The Prevalence of Psychotic Symptoms in Homeless Adolescents PETER MUNDY , PH.D., MARJORIE ROBERTSON , PH.D. , JULIA ROBERTSON , M.D., AND MILTON GREENBLATI, M.D .
Abstract. This study was designed to gather data on psychotic symptoms in a sample of homele ss adolescents . The sample included adolescents who were located in street sites as well as adolescents who were currently using shelter services. Ninety-six adolescents participated in this study (mean age = 16.1 years). The result s indicated that 29% of the sample reported the experience of four or more psychot ic symptoms on the Diagnostic Interv iew Schedule psychotic symptom index. These results suggested that the endorsement of psychotic symptoms is a relatively prominent feature of the self-report of psychopathology among homeless adolescents. These symptoms did not only include reports of paranoid ideation, which may be generally elev ated as part of the stress of street life, but also included reports of ideas of reference and auditory hallucinations . Moreover, these symptoms were correlated with reports of affective disturbance, abusive life experien ce, and a particular type of substance use. J . Am. Acad. Chi/dAdolesc. Psychiatry, 1990, 29, 5:724--731. Key Words: mental status , homele ss, adolescents. Homelessness is an unfortunate life circumstance which increasingly afflicts substanti al numbers of children and adolescents each year (Solarz , 1988; Robertson, 1989a). Atleast two subgroups of homeless children may be described: children, under 10 years of age , who are in homeless families (e.g., Bassuk and Rosenburg , 1988) and children, often older than 10 years of age, who are homeless and live unaccompanied by an adult . Current epidemiological data on homeless children are imprecise. Nevertheless , with regard to the latter group , recent estimates suggest that there are approximately 1,000,000 unaccompanied homeless children, between the ages of 10 and 17 years, living on the streets of towns and cities in the United States each year (U.S. Department of Health and Human Services , 1984, Solarz, 1988). This paper presents data on the mental status of a sample of unaccompanied homeless adolescents. It is part of a research program that has focussed on the relation between homelessness, residential instability, and psychopathology in adolescents (Mundy et aI., 1989; Robertson, 1989a, b). Adolescents who are homeless often report histories of physical and sexual abuse (Janus et al., 1987; Solarz, 1988), alcohol abuse in the family (Robertson, 1989b), and conflicted relations with family members (Adams et aI., 1985). Many homeless adolescents also report experiences with foster care or other institutional care settings (Shaffer and
AcceptedMarch 7,1990. Dr. Mundy is with the Depar tment of Psychiatry , UCLA Centerfor the Health Sciences ;Dr . M . Robertson is with the Alcohol Research Group , Medical Research Institut e of San Fran cisco; Drs . J. Robertson and Greenblatt are with the Department of Psychiatry , Olive View Medical Center and UCLA . Supp ort for this research was pr ovided, in part, by grant 85-76258 from the California Department of Mental Health, NlAAA Professional Services Contract 87M023952101D , and the Los Ang eles County-Olive View Medical Cent er Departm ent ofPsychiatry. Sin cere appre ciation is extended to Paul Koegel, Christine Grella, Robert Aisley , Kim Hollingshead, and Roger Skinner for assistance in the design and exec ution of this study. Requestsfor reprints to Dr. Mund y , Department ofPsychiatry, UCLA Center for the Health Sciences, 760 Westwood Plaza, Los Angeles, CA 90024. 0890-8567/90/2905-0724$ 02 .00/0 © 1990 by the American Academy of Child and Adolescent Psychiatry .
Caton , 1984; Solarz , 1988). Abuse, placement in foster care, and alcohol use in the family are interrelated factors that have been associated with psychopathology in children and adolescents (Lampert et aI. , 1977; Rogene ss et aI. , 1986). Moreover, it is likely that homelessness is a stressful life experience for most individuals. Therefore, it is not surprising that research suggests that homeless children and adolescents experience high rates of mental health problems (Solarz, 1988; Robertson, 1989a). This research , however, has been limited in at least two ways. First , studies of unaccompanied homeless adolescents have focussed on the prevalence of symptoms primarily associated with mood disorder or substance abuse. Homeless and runaway youth frequently report depressed mood, suicidal ideation, and suicide attempts (Shaffer and Caton, 1984; Yates et al., 1988). Many also report drug and alcohol use and abuse (Shaffer and Caton , 1984; Yates et al., 1988; Robertson, 1989b). However, other aspects of psychopathology have not been detailed in these reports. A second limit is that much of the data have been based exclusively on youth who used shelters or health clinics (e.g. , Shaffer and Canton , 1984; Yates et aI., 1988). While immensely valuable , shelter or clinic based studies may present a sampling bias. That is, these data may not reflect the characteristics of homeless adolescents who are less prone to use shelter or clinic services. To address these issues , this study was designed with four goals in mind. The first goal was to gather data on the prevalence of self-reported symptoms of psychotic though process (e.g. , auditory hallucinations) in a sample of homeless adolescents . This aspect of psychopathology has not been addressed in previous research. Moreover, these symptoms are commonly considered to be an index of serious psychiatric pathology and are widespread among psychiatric samples of children and adolescents (Burke et aI., 1985; Apter aI., 1987). The second goal was to examine the life experience and mental health phenomena associated with self-reported psychotic symptoms in homeless adolescents. This study examined the extent to which self-reported psychotic symptoms were correlated with the report of depressed or anxious mood , 724
HOMELESS ADOLESCENTS TABLE
1. Sample Description
MeanAge, 16.1 years (SO = 1.1) Males, 61 % (N = 59) Females, 39% (N = 37) Race Hispanic, 13%(N = 12) Black, 15%(N = 14) Asian, 3% (N = 3) White, 59% (N = 57) Other, 10% (N = 10) Interviewed in shelter sites, 9% (N = 9) Mean length of homeless episode, 306.7 days (SO = 541. 5) Median length of current homeless episode, 90 days Mean nights in shelters in the last 30 days, 6.0 nights (SO = lOA)
abuse history, and alcohol and other drug use. These variables may be expected to be associated with psychotic symptom presentation in adolescents (Simonds, 1975; Tsuang et al., 1982; Apter et al., 1987; Livingston, 1987; Sansonnet-Hayden et al., 1987). Moreover, inclusion of measures of depressed or anxious mood also enabled this study to provide data that were comparable with data provided by previous studies of homeless adolescents sampled from shelters (e.g., Shaffer and Canton 1984). Thus, a third goal of this study was to replicate earlier research on the self-report of mood disturbance in homeless adolescents. The final goal of this study was to recruit adolescents for this study from street sites as well as shelter sites. This sampling method enabled the examination of the effects of sample selection on the mental health data of homeless adolescents. The effect of homelessness per se on the development of psychotic symptoms was also examined, with the inclusion of a variable that assessed the length of the current homeless episode. Longer periods of homelessness, and presumably accumulated stress, were hypothesized to be associated with an increased tendency to report psychotic symptoms in these adolescents.
Method Subjects
The sample was drawn from the Hollywood section of Los Angeles. This included the incorporated city of West Los Angeles and parts of Los Angeles bounded by Franklin Avenue on the north, Melrose Avenue on the south, La Brea Avenue to the west, and Western Avenue to the east. A number of sites where homeless adolescents could be found were identified including seven service sites (shelters, meal programs, and day centers) and 24 street sites. The latter were identified by key informants such as professionals in shelters for the homeless and from homeless adolescents during their interviews. Nine adolescents were interviewed in shelters, while the remaining adolescents were interviewed in other service sites or street sites. In addition to data on the site of interview, data on the adolescents' reported use of shelter beds was obtained. Thirty-six adolescents reported that they had spent one or more nights in a shelter in the 30 days before the interview. The average number of nights spent in shelter l.Am.Acad. Child Adolesc, Psychiatry, 29:5, September 1990
sites for the total sample, along with other sample data, is presented in Table 1. One hundred adolescents were screened and invited to be interviewed. Ninety-nine ofthe identified adolescents agreed to participate in the interviews. Three cases were later excluded from data analyses because review of their data revealed they failed to meet age or homeless status criteria. Procedures
The Homeless Adolescent Interview Schedule (HAIS) was created to assess each adolescent on a variety of dimensions. The HAIS is not an instrument in its own right but rather an amalgamation of extant interview tools. (More information on the HAIS may be obtained by writing to: Marjorie Robertson, Alcohol Research Group, Medical Research Institute of San Francisco, 1816Scenic Avenue, Berkeley, CA 94709.) The HAIS incorporated items from standardized measures and structured interviews to assess aspects of the adolescents' self-reported mental health status. The following subsets of the HAIS were pertinent to this study. The HAIS contained the depression, alcohol use, drug use, and psychotic symptoms sections of the Diagnostic Interview Schedule (DIS) (Robins et al., 1981, 1982). The HAIS also contained the Revised Children's Manifest Anxiety Scale (RCMAS) (Reynolds and Richmond, 1984) and the Childhood Depression Inventory (CDI) (Kovacs, 1981). The DIS depression and psychotic indices were included to provide narrow band assessments of specific psychiatric symptoms. The RCMAS and CDI assess multiple factors associated with anxiety, self esteem, depressed effect, and oppositional behavior (Reynolds and Richmond, 1984; Carey, et al., 1987). Questions regarding the adolescent's mental health treatment history, physical health status and treatment history, family mental health and treatment history, social family history, abuse and neglect history, and history of homelessness were also included. All participants in this study spoke English, and all interviews were conducted in English by trained personnel. Interviewers received 32 hours of training before data collection. Training consisted of didactic sessions on survey research techniques and multiple sessions on standardized interviewing procedures, procedures specific to particular instruments (e.g., DIS items), probing strategies, and field conduct. To encourage honest self-reporting, no identifying information was collected, and confidentiality was guaranteed to all respondents. All of the respondents were screened for selection criteria by one of the authors (MR). This ensured that, without recording identifying information, adolescents did not participate more than once in this study. The criteria for participation in this study were a self-reported age of between 12 and 17 years and a self-report that the previous night was spent in an emergency shelter or in improvised shelters (such as abandoned buildings, vehicles, public parks, and beaches) or on the street. Adolescents were offered $10.00 to participate in this study, with interview data collection lasting approximately 2 hours for each adolescent. Additional details regarding the procedures and sampling strategy used in this study are available elsewhere (Robertson, 1989b). 725
MUNDY ET AL.
Results
Psychotic Symptoms The first goal of the data analyses was to examine the lifetime prevalence of psychotic symptoms in this sample. The HAIS contained 12 questions regarding psychotic symptoms (Appendix). Since data collection involved a single interview session, the intent was not to derive a qualitative, diagnostic interpretation from responses to these questions. Instead, responses were scored to yield a quantitative measure of the symptoms endorsed by each adolescent. A score was computed to reflect the total number of symptoms endorsed by the adolescents. Subscores were also computed to reflect the number of items endorsed that assessed paranoid ideation (Qs 1,2, and 3; Appendix), ideas of reference (Qs 4,5,6,7,8; Appendix), and auditory hallucinations (Q 10; Appendiz). Whether or not an adolescent stated a symptom was a result of medication, drug use or physical illness was noted. Responses associated with these explanations were excluded from an individual's psychotic symptom score. Preliminary analyses of variance indicated that there were neither effects of sex nor race on the psychotic symptom reports of adolescents in this sample. Therefore, the data were examined across sex and race in subsequent analyses. The mean total psychotic symptom score for the sample was 2.3 (SD = 2.5) endorsed items. Thirty-eight percent of the sample endorsed none of the psychotic symptoms, 32% endorsed one to three symptoms, and 30% endorsed four or more symptoms. With regard to paranoid ideation (X = 0.68, SD = 0.97), 60% endorsed none of the items, 19% endorsed one item, and 21% endorsed two or three items. Thirty-one percent of the adolescents stated that they had experienced auditory hallucinations (X = 0.32, SD = 0.47). Finally, 66% of the sample denied any experience with ideas of reference
while 17% endorsed one item in this subscale, and lJ% of the sample endorsed two to five items in this subscale (X = 0.56, SD = 0.90). Consistency in the data on psychotic symptoms was examined with correlational analyses. Throughout this study, correlational analyses employed the Pearson product moment coefficient r, and modifications of the Pearson formula for correlations involving one dichotomous variable (the point biserial correlation, rph) or two dichotomous variables (phi coefficient, ro; Cohen and Cohen, 1975). Consistency in the self-report of psychotic symptoms was indicated by significant correlations between the dichotomous measure of the report of auditory hallucinations and ideas of reference, r ph = 0.61, p < 0.001, and paranoid ideation, rph = 0.30, p < 0.01. The association between paranoid ideation and ideas of reference was also significant, r = 0.33, p < 0.01. All correlations between the subscales and the total psychotic symptoms score exceeded r or r ph = 0.31, p < 0.01. Unlike sex and ethnicity, age bore a significant association with the self-report of paranoid ideation (r = - 0.25, p < 0.05) and held marginally significant associations with the report of auditory hallucinations (r ph = - 0.19, p < 0.06) and the total psychotic symptom score (r = - 0.18, p < 0.07). Scatterplots for these correlations indicated that the 726
17-year-olds tended to report fewer psychotic symptoms than the 13- to 16-year-olds. This effect is illustrated with means for the total psychotic symptoms score from three age groups: 17-year-olds (N = 50) = 1.9 (SD = 1.4),16year-olds (N = 19) = 3.0 (SD = 2.6), and 13, 14, and 15-year-olds (N = 27) = 2.7 (SD = 2.5). Thus, the subsample of adolescents reporting more psychotic symptoms in this sample tended to be younger than 17. These results indicated that the endorsement of psychotic symptoms was a prominent feature of the self-reported mental health status of approximately 30% of this sample. These symptoms were not restricted to reports of paranoid ideation, which may be generally elevated in response to the potentially threatening nature of street life. Rather, they also included reports of auditory hallucinations and ideas of reference. The correlations among psychotic symptom subscale scores indicated that adolescents who endorsed one type of symptom (e.g., auditory hallucinations) also tended to endorse other types of symptoms (e.g., ideas of reference). Moreover, there was a significant tendency for younger rather than older adolescents in this sample to report paranoid ideation. The next goal in the analyses of the data in this study was to describe the adolescents' reports of mood related symptoms, mental health treatment history, abuse, and alcohol/drug use. Mood Disturbance The adolescents in this sample obtained a mean score of 12.4 (SD = 7.0) on the CDI. A r-test indicated that this score exceeds the normative mean of this scale, 9.09, SD = 7.04,N = 1252 (Smucker et al., 1986), t = 4.44, p < 0.001. Thus, this sample reported an above average number of symptoms of dysphoria. As with the psychotic symptoms, younger adolescents in this sample tended to report more symptoms on the COl (r = -0.22, P < 0.05). Twenty percent of the sample had CDI scores greater than or equal to 19. This is a cutoff score that, on the basis of the normative distribution of scores, has been suggested as evidence of a significant or clinical level of mood disturbance (Kovacs, 1981; Smucker et al., 1986). The presence of depressed mood in individuals within this sample was also suggested by the mean score of 4.9 (SD = 2.5) on the DIS depression items. Examination of the DIS items also revealed high rates of the self-report of suicidal ideation (62% of the sample), and high rates of reported attempted suicide (46% of the sample). None of these indices of depressed mood were significantly associated with age in this sample. With respect to anxiety, these adolescents endorsed an average of 11.7 (SD = 6.6) items on the RCMAS. At-test indicated that this did not exceed the normative mean for this scale of 13.84, SD = 5.79 (Reynolds and Richmond, 1984). Examination of individual scale scores indicated that this sample did not report more general worries, social anxiety, or somatic symptoms than a normative sample of adolescents. Individual differences on this measure were not associated with age. The Lie Scale from the RCMAS was included as a check on the tendency of these adolescents to provide unrealistically positive self-reports. The obtained mean for this J. Am. Acad. Child Adolesc.Psychiatry, 29:5, September 1990
HOMELESS ADOLESCENTS
scale was 1.6(SD = 1.7). This did not exceed the normative mean for this scale (3.56, SD = 2.37), suggesting that these adolescents, as a group, did not present false positive self-reports. Consistency in the adolescents' reporting of dysphoric mood across measures was indicated by the significant positive correlations of the DIS reports of suicidal ideation with cm score, rpb = 0.27,p < 0.01, and with RCMAS score, rpb = 0.29, P < 0.01. The CDI and DIS scores were also correlated, r = 0.52, p < 0.001, as were the cm and RCMAS scores, r = 0.61, p < 0.0001, and the ms and RCMAS scores, r = 0.50, p < 0.0001. Finally, the reports of frequency of suicide attempts were correlated with the cm score (r = 0.21, p < 0.05), and the ms report of suicidal ideation (r pb = 0.56, p < 0.01). Mental Health Treatment
Twenty-three adolescents (24%) reported that they had received treatment in an inpatient psychiatric facility (i.e., stayed overnight in a psychiatric hospital) at least once in their lives. Twenty-two or 23% of the sample reported that they had received professional help for mental or emotional distress outside of psychiatric inpatient facilities. These variables were orthogonal (r, = 0.09, p > 0.10). Abuse
The reported prevalences of familial neglect, physical abuse, and sexual abuse were high in this sample. However, 8% to 18% refused to answer one or more questions regarding abuse issues. These responses were counted among the negative self-reports of abuse and may reflect a false negative bias in the prevalence figures presented in this report. Adolescents who confirmed neglect, physical or sexual abuse were encouraged to provide sufficient information to identify themselves and others to enable reporting of the abuse to social services or the police. However, most abuse reporting adolescents declined to provide identifying information because these events had already been reported to authorities. In a few cases, the adolescents reported that the perpetrators were unknown. Fifty-one percent of the sample reported that they had felt neglected by their parents (e.g., left alone often, basic needs for food or clothing were not attended to). Fifty-two percent of the sample reported that they had been physically hurt by a family member, while 51% of the sample reported that they had been physically hurt by someone other than a family member. The correlation between these two variables was significant (ro = 0.25, p < 0.02). However, this correlation was not so high as to indicate complete overlap between these variables. Thirty-two adolescents reported both types of abuse and thirty adolescents reported one or the other type of physical abuse. Thus, a majority of the sample (N = 62) reported either familial or extrafamilial physical abuse or experience with both types of abuse. With respect to sexual abuse, 14% of the adolescents reported that they had been the target of sexual activity by a family member (e.g., voyeurism, fondling, intercourse), while 20% reported that they were the target of nonconsensual sexual activity involving someone other than a l.Am.Acad. Child Adolesc. Psychiatry, 29:5, September 1990
family member. The correlation between these reports was not significant (r 0 = 0.17, p > 0.10), indicating that there was little overlap between these two subgroups. With respect to the other associations among self-reported abuse variables, neglect was significantly correlated with reports of familial (ro = 0.29, p < 0.01) and nonfamilial physical abuse tr; = 0.25, P < 0.02) and familial sexual abuse (r o = 0.37, p < 0.001). Sexual abuse perpetrated by a nonfamily member was not correlated with reports of neglect but was associated with reports of physical abuse in the family (r o = 0.31, P < 0.001) and outside the family (ro = 0.27, p < 0.01). Thus, a subgroup of adolescents in this sample reported the experience of different types of abusive life experience. The report of neglect, physical abuse, or sexual abuse, however, was not correlated with age in this sample. Alcohol and Drug Use The frequency of alcohol use during the past year was rated according to an ordinal scale: never or almost never, less than once a month, 1 to 3 times a month, about once per week, or more than once per week. Thirty percent of the sample reported thatthey drank alcohol (e.g., beer, wine, hard liquor) at least weekly, and 49% of the sample reported that they had drunk the equivalent of six or more beers in order to get drunk at least one time. However, the report of alcohol consumption was not correlated with age in this sample. Questions with regard to drug use were posed assuming that many homeless adolescents had some experience with a variety of drugs. Therefore, the intent here was to identify the frequent use of a particular substance. Questions of drug use were posed in terms of whether an adolescent had used a particular drug five or more times. Seventy percent of the sample reported that they had used marijuana more than five times. The use of cocaine more than five times was endorsed by 42% of the sample. Cocaine use was the only drug use variable to be significantly correlated with age. Older adolescents tended to report cocaine use more often than younger adolescents (r pb = 0.39, p < 0.01). The use of amphetamines (e.g., Dexedrinev) more than five times was endorsed by 38% and the use of hallucinogens (e.g., LSD, peyote, mescaline) more than five times was endorsed by 43%. The use of heroin more than five times was endorsed by only 6%, and 19% reported that they had used barbiturates (e.g., Seconal'", Quaalude'"), and 15% reported that they had used tranquilizers (e.g., Valium", Libriumv) more than five times. Interview Site and Homeless Experience The next goal of the data analyses was to address the issue of whether sampling site (shelter site or street site) was associated with effects on the self-report of psychotic and other psychiatric symptoms among homeless adolescents. Sample site was converted to a dichotomous dummy variable and associations with this variable were examined with point biserial correlations. As can be seen in Table 2, there was no association between sampling site and the self-report measures of psychotic symptoms. Moreover, the number of nights spent in shelter in the 30 days before the interview did not yield significant Pearson r correlations with the self-report of
727
MUNDY ET AL.
2 indicated that adolescents who more frequently spent night in shelters in this sample tended to be younger, reported less frequent drug and alcohol use, and also reported more fears , worries, and self-esteem issues on the RCMAS . Another aspect of the homeless experience examined was the length of the adolescents' current homeless episode . The mean and median for this variable appear in Table 1. It was hypothesized that longer periods of homelessness, and presumably accumulated stress, would be related to the report of psychotic symptoms in these adolescents. However, as can be seen in Table 2, individual differences in length of homeless episode were not significantly correlated with reported psychotic symptoms or mood disturbance. To the degree that these coefficients approached significance (e.g., with auditory hallucination, p < O.09), they were negative. If anything, then, adolescents who were relatively new to the experience of homelessness tended to report psychotic symptoms . Length of homeless episode was not correlated with any of the other indices of mental status listed in Table 2. However, a significant correlation with age was obtained (Table 2). This indicated that older adolescents tended to report longer episodes of homeless ness.
TABLE2. Correlates of Sample Site",Nights Slept in Shelters",
and Length of Current HomelessEpisode Site Psychotic symptoms Tolal Paranoia Ideas of reference Auditory CDiscore RCMAS total score DIS depression Suicidal ideation Suicide attempt Alcohol use Drug use Age
-0.16 -0.11 -0.08 - 0.Q7 0.27* 0.28** 0.03 0.02 -0.16 -0 .26* -0 .13 -0.18
Nights in Shelter
Length Homeless
0.03 0.01 -0.01 0.08 0.22* 0.22* 0.13 -0.01 -0.09 -0.12 -0.28** -0.24*
-0.15 -0.16 -0.05 -0.18 0.03 - 0.Q2 -0.09 0.17 0.01 0.Q7 0.06 0.25*
"Dichotomous variable = shelteror other site. QNights spent in shelters during 30 days before interview. *p
Abstract. This study was designed to gather data on psychotic symptoms in a sample of homele ss adolescents . The sample included adolescents who were located in street sites as well as adolescents who were currently using shelter services. Ninety-six adolescents participated in this study (mean age = 16.1 years). The result s indicated that 29% of the sample reported the experience of four or more psychot ic symptoms on the Diagnostic Interv iew Schedule psychotic symptom index. These results suggested that the endorsement of psychotic symptoms is a relatively prominent feature of the self-report of psychopathology among homeless adolescents. These symptoms did not only include reports of paranoid ideation, which may be generally elev ated as part of the stress of street life, but also included reports of ideas of reference and auditory hallucinations . Moreover, these symptoms were correlated with reports of affective disturbance, abusive life experien ce, and a particular type of substance use. J . Am. Acad. Chi/dAdolesc. Psychiatry, 1990, 29, 5:724--731. Key Words: mental status , homele ss, adolescents. Homelessness is an unfortunate life circumstance which increasingly afflicts substanti al numbers of children and adolescents each year (Solarz , 1988; Robertson, 1989a). Atleast two subgroups of homeless children may be described: children, under 10 years of age , who are in homeless families (e.g., Bassuk and Rosenburg , 1988) and children, often older than 10 years of age, who are homeless and live unaccompanied by an adult . Current epidemiological data on homeless children are imprecise. Nevertheless , with regard to the latter group , recent estimates suggest that there are approximately 1,000,000 unaccompanied homeless children, between the ages of 10 and 17 years, living on the streets of towns and cities in the United States each year (U.S. Department of Health and Human Services , 1984, Solarz, 1988). This paper presents data on the mental status of a sample of unaccompanied homeless adolescents. It is part of a research program that has focussed on the relation between homelessness, residential instability, and psychopathology in adolescents (Mundy et aI., 1989; Robertson, 1989a, b). Adolescents who are homeless often report histories of physical and sexual abuse (Janus et al., 1987; Solarz, 1988), alcohol abuse in the family (Robertson, 1989b), and conflicted relations with family members (Adams et aI., 1985). Many homeless adolescents also report experiences with foster care or other institutional care settings (Shaffer and
AcceptedMarch 7,1990. Dr. Mundy is with the Depar tment of Psychiatry , UCLA Centerfor the Health Sciences ;Dr . M . Robertson is with the Alcohol Research Group , Medical Research Institut e of San Fran cisco; Drs . J. Robertson and Greenblatt are with the Department of Psychiatry , Olive View Medical Center and UCLA . Supp ort for this research was pr ovided, in part, by grant 85-76258 from the California Department of Mental Health, NlAAA Professional Services Contract 87M023952101D , and the Los Ang eles County-Olive View Medical Cent er Departm ent ofPsychiatry. Sin cere appre ciation is extended to Paul Koegel, Christine Grella, Robert Aisley , Kim Hollingshead, and Roger Skinner for assistance in the design and exec ution of this study. Requestsfor reprints to Dr. Mund y , Department ofPsychiatry, UCLA Center for the Health Sciences, 760 Westwood Plaza, Los Angeles, CA 90024. 0890-8567/90/2905-0724$ 02 .00/0 © 1990 by the American Academy of Child and Adolescent Psychiatry .
Caton , 1984; Solarz , 1988). Abuse, placement in foster care, and alcohol use in the family are interrelated factors that have been associated with psychopathology in children and adolescents (Lampert et aI. , 1977; Rogene ss et aI. , 1986). Moreover, it is likely that homelessness is a stressful life experience for most individuals. Therefore, it is not surprising that research suggests that homeless children and adolescents experience high rates of mental health problems (Solarz, 1988; Robertson, 1989a). This research , however, has been limited in at least two ways. First , studies of unaccompanied homeless adolescents have focussed on the prevalence of symptoms primarily associated with mood disorder or substance abuse. Homeless and runaway youth frequently report depressed mood, suicidal ideation, and suicide attempts (Shaffer and Caton, 1984; Yates et al., 1988). Many also report drug and alcohol use and abuse (Shaffer and Caton , 1984; Yates et al., 1988; Robertson, 1989b). However, other aspects of psychopathology have not been detailed in these reports. A second limit is that much of the data have been based exclusively on youth who used shelters or health clinics (e.g. , Shaffer and Canton , 1984; Yates et aI., 1988). While immensely valuable , shelter or clinic based studies may present a sampling bias. That is, these data may not reflect the characteristics of homeless adolescents who are less prone to use shelter or clinic services. To address these issues , this study was designed with four goals in mind. The first goal was to gather data on the prevalence of self-reported symptoms of psychotic though process (e.g. , auditory hallucinations) in a sample of homeless adolescents . This aspect of psychopathology has not been addressed in previous research. Moreover, these symptoms are commonly considered to be an index of serious psychiatric pathology and are widespread among psychiatric samples of children and adolescents (Burke et aI., 1985; Apter aI., 1987). The second goal was to examine the life experience and mental health phenomena associated with self-reported psychotic symptoms in homeless adolescents. This study examined the extent to which self-reported psychotic symptoms were correlated with the report of depressed or anxious mood , 724
HOMELESS ADOLESCENTS TABLE
1. Sample Description
MeanAge, 16.1 years (SO = 1.1) Males, 61 % (N = 59) Females, 39% (N = 37) Race Hispanic, 13%(N = 12) Black, 15%(N = 14) Asian, 3% (N = 3) White, 59% (N = 57) Other, 10% (N = 10) Interviewed in shelter sites, 9% (N = 9) Mean length of homeless episode, 306.7 days (SO = 541. 5) Median length of current homeless episode, 90 days Mean nights in shelters in the last 30 days, 6.0 nights (SO = lOA)
abuse history, and alcohol and other drug use. These variables may be expected to be associated with psychotic symptom presentation in adolescents (Simonds, 1975; Tsuang et al., 1982; Apter et al., 1987; Livingston, 1987; Sansonnet-Hayden et al., 1987). Moreover, inclusion of measures of depressed or anxious mood also enabled this study to provide data that were comparable with data provided by previous studies of homeless adolescents sampled from shelters (e.g., Shaffer and Canton 1984). Thus, a third goal of this study was to replicate earlier research on the self-report of mood disturbance in homeless adolescents. The final goal of this study was to recruit adolescents for this study from street sites as well as shelter sites. This sampling method enabled the examination of the effects of sample selection on the mental health data of homeless adolescents. The effect of homelessness per se on the development of psychotic symptoms was also examined, with the inclusion of a variable that assessed the length of the current homeless episode. Longer periods of homelessness, and presumably accumulated stress, were hypothesized to be associated with an increased tendency to report psychotic symptoms in these adolescents.
Method Subjects
The sample was drawn from the Hollywood section of Los Angeles. This included the incorporated city of West Los Angeles and parts of Los Angeles bounded by Franklin Avenue on the north, Melrose Avenue on the south, La Brea Avenue to the west, and Western Avenue to the east. A number of sites where homeless adolescents could be found were identified including seven service sites (shelters, meal programs, and day centers) and 24 street sites. The latter were identified by key informants such as professionals in shelters for the homeless and from homeless adolescents during their interviews. Nine adolescents were interviewed in shelters, while the remaining adolescents were interviewed in other service sites or street sites. In addition to data on the site of interview, data on the adolescents' reported use of shelter beds was obtained. Thirty-six adolescents reported that they had spent one or more nights in a shelter in the 30 days before the interview. The average number of nights spent in shelter l.Am.Acad. Child Adolesc, Psychiatry, 29:5, September 1990
sites for the total sample, along with other sample data, is presented in Table 1. One hundred adolescents were screened and invited to be interviewed. Ninety-nine ofthe identified adolescents agreed to participate in the interviews. Three cases were later excluded from data analyses because review of their data revealed they failed to meet age or homeless status criteria. Procedures
The Homeless Adolescent Interview Schedule (HAIS) was created to assess each adolescent on a variety of dimensions. The HAIS is not an instrument in its own right but rather an amalgamation of extant interview tools. (More information on the HAIS may be obtained by writing to: Marjorie Robertson, Alcohol Research Group, Medical Research Institute of San Francisco, 1816Scenic Avenue, Berkeley, CA 94709.) The HAIS incorporated items from standardized measures and structured interviews to assess aspects of the adolescents' self-reported mental health status. The following subsets of the HAIS were pertinent to this study. The HAIS contained the depression, alcohol use, drug use, and psychotic symptoms sections of the Diagnostic Interview Schedule (DIS) (Robins et al., 1981, 1982). The HAIS also contained the Revised Children's Manifest Anxiety Scale (RCMAS) (Reynolds and Richmond, 1984) and the Childhood Depression Inventory (CDI) (Kovacs, 1981). The DIS depression and psychotic indices were included to provide narrow band assessments of specific psychiatric symptoms. The RCMAS and CDI assess multiple factors associated with anxiety, self esteem, depressed effect, and oppositional behavior (Reynolds and Richmond, 1984; Carey, et al., 1987). Questions regarding the adolescent's mental health treatment history, physical health status and treatment history, family mental health and treatment history, social family history, abuse and neglect history, and history of homelessness were also included. All participants in this study spoke English, and all interviews were conducted in English by trained personnel. Interviewers received 32 hours of training before data collection. Training consisted of didactic sessions on survey research techniques and multiple sessions on standardized interviewing procedures, procedures specific to particular instruments (e.g., DIS items), probing strategies, and field conduct. To encourage honest self-reporting, no identifying information was collected, and confidentiality was guaranteed to all respondents. All of the respondents were screened for selection criteria by one of the authors (MR). This ensured that, without recording identifying information, adolescents did not participate more than once in this study. The criteria for participation in this study were a self-reported age of between 12 and 17 years and a self-report that the previous night was spent in an emergency shelter or in improvised shelters (such as abandoned buildings, vehicles, public parks, and beaches) or on the street. Adolescents were offered $10.00 to participate in this study, with interview data collection lasting approximately 2 hours for each adolescent. Additional details regarding the procedures and sampling strategy used in this study are available elsewhere (Robertson, 1989b). 725
MUNDY ET AL.
Results
Psychotic Symptoms The first goal of the data analyses was to examine the lifetime prevalence of psychotic symptoms in this sample. The HAIS contained 12 questions regarding psychotic symptoms (Appendix). Since data collection involved a single interview session, the intent was not to derive a qualitative, diagnostic interpretation from responses to these questions. Instead, responses were scored to yield a quantitative measure of the symptoms endorsed by each adolescent. A score was computed to reflect the total number of symptoms endorsed by the adolescents. Subscores were also computed to reflect the number of items endorsed that assessed paranoid ideation (Qs 1,2, and 3; Appendix), ideas of reference (Qs 4,5,6,7,8; Appendix), and auditory hallucinations (Q 10; Appendiz). Whether or not an adolescent stated a symptom was a result of medication, drug use or physical illness was noted. Responses associated with these explanations were excluded from an individual's psychotic symptom score. Preliminary analyses of variance indicated that there were neither effects of sex nor race on the psychotic symptom reports of adolescents in this sample. Therefore, the data were examined across sex and race in subsequent analyses. The mean total psychotic symptom score for the sample was 2.3 (SD = 2.5) endorsed items. Thirty-eight percent of the sample endorsed none of the psychotic symptoms, 32% endorsed one to three symptoms, and 30% endorsed four or more symptoms. With regard to paranoid ideation (X = 0.68, SD = 0.97), 60% endorsed none of the items, 19% endorsed one item, and 21% endorsed two or three items. Thirty-one percent of the adolescents stated that they had experienced auditory hallucinations (X = 0.32, SD = 0.47). Finally, 66% of the sample denied any experience with ideas of reference
while 17% endorsed one item in this subscale, and lJ% of the sample endorsed two to five items in this subscale (X = 0.56, SD = 0.90). Consistency in the data on psychotic symptoms was examined with correlational analyses. Throughout this study, correlational analyses employed the Pearson product moment coefficient r, and modifications of the Pearson formula for correlations involving one dichotomous variable (the point biserial correlation, rph) or two dichotomous variables (phi coefficient, ro; Cohen and Cohen, 1975). Consistency in the self-report of psychotic symptoms was indicated by significant correlations between the dichotomous measure of the report of auditory hallucinations and ideas of reference, r ph = 0.61, p < 0.001, and paranoid ideation, rph = 0.30, p < 0.01. The association between paranoid ideation and ideas of reference was also significant, r = 0.33, p < 0.01. All correlations between the subscales and the total psychotic symptoms score exceeded r or r ph = 0.31, p < 0.01. Unlike sex and ethnicity, age bore a significant association with the self-report of paranoid ideation (r = - 0.25, p < 0.05) and held marginally significant associations with the report of auditory hallucinations (r ph = - 0.19, p < 0.06) and the total psychotic symptom score (r = - 0.18, p < 0.07). Scatterplots for these correlations indicated that the 726
17-year-olds tended to report fewer psychotic symptoms than the 13- to 16-year-olds. This effect is illustrated with means for the total psychotic symptoms score from three age groups: 17-year-olds (N = 50) = 1.9 (SD = 1.4),16year-olds (N = 19) = 3.0 (SD = 2.6), and 13, 14, and 15-year-olds (N = 27) = 2.7 (SD = 2.5). Thus, the subsample of adolescents reporting more psychotic symptoms in this sample tended to be younger than 17. These results indicated that the endorsement of psychotic symptoms was a prominent feature of the self-reported mental health status of approximately 30% of this sample. These symptoms were not restricted to reports of paranoid ideation, which may be generally elevated in response to the potentially threatening nature of street life. Rather, they also included reports of auditory hallucinations and ideas of reference. The correlations among psychotic symptom subscale scores indicated that adolescents who endorsed one type of symptom (e.g., auditory hallucinations) also tended to endorse other types of symptoms (e.g., ideas of reference). Moreover, there was a significant tendency for younger rather than older adolescents in this sample to report paranoid ideation. The next goal in the analyses of the data in this study was to describe the adolescents' reports of mood related symptoms, mental health treatment history, abuse, and alcohol/drug use. Mood Disturbance The adolescents in this sample obtained a mean score of 12.4 (SD = 7.0) on the CDI. A r-test indicated that this score exceeds the normative mean of this scale, 9.09, SD = 7.04,N = 1252 (Smucker et al., 1986), t = 4.44, p < 0.001. Thus, this sample reported an above average number of symptoms of dysphoria. As with the psychotic symptoms, younger adolescents in this sample tended to report more symptoms on the COl (r = -0.22, P < 0.05). Twenty percent of the sample had CDI scores greater than or equal to 19. This is a cutoff score that, on the basis of the normative distribution of scores, has been suggested as evidence of a significant or clinical level of mood disturbance (Kovacs, 1981; Smucker et al., 1986). The presence of depressed mood in individuals within this sample was also suggested by the mean score of 4.9 (SD = 2.5) on the DIS depression items. Examination of the DIS items also revealed high rates of the self-report of suicidal ideation (62% of the sample), and high rates of reported attempted suicide (46% of the sample). None of these indices of depressed mood were significantly associated with age in this sample. With respect to anxiety, these adolescents endorsed an average of 11.7 (SD = 6.6) items on the RCMAS. At-test indicated that this did not exceed the normative mean for this scale of 13.84, SD = 5.79 (Reynolds and Richmond, 1984). Examination of individual scale scores indicated that this sample did not report more general worries, social anxiety, or somatic symptoms than a normative sample of adolescents. Individual differences on this measure were not associated with age. The Lie Scale from the RCMAS was included as a check on the tendency of these adolescents to provide unrealistically positive self-reports. The obtained mean for this J. Am. Acad. Child Adolesc.Psychiatry, 29:5, September 1990
HOMELESS ADOLESCENTS
scale was 1.6(SD = 1.7). This did not exceed the normative mean for this scale (3.56, SD = 2.37), suggesting that these adolescents, as a group, did not present false positive self-reports. Consistency in the adolescents' reporting of dysphoric mood across measures was indicated by the significant positive correlations of the DIS reports of suicidal ideation with cm score, rpb = 0.27,p < 0.01, and with RCMAS score, rpb = 0.29, P < 0.01. The CDI and DIS scores were also correlated, r = 0.52, p < 0.001, as were the cm and RCMAS scores, r = 0.61, p < 0.0001, and the ms and RCMAS scores, r = 0.50, p < 0.0001. Finally, the reports of frequency of suicide attempts were correlated with the cm score (r = 0.21, p < 0.05), and the ms report of suicidal ideation (r pb = 0.56, p < 0.01). Mental Health Treatment
Twenty-three adolescents (24%) reported that they had received treatment in an inpatient psychiatric facility (i.e., stayed overnight in a psychiatric hospital) at least once in their lives. Twenty-two or 23% of the sample reported that they had received professional help for mental or emotional distress outside of psychiatric inpatient facilities. These variables were orthogonal (r, = 0.09, p > 0.10). Abuse
The reported prevalences of familial neglect, physical abuse, and sexual abuse were high in this sample. However, 8% to 18% refused to answer one or more questions regarding abuse issues. These responses were counted among the negative self-reports of abuse and may reflect a false negative bias in the prevalence figures presented in this report. Adolescents who confirmed neglect, physical or sexual abuse were encouraged to provide sufficient information to identify themselves and others to enable reporting of the abuse to social services or the police. However, most abuse reporting adolescents declined to provide identifying information because these events had already been reported to authorities. In a few cases, the adolescents reported that the perpetrators were unknown. Fifty-one percent of the sample reported that they had felt neglected by their parents (e.g., left alone often, basic needs for food or clothing were not attended to). Fifty-two percent of the sample reported that they had been physically hurt by a family member, while 51% of the sample reported that they had been physically hurt by someone other than a family member. The correlation between these two variables was significant (ro = 0.25, p < 0.02). However, this correlation was not so high as to indicate complete overlap between these variables. Thirty-two adolescents reported both types of abuse and thirty adolescents reported one or the other type of physical abuse. Thus, a majority of the sample (N = 62) reported either familial or extrafamilial physical abuse or experience with both types of abuse. With respect to sexual abuse, 14% of the adolescents reported that they had been the target of sexual activity by a family member (e.g., voyeurism, fondling, intercourse), while 20% reported that they were the target of nonconsensual sexual activity involving someone other than a l.Am.Acad. Child Adolesc. Psychiatry, 29:5, September 1990
family member. The correlation between these reports was not significant (r 0 = 0.17, p > 0.10), indicating that there was little overlap between these two subgroups. With respect to the other associations among self-reported abuse variables, neglect was significantly correlated with reports of familial (ro = 0.29, p < 0.01) and nonfamilial physical abuse tr; = 0.25, P < 0.02) and familial sexual abuse (r o = 0.37, p < 0.001). Sexual abuse perpetrated by a nonfamily member was not correlated with reports of neglect but was associated with reports of physical abuse in the family (r o = 0.31, P < 0.001) and outside the family (ro = 0.27, p < 0.01). Thus, a subgroup of adolescents in this sample reported the experience of different types of abusive life experience. The report of neglect, physical abuse, or sexual abuse, however, was not correlated with age in this sample. Alcohol and Drug Use The frequency of alcohol use during the past year was rated according to an ordinal scale: never or almost never, less than once a month, 1 to 3 times a month, about once per week, or more than once per week. Thirty percent of the sample reported thatthey drank alcohol (e.g., beer, wine, hard liquor) at least weekly, and 49% of the sample reported that they had drunk the equivalent of six or more beers in order to get drunk at least one time. However, the report of alcohol consumption was not correlated with age in this sample. Questions with regard to drug use were posed assuming that many homeless adolescents had some experience with a variety of drugs. Therefore, the intent here was to identify the frequent use of a particular substance. Questions of drug use were posed in terms of whether an adolescent had used a particular drug five or more times. Seventy percent of the sample reported that they had used marijuana more than five times. The use of cocaine more than five times was endorsed by 42% of the sample. Cocaine use was the only drug use variable to be significantly correlated with age. Older adolescents tended to report cocaine use more often than younger adolescents (r pb = 0.39, p < 0.01). The use of amphetamines (e.g., Dexedrinev) more than five times was endorsed by 38% and the use of hallucinogens (e.g., LSD, peyote, mescaline) more than five times was endorsed by 43%. The use of heroin more than five times was endorsed by only 6%, and 19% reported that they had used barbiturates (e.g., Seconal'", Quaalude'"), and 15% reported that they had used tranquilizers (e.g., Valium", Libriumv) more than five times. Interview Site and Homeless Experience The next goal of the data analyses was to address the issue of whether sampling site (shelter site or street site) was associated with effects on the self-report of psychotic and other psychiatric symptoms among homeless adolescents. Sample site was converted to a dichotomous dummy variable and associations with this variable were examined with point biserial correlations. As can be seen in Table 2, there was no association between sampling site and the self-report measures of psychotic symptoms. Moreover, the number of nights spent in shelter in the 30 days before the interview did not yield significant Pearson r correlations with the self-report of
727
MUNDY ET AL.
2 indicated that adolescents who more frequently spent night in shelters in this sample tended to be younger, reported less frequent drug and alcohol use, and also reported more fears , worries, and self-esteem issues on the RCMAS . Another aspect of the homeless experience examined was the length of the adolescents' current homeless episode . The mean and median for this variable appear in Table 1. It was hypothesized that longer periods of homelessness, and presumably accumulated stress, would be related to the report of psychotic symptoms in these adolescents. However, as can be seen in Table 2, individual differences in length of homeless episode were not significantly correlated with reported psychotic symptoms or mood disturbance. To the degree that these coefficients approached significance (e.g., with auditory hallucination, p < O.09), they were negative. If anything, then, adolescents who were relatively new to the experience of homelessness tended to report psychotic symptoms . Length of homeless episode was not correlated with any of the other indices of mental status listed in Table 2. However, a significant correlation with age was obtained (Table 2). This indicated that older adolescents tended to report longer episodes of homeless ness.
TABLE2. Correlates of Sample Site",Nights Slept in Shelters",
and Length of Current HomelessEpisode Site Psychotic symptoms Tolal Paranoia Ideas of reference Auditory CDiscore RCMAS total score DIS depression Suicidal ideation Suicide attempt Alcohol use Drug use Age
-0.16 -0.11 -0.08 - 0.Q7 0.27* 0.28** 0.03 0.02 -0.16 -0 .26* -0 .13 -0.18
Nights in Shelter
Length Homeless
0.03 0.01 -0.01 0.08 0.22* 0.22* 0.13 -0.01 -0.09 -0.12 -0.28** -0.24*
-0.15 -0.16 -0.05 -0.18 0.03 - 0.Q2 -0.09 0.17 0.01 0.Q7 0.06 0.25*
"Dichotomous variable = shelteror other site. QNights spent in shelters during 30 days before interview. *p
