetence – it is the cost of caring • Seek help with your own trauma • Talk to a Professional • Attend to self care

50. What you can do • Advocate • Medicaid Expansion – expands resources for underserved populations. Many states utilize Medicaid funding for supportive services for homeless families and youth. • MS Interagency Council on Homelessness – Bringing all parties to the table addressing homelessness – Bill passed in 2012 – Awaiting Government action to implement • For LGBTQ inclusive policies in your facility/organization. Ensure policies are in place that include culturally competent approaches to care. • For training for all law enforcement agencies. Help first responders to better understand the complex needs of homeless individuals and families. • For expanded training opportunities within your organization. • Participate • Join your local Continuum of Care • Get to know your Homeless Liaisons at your local school district • Expand the community resource list by sharing your knowledge of mental health resources available at little or no cost for homeless families/youth. • Volunteer • Without critical resources, many agencies don’t have the funding to attend to the needs of children and youth in their programs. Offer time to provide trauma informed care to children and youth in local shelters