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Homelessness & Health in Canada

 | 
Manal Guirguis-Younger
, 
Ryan McNeil
, 
Stephen W. Hwang

Part I-Homelessness & Health in Canadian Populations

Chapter 1. Being Young and Homeless: Addressing Youth Homelessness from Drop-in to Drafting Policy

Jeff Karabanow et Sean Kidd

Texte intégral

I met this chick that I was squeegeeing with two years ago. We were squeegeeing together. And I don't know how it happened but she got in this fight with this lady and this bitch took her garbage out of her car and threw it in the chick's face and said "Here's a bunch of trash for street trash like you" or something like that. And this girl had just left home, and she was like 16 or 17 or something, maybe a year older than me, she was just dealing with the whole leaving home situation, and this happened, and the car drove away and she came back to the sidewalk and she was like "fucking bitch blah blah blah", and then she just lost it. She started crying.
– 19-year-old girl, Toronto, interviewed between squeegee runs

Introduction

1Street youth populations are increasingly understood as being diverse, complex and heterogeneous. The generic terms street youth and homeless youth are made up of a number of intersecting subcultures including hardcore street entrenched young people, squatters, group home kids, child welfare kids, softcore twinkies, in-and-outers, punks, runaways, throwaways, refugees and immigrants, young single mothers and those who are homeless because their entire family is homeless. Within these makeshift categories are numerous labels that tend to be associated with street activities, such as gang bangers, sex trade workers, drug dealers, drug users, panhandlers and squeegeers. While these labels may denote some of the actions of young people on the street, for the purposes of this chapter, street youth or homeless youth (terms used interchangeably throughout the text) are defined as young people between the ages of 12 and 24 who do not have a permanent place to call home and who instead spend a significant amount of time and energy on the street, in squats (abandoned buildings), at youth shelters and centres and/or with friends (referred to as couch surfers) (Karabanow 2004a; Kidd and Scrimenti 2004).

2While many estimates have been made regarding the number of homeless youth at city and national levels in Canada, to date there have been no enumerations that might be considered definitive. This is due to the tremendous difficulty identifying youths who do not regularly use youth services and ambiguity regarding the definition of homelessness. A generally accepted estimate for all homeless persons in Canada is 150,000 (National Homelessness Initiative 2006), with youth between the ages of 16 and 24 considered the fastest growing segment of the homeless population in Canada.

3In the following literature review, we draw upon the North American literature, a large proportion of which is American. While there are clearly marked differences in the homeless child and youth experiences in South America and Africa (two other substantial bodies of literature), findings across studies in Canada and the United States are very similar. As such, we draw on a wider literature to frame this discussion highlighting key issues specific to the Canadian context. With research into the determinants of youth homelessness having largely run its course and a policy landscape that is, in most contexts, inadequate to take on the task of effectively addressing this pervasive social problem, it would seem timely to 'take a step back' and consider the knowledge gathered to date. We have sought, through this comprehensive review, to consolidate the research base and highlight domains where research and action needs to turn if we are to make inroads into this problem that compromises the health and lives of so many young people and has major impacts on their families and our communities.

Shifting Conceptualizations of Youth Homelessness

4By far the most common question asked in both research and public commentary is, why are these young people living on the street? As is the case with many social problems, the answers to these questions tend to be totalistic, with a range of themes waxing and waning as a function of the cultural norms in a given time. For instance, early 19th-century labelling referred to street youth as "petty thieves", "street sinners", "street urchins" and "begging impostors", while in the early 20th century, street youth were commonly branded as "young barbarians" and "street wandering children". In the late 19th century, an official from the Children's Aid Society commented:

Enjoying the idle and lazzaroni life on the docks, living in the summer almost in the water, and curling down at night, as the animals do, in any corner they can find... this is without a doubt in the blood of most children—as an inheritance, perhaps from some remote barbarian ancestor—a passion for roving. (Rivlin and Manzo 1988: 27–28)

5By the 1950s, popular perceptions of this same population were influenced by notions of psychological deviance, and street youth were thought to be mentally disturbed (Rivlin and Manzo 1988). Robertson (1992: 288) describes the common psychiatric understanding of homeless youth that helped shape the image of this population in the 1950s and 1960s, during a period when psychoanalysis was at the forefront of accepted wisdom:

Individuals characteristically escape from threatening situations by running away from home for a day or more without permission... typically they are immature and timid and often feel rejected at home, inadequate, friendless. They often steal furtively.

6The present day image of street kids is that of the sexually and/ or physically abused runaway. Ruddick's (1996) comprehensive analysis of homeless youth in Hollywood highlights a series of changes from the 1970s onward that were responsible for the shift away from the image of the street youth as a juvenile delinquent and criminal. The deinstitutionalization of the runaway from the juvenile penal system, combined with an increase in public recognition of the reality of abuse within dysfunctional families and the lack of employment and shelter opportunities, all played central roles in the transformation of the popular perception of street youth (Karabanow 2000). A crucial outcome of those changes was the novel awareness that these children had been forgotten or had 'slipped through the cracks' of the conventional child welfare system. The street kid/homeless youth of today evokes varied images that include young mothers, runaways, immigrant youth and squeegee kids. A single, though significant, element binding these perceptions together is the growing acceptance that youth are homeless because of reasons beyond their own control. A study of street youth in Halifax found that over 60 percent of public citizens interviewed perceived the root causes of youth homelessness as other than individual pathology (Karabanow 2004b). Today's street kid is often thought to be fleeing an abusive, dysfunctional family life or a miserable institutional situation and finding refuge on the street or in a short-term emergency shelter.

Etiology

7In the past 20 years, a consensus has emerged around the pathways to youth homelessness. There is growing agreement that for the most part, homeless youth are 'running away' from problematic and traumatic environments rather than 'running towards' street cultures (Karabanow 2003). The major commonality lies in various forms of troubled/strained family histories. High rates of drug and alcohol abuse and criminality are found among the parents of many homeless youth (Hagan and McCarthy 1997; MacLean, Embry and Cauce 1999). Poverty is a prominent finding with a high percentage of the families on social assistance (Ringwalt, Greene and Robertson 1998) and disrupted families are common, with few homeless youth reporting having lived with both biological parents (Hagan and McCarthy 1997). Also common are reports of marital discord (Dadds et al. 1993), domestic violence and a greater than average number of household moves involving frequent changes of school (Buckner and Bassuk 1997; Karabanow 2004a). Reports of childhood physical and sexual abuse are consistently high, as are histories of emotional abuse and neglect (Karabanow 2003, 2004a; Kidd 2006; MacLean, Embry and Cauce 1999; Molnar et al. 1998; Ringwalt, Greene and Robertson 1998). These negative home experiences intersect with a host of other problems, including poor performance in school, conflict with teachers and other adults in positions of authority and conduct problems (Feitel et al. 1992; Hagan and McCarthy 1997; Rotheram-Borus 1993).

8Another disturbing finding is that street youth populations in numerous studies speak to problematic child welfare placements as a major reason for their entry into street life (Karabanow 2003, 2004a, 2008; Kurtz, Jarvis and Kurtz 1991; van der Ploeg 1989). These experiences were most often described as uncaring, exploitative and unstable (Michaud 1989; Raychaba 1989). Numerous moves from group home to group home or between foster parents, coupled with feelings of being treated as 'criminals', 'delinquents' or 'unwanted', shaped young people's transition to street life (Edney 1988a, 1988b; Morrisette and MacIntyre 1989). Child welfare settings were routinely described by young people as unresponsive to their needs and perceived as 'prison' environments rather than loving and home-like structures (Raychaba 1989). Street life became an enticing option for young people who either experienced episodes of 'running away' from or graduating from child welfare placements. Finally, in line with the above body of research, most homeless youths with mental illness on the streets report that their mental illness began prior to their leaving home and, not surprisingly, was exacerbated by street living (Craig and Hodson 1998; Karabanow et al. 2007).

9One topic that has been largely absent throughout the discussion of youth homelessness in the media and in research is diversity. Similar to other subcultures, the culture of street life is diverse and complex. Street youth are equally diverse in terms of background, present experiences and future aspirations. Labels such as squeegee kids, punks, street-entrenched, group-home, in-and-outers, runaways or shelter youth are used in the literature as an attempt to make sense of the diverse population and to organize analytical discussions (see, e.g., Kufeldt and Nimmo 1987; McCarthy 1990; Morrisette and McIntyre 1989; Shane 1989; van der Ploeg 1989). Only a few studies have addressed the implications and outcomes of various subgroups of homeless youth. Kipke and colleagues (1997) typologized homeless youths into five groups: punks, gang members, loners, hustlers (sex trade involved youth) and druggies, with the participants indicating which group they most strongly identified with. It was found that group affiliation had a major impact on residential status (e.g., punks are more likely to live on the streets or in an abandoned building), subsistence pattern (e.g., gang members are more involved in drug dealing) and service use (e.g., hustlers are most often accessed by outreach workers). In line with Kipke's work, studies looking at the experiences of sex trade involved youth have highlighted the unique risks and heightened discrimination experienced by these youth (Cusick 2002; Kidd and Kral 2002; Kidd and Liborio 2011; Yates et al. 1991). Those who use the sex trade as a primary source of income and become associated with it as an identity have markedly poorer mental health and far worse trajectories of risk than most other youth.

10Some studies in the past few years have also started to take a closer look at gender and sexual orientation on the streets. It has been found that, relative to boys, girls have more extensive sexual abuse histories, are more often sexually victimized on the streets and have a harder time subsisting on the streets (Cauce et al. 2000; Karabanow 2004a; O'Grady and Gaetz 2004). Youth with lesbian, gay, bisexual or transgendered (lgbt) sexual orientation are in many cases homeless because of abuse and rejection by family who are intolerant of their revealing and exploring their sexual orientation (Karabanow 2008). lgbt youth have more often been abused at home, are victimized more often on the streets and generally have poorer mental health and greater involvement in risk activities relative to other homeless youth (Noell and Ochs 2001; Kruks 1991; Cochran et al. 2002).

11In sum, the vast majority of youth become homeless due to external circumstances. For the most part, these are young people who have rarely experienced a stable, loving family unit—rarely did they feel loved, cared for, supported or experience a sense of belonging. As such, it is of little wonder why street life is consistently perceived by the vast majority of the street youth population as a safer and more stable environment than home.

Street Contexts and Cultures

12Complementing the large body of work documenting pathways to homelessness, a substantial body of work has developed in recent years documenting risks and subsistence strategies on the streets. This line of work has revealed diverse, complex and, at times, contradictory narratives of survival among homeless youth. While street life may be perceived initially as a place of freedom, community and relative security, these feelings quickly fade or become demystified (Karabanow 2006, 2008; Visano 1990). As such, street cultures present complex and often dichotomous narratives; they can be sites of excitement, belonging and acceptance as well as exploitation, violence, hunger, boredom and stress (Karabanow 2003, 2006; Karabanow et al. 2007). Much of the literature has focused upon these negative attributes of street culture. More recent focus of academic investigations has explored street youth survival strategies (Karabanow et al. 2009; O'Grady and Greene 2003).

13To support themselves, homeless youth engage in numerous activities including employment seeking, seeking money from family/ friends, panhandling, prostitution, survival sex (sex for food, shelter etc.), dealing drugs and theft (Greene, Ennett and Ringwalt 1999; Hagan and McCarthy 1997; Kipke et al. 1997). The difficulty of surviving on the streets is evident in the large number of homeless youth who regularly lack shelter and go hungry (Antoniades and Tarasuk 1998). Moreover, street life presents numerous dangers and stresses in the form of physical and sexual assaults and other types of victimization (Karabanow et al. 2007; Whitbeck, Hoyt and Bao 2000). Drug abuse is a common way of coping with these stressors (Adlaf, Zdanowicz and Smart 1996; Karabanow et al. 2007), and addiction is a major problem among this population (Greene and Ringwalt 1996). There is a high incidence of mental disorders among homeless youth, with depression, post-traumatic stress disorder and suicidal behaviours highlighted as common problem areas (Karabanow et al. 2007; Kidd 2004; Whitbeck, Hoyt and Bao 2000; Yoder 1999). Mortality rates for these youth have been found to be 12 to 40 times that of the general population (Shaw and Dorling 1998), with suicide and drug overdose having been found as the leading cause of death among Canadian homeless youth (Roy et al. 2004). In general, it has been found that victimization and decline in physical and mental health on the streets would seem to occur as a function of the degree of victimization in the lives of homeless youth prior to coming to the streets.

14Youths characterize their lives on the streets, for the most part, as unhealthy, difficult, boring, requiring an unrelenting effort to meet basic needs, violent and dangerous and lonely and exploitative (Karabanow et al. 2007; Karabanow 2004a; Kidd 2004). However, the street continues to be seen by many as the best option in their lives, especially within the context of their youth, poverty, low self-esteem/ confidence, instability, lack of education and lack of employment/life skills (Karabanow 2008). They are consistently in survival mode— spending much of their talents, energies and resources securing food, shelter, clothing, emotional support and some form of formal or informal employment. Travel makes up some of their activity— moving from place to place, city to city, province to province—for the most part searching for, first, better supports; second, a new environment (in order to clean up, escape problematic situations, etc.); and, third, building different communities (punk, squatter, squeegee) (Karabanow 2006; Karabanow et al. 2007). While the majority of these young people work in informal or formal sectors, employment tends to be sporadic, fluid and uncompromising (Karabanow et al. 2009). Some seek out jobs as day labourers, others squeegee/pan to survive, others perform on the street (playing music), others act as drug peddlers, while others sell their bodies. Work is important to this population, providing a means to survive and/or a means to feel good about themselves (Karabanow et al. 2009).

15Finally, youths describe extensive experiences with social stigma. Most regularly experience insulting interactions with the general public based upon their appearance and homeless status, and stigmatization extends to difficulty finding work and housing and to criminalization (Kidd 2003, 2004; Karabanow 2004a; Karabanow et al. 2009; Schissel 1997). Numerous studies have highlighted how street youth feel outside of civil society, alienated from mainstream culture and without a sense of belonging or acceptance (e.g., Kidd and Davidson 2007). This stigma is particularly salient for visibly homeless youth and youths who face multiple forms of stigma based on other aspects of identity (e.g., sexual minorities) and activities (e.g., sex trade involved youth) and has been linked to a greater risk of suicide and negative mental health outcomes (Kidd 2006).

16The topics of resilience, strength and survival have increasingly been addressed in the North American youth homelessness literature. The coping literature has highlighted several themes which emerged in this study including self-reliance, the support of other youth, spirituality and caring for others (Karabanow 2003, 2004a, 2008; Kidd 2003; Lindsey et al. 2000; Rew and Horner 2003; Williams et al. 2001). There has also been some emerging work addressing the deeper identity and cultural shifts that determine how homeless youth understand and experience their world which, in turn, defines and drives their coping efforts (Karabanow 2006; Visano 1990). In a large study examining the experiences of youth in New York City and Toronto, Kidd and Davidson (2007) highlighted the manner in which coping efforts were framed within youths testing, adopting and rejecting the various meaning systems made available in the street context. This adaptation, or the particular version of 'normal' used, has major implications for their trajectories on and off the streets. For youths who don't take on street value systems and norms, the streets are far more difficult to survive in and these youth are much more motivated to make use of services to exit the street. For those who take on one or more of the value systems/subcultures on the streets, they might experience a better quality of life in the street context but also face far greater risks and are more difficult to engage in interventions (e.g., youths for whom sex trade work has become the norm). Such meaning systems are typically challenged many times over the course of youths' time on the streets in the face of any number of contradictions: friends prove untrustworthy, serious criminal charges arise, health fails, assaults occur, addictions take over, caring and respected supports describe other ways of living that are more meaningful and healthier. However it is described, be it shift in worldview, value systems, or culture, it is the person's own view of their world that sets the nature and parameters of their coping, efforts to survive and sources of happiness.

Street Disengagement

17While much of the literature concerning street youth has focused upon trajectories onto the streets and youths' efforts to survive in street contexts, there have been few systematic analyses of strategies employed by this population to disengage from homelessness. Karabanow and colleages (2005) and Karabanow (2006, 2008) explored how Canadian street youth successfully and unsuccessfully disengaged from street culture through in-depth qualitative interviews with youth and service providers in Halifax, Montreal, Ottawa, Toronto, Calgary and Vancouver. A comprehensive portrait of street exiting involves numerous stages or dimensions:

  1. Precipitating Factors: The precipitating factors that propel contemplation of street disengagement tend to include the experience of a traumatic event (such as physical/sexual assault, drug overdoses, witness of street violence or involvement with the criminal justice system), becoming disenchanted with street culture and/or becoming worn down, physically, emotionally and/or spiritually, by daily street existence.
  2. Courage to Change: Layer two involves the individual's courage to change and this was highly influenced by such factors as increased responsibility (becoming pregnant, having an intimate partner or recognition that someone was dependent on them), having someone who cares, having support from family and/or friends and being internally motivated and committed to street transitioning. Young people talked about having "strong will power" to combat impressive obstacles like drug addiction, trauma and lack of supports. Knowing someone truly cares for you, or having steady support builds motivation.
  3. Seeking Support: The third step is highly interrelated with layer two and involves seeking available support (primarily in relation to housing and employment) within the initial stages of street disembarking. This aspect is about asking for help—being able to use available services and being able to articulate one's needs, in many instances, to service providers.
  4. Transitioning away from the Street: Layer four deals with transitioning away from the street and entailed physically leaving the downtown core, reducing ties with street culture and street friends and constructing or reconstructing relationships with mainstream society. Cutting street ties meant leaving friends, surrogate families and a culture associated with the downtown core. Participants expressed that it was as difficult leaving the street culture/street friends as it was entering into the more mainstream society and building new relationships. Despite the emotional strains of leaving relationships with people who had helped support them on the street, building new relationships outside of street culture was highlighted as essential for healthy transitioning. New friends and communities tended to be seen by participants as "good influences" in their day-to-day living. But this transitional time was also characterized by feelings of loneliness and uncertainty.
  5. Restructuring: Next there is a clear restructuring of one's routine in terms of employment, education and housing; a shift in thinking about future aspirations; and the ability to acquire some form of financial assistance to support one's transitioning. During this stage, young people highlighted a renewed sense of health/wellness, self-confidence and personal motivation. Participants described both physical and psychological shifts occurring in their lives, such as sleeping better, feeling healthier and experiencing increased self-esteem and self-confidence. Such changes tended to be linked to young people having more stability and consistency in their lives. Shifts in routine were commonly seen as interwoven with the notion of building new communities and tended to focus upon replacing street activities with formal employment and returning to school. However, subtle day-to-day shifts in routine (such as waking up and making some coffee or coming home and watching television) were as celebrated as more tangible elements such as living in one's own apartment or going to work each day. These transitions allowed many youth to reflect upon their past experiences, and for the majority of participants, this meant perceiving the street as an unhealthy and destructive environment. Along with a healthier sense of self, young people were more ready to develop longer-term plans and envision some control in their futures.
  6. Successful Exiting: The final stage primarily embodies young people's emotional and spiritual sense of identity. "Successful exiting" was exemplified by a sense of "being in control" and "having direction" in one's life. The majority of participants spoke of feeling proud of their movements out of street life, being able to finally enjoy life on their own terms, having healthy self-esteem and self-confidence, being able to take care of themselves and feeling stable in terms of both housing/security and wellness. "Getting off the street" translated into more than simply finding an apartment and physically removing oneself from a street lifestyle. Truly becoming an "ex-street youth" entailed emotional and spiritual shifts within the individual.

18Challenges and obstacles pepper young people's travels throughout these layers of street exiting. Structural and personal barriers include drug and alcohol addictions, past and present traumas, mental health issues, discrimination, lack of reasonable employment, a dearth of affordable housing stock, loneliness and isolation and the often difficult process of breaking ties with street culture and street friends. At times, these challenges appear monumental and young people are forced back to the street an average of six times; however, with the support of innovative and caring service providers throughout the country, each exiting attempt creates greater distance, both physically and emotionally, between them and street culture (Karabanow 2008).

Intervention

19There exists a vast array of shelters, drop-ins, clinics and other emergency services that do primary basic-needs support, some outreach/ prevention and short term counselling. Unfortunately, relative to the large body of research literature describing homeless youth and their various risk trajectories, there are very few studies and informal descriptions of services, their strengths and limitations. The literature developed to date tends to cluster around the following areas.

Basic Needs and Physical Health

20Many researchers recommend that the first priority is to ensure that youths are provided with the basic necessities of life in an immediate fashion (Cauce et al. 1994; Karabanow and Clement 2004; Terrell 1997). This includes assistance with obtaining adequate food, shelter and attention to physical ailments. Assessment of needs in this area is crucial, with many suffering from multiple health problems, including poor nutrition (Antoniades and Tarasuk 1998; Yates et al. 1991). Related to health issues, there is a need to ensure that youth are educated regarding the risks of communicable diseases, unprotected sex and sharing needles, by both peers and trusted workers or other individuals whose opinions are respected (Booth, Zhang and Kwiatkowski 1999; Ensign and Gittelsohn 1998; Greene and Ringwalt 1996). Of the intervention strategies that focus on interventions to reduce sexually transmitted disease, peer-based strategies have been found to increase street youths' hiv knowledge (Podschun 1993). Tenner and colleagues (1998) described an intensive case management approach with hiv-positive youth, noting the importance of a flexible and responsive service system that responds to both the medical and other social service needs of its clients. A recent study has also shown that cognitive behavioural intervention that focuses on skill building and education was more effective than treatment as usual in increasing condom use (Slesnick and Kang 2008). Lastly, researchers have highlighted the importance of making prenatal education and care available given the high rates of pregnancy among street-involved youth (Greene and Ringwalt 1998).

Drug Use and Addiction

21Assessment of substance use is regarded as a necessary aspect of services for homeless youths given the extremely high rates of alcohol and drug use (Baron 1999). It is important to recognize that the mechanisms underlying substance abuse may differ greatly from youth to youth. MacLean, Embry and Cauce (1999) have found different motives for drug use as a function of gender and other factors such as affect regulation. Several researchers caution, however, that too heavy a focus on drug use alone is ineffective and that drug use is likely a symptom of other problems that need to be addressed just as urgently (Adlaf, Zdanowicz and Smart 1996; Sibthorpe et al. 1995). With respect to specific interventions, Natasha Slesnick has done a considerable amount of work in the area of family therapy. She has found that ecologically based family therapy, with both family and individual sessions focused on decision-making, emotion regulation or other intrapersonal factors, results in greater reductions in substance use when compared with treatment as usual (Slesnick and Prestopnik 2005). Several studies in this area have also discussed motivational intervention as a model for working with substance-using street youth (Baer, Peterson and Wells 2004), with findings indicating a sustained reduction in substance use following a brief group-based motivational enhancement intervention (Peterson et al. 2006). Lastly, peer-led groups have also been cited as more effective for substance-using homeless youths than adult-led groups (Fors and Jarvis 1995). While concurrent mental illness and addictions problems are undoubtedly present in this group, integrated treatment models have yet to receive substantial attention in the research literature.

Mental Health

22Many researchers stress the importance of screening for symptoms of mental health problems. Specifically, it has been suggested that workers screen for suicidality, depression and histories of maltreatment and abuse, which are potentially indicative of increased vulnerability (Kidd 2006; Kurtz, Jarvis and Kurtz 1991; Ringwalt, Greene and Robertson 1998; Rotheram-Borus 1993; Stiffman 1989; Yoder 1999; Yoder et al. 1998). It has also been recommended that interventions be tailored to specific subpopulations of youth. For example, Cauce and colleagues (2000) recommended that service providers working with males who have experienced physical violence and are more likely to have conduct-related problems develop interventions that focus on limit setting and impulse control. Other recommendations include training in a wide range of best practice approaches to mental health intervention for staff (Cauce et al. 2000), the integration of peers as supports (Fisk, Rowe and Brooks 2000) and the importance of providing effective interventions for trauma in mental health counselling with this population (McManus and Thompson 2008). Outcome research on specific mental health interventions for this group are, however, very rare. One exception is an evaluation of the Community Reinforcement Approach (cra), which used a cognitive behavioural approach to address the systematic challenges faced by youth and demonstrated better outcomes than treatment as usual across a number of domains (Slesnick et al. 2007).

Housing

23The most common housing service for street youth is short-term emergency shelters that provide basic sleeping arrangements and often case management support/guidance. These shelters proliferated in the seventies and eighties due to the growing number of runaways and street kids in need of a safe refuge. Alleva (1988) and Karabanow (1999, 2000, 2004) argue that these shelters were portrayed as alternatives for youth who mistrusted traditional services. While street youth have objected to particular sets of rules and structures within shelters, for the most part, they have perceived such settings as surrogate families and its workers as highly supportive (Alleva 1988; Karabanow 2004a). Karabanow (2003, 2008) has argued that the vast diversity of street youth shelters are for the most part "symbolic spaces" for troubled and alienated youth to find acceptance/ belonging, satisfy immediate basic needs, explore options for street exiting, manage personal traumas and structural challenges and gain self esteem and confidence. However, access is generally more complicated for youths with addictions who do not view abstinence-focused shelters as a viable option (Krusi et al. 2010).

Service Provider Perspectives

24With respect to service provider perspectives on their work, a study of the narratives of 15 youth workers in Toronto suggested that what they viewed as effective revolved mostly around their relationships with clients (Kidd et al. 2007). Themes included a need to have a versatile approach that can be tailored to an individual youth's circumstances and establishing a connection based upon valuing, respecting and 'liking' youths. This trusting relationship was, in turn, essential; youths are drawn to that rare experience of trust, which serves as a platform for effective work. Youth workers also described the challenges associated with working with street-involved youth. These challenges included the complexity of the needs of youths, the various barriers that exist as a function of social stigma and marginalization and the minimal resources available to do the work. These challenges can readily lead to burnout and high staff turnover, both of which can negatively affect the services provided.

Policy

25Of the range of factors involved in youth homelessness, socio-cultural and policy issues have arguably received the least attention in the literature. This circumstance exists despite emerging evidence that social stigma at both public (e.g., insults, physical assaults, etc.) and structural levels (e.g., multiple arrests, inadequate funding for services, etc.) have a profound impact on the health and well-being of this population (Karabanow 2004a; Kidd 2003; Kidd and Carroll 2007; Schissel 1997). Specific difficulties present in the Canadian context include, first, difficulty accessing income support, unemployment insurance and disability payments; second, increasing criminalization and disproportionate arrests; third, declines in affordable housing, difficulty accessing socially supported housing and increasing evictions; fourth, breakdowns in continuity of care due to child welfare service age cutoffs (ranging from 16 to 19) and youth services age cutoffs (typically 24); and, finally, a lack of services specific to the needs of homeless youths, such as adequate discharge planning from health care and criminal justice systems (Kidd and Davidson 2006). Additionally, prevention efforts, which are almost ubiquitously called for across all forums, have yet to materialize and be evaluated in a substantive manner.

26At the policy level, there are a range of approaches that might serve to reduce both the extent of youth homelessness and the degree of risk faced by homeless youths. Such strategies might include reducing criminalization of minor non-violent and victimless crimes (e.g., panhandling), as this serves to hamper access to public assistance and supported housing. Underlying such an argument is the need to initiate preventive structures that tap into the true reasons for youth homelessness: child welfare failures, poverty, family distress, abuse and neglect and violence. We need thoughtful educational strategies (such as runaway prevention programs carried out by numerous street youth organizations) to disentangle myths and stereotypes as to why these young people enter street life and remain on the street.

27Another need area is the provision of sustained funding that is commensurate with both the extent of the problem in terms of number of homeless youth and the complexity of their needs. At present, most services operate within budget restrictions that markedly hamper their ability to provide the sorts of comprehensive approaches highlighted in the review above. Furthermore, the fierce competition that exists for the small amount of funding available in a given city can impede inter-agency cooperation. Numerous scholars have argued for the emergence of thoughtful long-term structural development initiatives including supportive and independent housing and meaningful employment opportunities (see, for example, Karabanow 2008; Kidd and Davidson 2006). There are many case examples throughout North America of innovative linkages between government, business and non-profit sectors to build such initiatives (e.g., Montreal's Dans La Rue, Toronto's Covenant House and Eva's Place and Calgary's Open Door). Young people have been unequivocal about the need for safe and sustainable housing in order to seek out employment opportunities.

Conclusion

28The last twenty years have witnessed a more sympathetic perspective on homeless youth in both the academic literature and popular media. Rather than being seen as social misfits, increasingly they are understood as victims of social structures. The academic literature reviewed makes it clear that street youth are a highly marginalized and alienated population, and forms of intervention that attempt to support, care for and show genuine interest towards these adolescents have the best chance of proving successful.

29We conclude that youth homelessness is fundamentally a systemic problem that requires a systemic response. We highlight the key domains that would form such a response, but how such an effort might be undertaken in a coherent and coordinated manner is less clear. We suggest that, following the example of the Mental Health Commission of Canada, a body be formed that cuts across research, policy and practice sectors to facilitate a coordinated response to youth homelessness and stimulate partnerships. Until such a response is developed, we will continue to have young people funnelling through pathways of inadequate supports onto our streets—at profound personal and social cost.

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Auteurs

Professor of Social Work at Dalhousie University. He has worked with homeless young people in Toronto, Montreal, Halifax and Guatemala. He has published numerous academic articles about housing stability, service delivery systems, street health and homeless youth culture. He has also completed a film documentary looking at the plight of street youth in Guatemala City and several animated shorts on Canadian street culture. His most recent book, Leaving the Streets: Stories of Canadian Youth (Fernwood Press), was released in fall 2010

Head of the Psychology Service in the Centre for Addiction and Mental Health's Schizophrenia Program and is an Assistant Professor with the McMaster and University of Toronto Departments of Psychiatry. His research interests include examining mechanisms of resilience among marginalized persons and the effectiveness of psychiatric rehabilitation interventions. His past work has focused on Assertive Community Treatment, policy and service development for homeless youths and the delivery of recovery-oriented services

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