RESEARCH AND PRACTICE
Adverse Outcomes Among Homeless Adolescents and Young Adults Who Report a History of Traumatic Brain Injury Jessica L. Mackelprang, PhD, Scott B. Harpin, RN, PhD, MPH, Joseph A. Grubenhoff, MD, and Frederick P. Rivara, MD, MPH
Homelessness is a serious public health problem that emerges at the intersection of complex socioecological factors. According to US Department of Housing and Urban Development estimates, at least 200 000 children, adolescents, and young adults were homeless on the night of a survey conducted in January 2013, representing one third of all homeless people in the United States.1 Homeless youths may be counted along with families but are often unaccompanied and moving between shelters or living on the streets. The unpredictable and often dangerous circumstances that accompany homelessness leave homeless individuals vulnerable to injury, illness, and victimization. Homeless individuals experience poorer health than people with stable housing and have a shorter life expectancy,2---4 and homeless young people experience high rates of internalizing (e.g., depression), externalizing (e.g., conduct disorder), and substance use disorders.5 A number of studies have documented cognitive difficulties, health problems, and violence exposure among homeless youths6---10; however, traumatic brain injury (TBI) has garnered minimal empirical attention. TBI is a leading cause of death and disability in the United States.11 However, a 2012 systematic review showed that only 8 studies have investigated TBI among homeless populations.12 The lifetime prevalence of TBI in these samples ranged from 8% to 53%, with all but 1 investigation reporting a rate above 20%. Five of the 8 studies were conducted in North America, with each recruiting from a single urban area and only one sampling multiple shelters. Most were limited by modest sample sizes, with only 2 exceeding100 participants.13,14 Moreover, although 2 studies included adolescents, the samples were small and the prevalence of TBI among youths was not separated
Objectives. We examined the prevalence of self-reported traumatic brain injury (TBI) among homeless young people and explored whether sociodemographic characteristics, mental health diagnoses, substance use, exposure to violence, or difficulties with activities of daily living (ADLs) were associated with TBI. Methods. We analyzed data from the Wilder Homelessness Study, in which participants were recruited in 2006 and 2009 from streets, shelters, and locations in Minnesota that provide services to homeless individuals. Participants completed 30-minute interviews to collect information about history of TBI, homelessness, health status, exposure to violence (e.g., childhood abuse, assault), and other aspects of functioning. Results. Of the 2732 participating adolescents and young adults, 43% reported a history of TBI. Participants with TBI became homeless at a younger age and were more likely to report mental health diagnoses, substance use, suicidality, victimization, and difficulties with ADLs. The majority of participants (51%) reported sustaining their first injury prior to becoming homeless or at the same age of their first homeless episode (10%). Conclusions. TBI occurs frequently among homeless young people and is a marker of adverse outcomes such as mental health difficulties, suicidal behavior, substance use, and victimization. (Am J Public Health. 2014;104:1986–1992. doi:10. 2105/AJPH.2014.302087)
from that of adults.13,14 Hwang et al.14 and Oddy et al.15 reported that injuries tend to occur in late adolescence, with 70% or more occurring prior to the onset of homelessness. Hwang et al.14 also found that TBI was associated with mental health, substance use, and other difficulties. To date, no studies to our knowledge have reported TBI prevalence specifically among homeless adolescents and young adults. We sought to determine the prevalence of selfreported TBI among homeless adolescents and young adults in a population-based study and to investigate whether sociodemographic characteristics, mental health history, exposure to violence, and ability to perform routine activities of daily living (ADLs) differ between young people who report a history of TBI and those who do not. We hypothesized that homeless young people with a history of TBI would report greater difficulties in the domains assessed and that most respondents’ first TBI would precede their first episode of homelessness.
1986 | Research and Practice | Peer Reviewed | Mackelprang et al.
METHODS The Wilder Homelessness Study (conducted by Wilder Research, St. Paul, MN) is a crosssectional survey in Minnesota completed triennially during a single evening in October. We used data from the 2006 and 2009 cohorts because these were the only cohorts in which questions about exposure to TBI and age at first injury were included. In both 2006 and 2009, homeless individuals of all ages were recruited from homeless shelters and drop-in centers, shelters for domestic violence survivors, and streets in approximately 80 communities across Minnesota. Surveys required approximately 30 minutes to complete and were administered by a team of trained volunteers who read the questionnaire aloud to each participant individually. Responses were anonymous, and respondents were provided a $5 honorarium for participating. Findings from the study have
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been used to inform local and state policies on housing, employment, and social service delivery for homeless individuals.
Exposures of Interest Sociodemographic variables. Information was obtained on respondents’ age, gender, race, sexual orientation, marital status, and education. The difference between age and years of education was calculated to determine whether educational attainment was lower than, commensurate with, or higher than the level expected relative to a respondent’s age. Among those aged 19 years or older, more than 12 years of education was considered higher than expected. The survey also ascertained respondents’ history of having an individual education plan (IEP), receiving special education services, being in foster care, being involved in the juvenile justice system, and serving in the military. Variables documenting the age at which respondents experienced their first homeless episode, the number of times they had been homeless, and the duration of their current homeless episode were included. Mental health, substance use, and exposure to violence. To assess mental health history, respondents were asked whether they had been told by a doctor or nurse in the preceding 2 years that they had any of 8 mental health diagnoses (e.g., major depression, posttraumatic stress disorder). Those who reported a history of suicidal ideation were asked whether they had ever attempted suicide. In addition, the survey asked about substance use in the preceding 30 days, including use of alcohol, marijuana, crack or cocaine, heroin, inhalants, methamphetamine, and hallucinogens. Responses to both mental health and substance use questions were dichotomous. Respondents were asked whether they had been physically or sexually abused during childhood and whether their parents ever neglected to provide them with food, shelter, or medical care. Intimate partner violence was assessed with the question “During any time in the last 12 months, have you been in a personal relationship with someone who hit you, slapped you, or pushed you around or threatened to do so?” A pair of questions were used to assess exposure to violence during a homeless episode and participation in survival sex: “Have you ever been physically or sexual attacked or
beaten while you have been without a regular place to stay?” and “Have you ever been sexual with someone only for the purpose of getting shelter, clothing, food, or other things?” Activities of daily living. Participants were asked 3 questions regarding ADLs: “Do you have any physical, mental, or other health condition that limits the kind or amount of work you can do?” “Do you have a physical, mental, or other health condition that makes it hard for you to bathe, eat, get dressed, get in or out of bed or a chair, or get around by yourself?” and “Do you often feel confused or have trouble remembering things, or have problems making decisions, to the point that it interferes with daily activities?”
We also conducted exploratory analyses to determine whether participants differed with respect to sociodemographic and mental health characteristics, depending on whether they reported sustaining a TBI before the age at which they first became homeless, the same age at which they became homeless, or after their first homeless episode. Finally, because some respondents may have participated at both study points (i.e., as a result of recurrent or chronic homelessness), we conducted sensitivity analyses by rerunning our primary analyses with only the larger of the 2 cohorts (the 2009 cohort). Stata version 12.1 (StataCorp LP, College Station, TX) was used in these analyses, which were conducted on unweighted data.
Outcome Variable
RESULTS
Our dependent variable was self-reported history of TBI, which was assessed with the question “Have you ever been hit in the head so hard that you saw stars or were knocked unconscious—for example, from a blow, a fall, or a motor vehicle accident?” Similar self-report questions have been used in prior studies to assess TBI among homeless adults.14,15 Participants who reported a history of TBI were asked “After your head injury, did you start having problems with headaches, concentration or memory, understanding, excessive worry, sleeping, or getting along with people?” Age at first injury was also ascertained, allowing us to determine the temporal relationship between TBI and the first episode of homelessness (i.e., prior to homelessness, at the same age as the first homeless episode, after becoming homeless).
The 2732 participating homeless adolescents and young adults were between the ages of 11 and 28 years, with a mean age of 21.8 years (SD = 3.6; Table 1). Most participants were female (63.3%) and self-identified either as White (37.9%) or as Black or African Native (35.3%). Approximately 10% identified as being gay or lesbian, bisexual, or unsure of their sexual orientation. The majority of participants had never been married (88.8%). Forty percent had less education than would be expected given their age, and 36.8% reported a history of receiving special education services or having an IEP. Three fourths were unemployed. Nearly 32% had been in foster care, and 28.9% had been detained in a juvenile justice center for 1 week or longer; only 2.3% had served in the military.
Statistical Analyses We used Poisson regression models with robust standard errors to determine associations between the exposures of interest and self-reported TBI, as well as to obtain prevalence ratios (PRs) and their corresponding confidence intervals (CIs). Initially, we constructed bivariate Poisson regression models to examine unadjusted associations between sociodemographic characteristics and history of TBI. We then investigated the association among respondents’ history of homelessness, mental health diagnoses, substance use, exposure to violence, and ADL difficulties, all of which were adjusted for age, gender, race, and education.
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Prevalence of Traumatic Brain Injury and Correlates of Injury Forty-three percent of the respondents reported a history of a TBI. The average age at first injury was 15.0 years (SD = 5.7). TBI was more common among male (PR = 1.47; 95% CI = 1.31, 1.65) and bisexual (PR = 1.26; 95% CI = 1.00, 1.59) respondents. A history of TBI was significantly less common among participants who self-identified as Black or African Native than among those who self-identified as White (PR = 0.73; 95% CI = 0.63, 0.84). Lower education than expected for age was associated with a higher prevalence of TBI, as was having a history of an IEP or special
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RESEARCH AND PRACTICE
TABLE 1—Sociodemographic Characteristics of Homeless Adolescents and Young Adults With and Without Traumatic Brain Injury (TBI): Wilder Homelessness Study, Minnesota, 2006 and 2009 (n = 2732)
Variable
Total, No. (%) or Mean (SD)
History of TBI,a % or Mean (SD) Yes (n = 1145)
No (n = 1549)
PRb (95% CI)
Age, y 11–15
69 (2.5)
1.9
3.0
0.77 (0.50, 1.18)
16–18 19–24
794 (29.1) 1107 (40.5)
26.6 40.2
30.7 40.9
0.93 (0.80, 1.07) 1.00 (Ref)
25–28
762 (27.9)
31.4
25.4
1.13 (0.99, 1.30)
1730 (63.3)
54.2
70.2
1.00 (Ref)
990 (36.2)
45.4
29.3
1.47 (1.31, 1.65)
12 (0.4)
0.4
0.5
0.92 (0.34, 2.45)
952 (35.3) 372 (13.8)
29.4 14.9
39.5 13.2
0.73 (0.63, 0.84) 0.93 (0.78, 1.11) 0.70 (0.43, 1.13)
Gender Female Male Transgender Race/ethnicity Black/African Native American Indian/Native American Asian/Pacific Islander
53 (2.0)
1.5
2.2
1022 (37.9)
43.5
33.9
1.00 (Ref)
Other (including multiracial)
297 (11.0)
10.8
11.2
0.85 (0.70, 1.04)
Hispanicc
273 (10.4)
9.7
11.1
0.91 (0.75, 1.11)
2363 (90.2)
88.0
91.9
1.00 (Ref)
75 (2.9) 149 (5.7)
3.7 7.0
2.2 4.7
1.33 (0.98, 1.82) 1.26 (1.00, 1.59)
33 (1.3)
1.4
1.2
1.09 (0.66, 1.82)
White
Sexual orientation Heterosexual/straight Gay/lesbian Bisexual Unsure Marital status Single, never married
2407 (88.8)
88.0
89.5
Married
114 (4.2)
4.2
4.1
1.00 (Ref) 1.02 (0.77, 1.37)
Separated, divorced, or widowed
191 (7.0)
7.8
6.5
1.12 (0.90, 1.39)
Lower than expected for age Commensurate with age
1074 (39.9) 1024 (38.0)
43.4 36.3
37.3 39.3
1.00 (Ref) 0.88 (0.77, 1.00)
Higher than expected for age
596 (22.1)
20.3
23.5
0.84 (0.72, 0.98)
Educational attainment in relation to aged
Employment statuse Unemployed
education, foster care involvement, juvenile justice detainment, and military service (Table 1). Fifty-one percent of the respondents sustained their first injury prior to becoming homeless for the first time, and 10% experienced their first TBI at the same age they became homeless (Figure 1). Forty-five percent of the respondents reported onset of headaches, concentration or memory difficulties, excessive worry or sleeping, or difficulty getting along with others after their injury. Adjusted analyses showed that respondents who reported a history of TBI became homeless at a younger age (16.2 vs 17.4 years) and reported a greater number of episodes of homelessness (4.4 vs 3.4; Table 1) than did their noninjured counterparts. Few differences were observed with regard to the duration of the current episode of homelessness. A history of TBI was associated with a higher prevalence of reporting all of the mental illnesses that were assessed, with rates 34% to 77% greater than among those without a history of TBI. Prevalence of TBI increased with comorbidity; participants who reported having 3 or more mental health diagnoses were more than twice as likely as those with no diagnoses to report a TBI (PR = 2.10; 95% CI = 1.79, 2.47). Alcohol use, marijuana use, and crack or cocaine use in the preceding 30 days were more common among participants who reported a history of TBI, as were lifetime suicidal ideation and attempts. A history of TBI was associated with a history of childhood physical and sexual abuse, childhood neglect, and intimate partner violence. Exposure to violence during a homeless episode was more prevalent among participants with a history of TBI; participants with a TBI were 88% and 51% more likely to report physical or sexual assault and survival sex, respectively. In addition, a history of TBI was associated with difficulties in all of the ADLs assessed (Table 2). The sensitivity analyses showed no substantive differences in the magnitude or pattern of findings.
1969 (73.1)
74.4
71.9
1.00 (Ref)
Part time
573 (21.3)
20.4
22.1
0.94 (0.81, 1.08)
Full time
152 (5.6)
5.2
6.0
0.90 (0.69, 1.17)
1689 (63.2)
55.8
68.3
1.00 (Ref)
985 (36.8)
44.2
31.7
1.35 (1.20, 1.52)
No
1848 (68.1)
62.5
72.5
1.00 (Ref)
Yes
865 (31.9)
37.5
27.6
1.29 (1.14, 1.45)
Traumatic Brain Injury in Relation to Onset of Homelessness
No
1924 (71.1)
62.9
77.2
1.00 (Ref)
Yes
783 (28.9)
37.1
22.9
1.45 (1.29, 1.63)
We conducted stratified analyses among the 1081 individuals who had a history of TBI and data on age at first injury to determine whether the relationships between the different TBI risk factors differed by the age at which
History of individualized education plan or special education services No Yes History of foster care
History of juvenile justice detainment
Continued
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TABLE 1—Continued History of military service No
2650 (97.7)
96.0
99.0
Yes
62 (2.3)
4.0
1.0
1.80 (1.34, 2.42)
16.9 (5.4)
16.2 (5.5)
17.4 (5.3)
0.98 (0.97, 0.99)
3.9 (2.7)
4.4 (2.7)
3.4 (2.6)
1.08 (1.06, 1.10)
Age at first homeless episode Lifetime no. of homeless episodes Duration of current homeless episode £ 6 mo
1.00 (Ref)
1356 (50.7)
48.1
52.6
1.00 (Ref)
7–12 mo
285 (10.7)
11.3
10.3
1.11 (0.92, 1.35)
1–3 y
676 (25.3)
24.7
26.0
1.02 (0.88, 1.18)
3–5 y
227 (8.5)
9.7
7.4
1.22 (0.99, 1.50)
‡5 y
132 (4.9)
6.3
3.8
1.36 (1.07, 1.75)
Note. CI = confidence interval; PR = prevalence ratio. Percentages may not equal 100% because of rounding. a Data regarding history of TBI were missing for 38 respondents. b Unadjusted comparison. c Data on Hispanic ethnicity were collected separately from data on race to enable participants to represent most accurately their ethnoracial identity; thus, tallies for race and ethnicity exceed the total sample size. d The difference between age and years of education was calculated to determine whether educational attainment was lower, commensurate with, or higher than the level expected relative to respondents’ ages. Among those aged 19 years or older, more than 12 years of education was considered higher than expected. e 6.3% (n = 4) and 22.1% (n = 47) of respondents 11–15 and 16–17 years of age reported being employed, respectively. Consistent with Minnesota child labor laws specific to school years, no respondents younger than 16 years were employed more than 18 hours per week.
participants sustained their first TBI (i.e., prior to the first homeless episode, at the same age as the first homeless episode, after the first homeless episode). The findings were similar to those reported in our primary analyses, with some exceptions (Table A, available as a supplement to the online version of this article at http://www.ajph.org). Individuals who reported a TBI after their first homeless episode became homeless at a younger age (mean = 12.9; SD = 5.4) than did respondents who had been injured prior to becoming homeless (mean = 18.6; SD = 4.4) or at the same age of the first homeless episode (mean = 17.4, SD = 4.6). Also, they were more likely to self-identify as gay or lesbian or as bisexual. Finally, they were less likely to have completed a level of education commensurate with or higher than that expected relative to their age, less likely to have been employed on a parttime basis at the time of their study participation, and more likely to report a suicide attempt.
DISCUSSION To our knowledge, this is the first study to examine TBI among homeless young people. The lifetime prevalence of TBI in our sample (43%) was comparable to the prevalence
observed in the few studies that have examined TBI among homeless adults,12 indicating that young people who are homeless are as likely as individuals in older cohorts to have sustained a TBI. Fifty-one percent of participants who reported a history of TBI reported sustaining their injury prior to becoming homeless. The proportion of participants who reported sustaining a TBI after becoming homeless was greater than the proportions reported in the 2 adult studies that examined the temporal relationship between TBI and homelessness.14,15 Our findings might be explained by sample differences. The mean age of participants in the Hwang et al. Toronto study was 37.4 years, and the first homeless episode occurred at a mean age of 28.5 years.14 On average, our respondents were 15 years younger (i.e., 21.8 years) and became homeless considerably earlier in their lives (i.e., 16.9 years); thus, it is possible that the reasons for becoming homeless were also distinct. Becoming homeless at a younger age may point to greater early life instability (e.g., a chaotic family life, an unsafe or abusive home), to engagement in risk-taking behavior (e.g., substance use),16 or to aging out of the foster care system.17 Consistent with the results of Hwang et al.,14 the age at which the greatest percentage of
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TBIs was sustained was the same age at which participants became homeless (7% in the Hwang et al. study and 10% in our study). This finding suggests that, among young people and adults alike, the time at which a person becomes homeless is a point of particular vulnerability to sustaining potentially life-altering injuries. This may signify a peak period of risk-taking behavior or of vulnerability to victimization associated with the loss of stable housing, although risk-taking behavior is increased among adolescents with stable housing as well. Mental illnesses were common in our sample, and increased mental health comorbidities were associated with reporting a TBI, as were use of alcohol, marijuana, and crack or cocaine in the preceding month. Suicide attempts are disproportionately high among homeless young people.18,19 Participants with a history of TBI were 83% more likely to report lifetime suicidal ideation, and those who reported suicide ideation were 22% more likely to have attempted suicide. In addition, respondents with a history of TBI were 47% to 80% more likely to report exposure to violence during childhood (physical or sexual abuse, neglect), intimate partner violence, victimization during a homeless episode (physical or sexual assault), or engagement in survival sex. Although these difficulties have been documented in previous research,5,9,20,21 this is the first study to associate them with TBI. Given the cross-sectional nature of our data, we cannot speculate regarding causal relationships between the aforementioned variables; nonetheless, a self-reported history of TBI among homeless young people may be an indicator of risk-taking activities or other difficulties. Several findings in our exploratory analyses merit mention. Relative to heterosexual respondents, participants who identified as gay or lesbian or as bisexual were 80% and 51% times more likely to report a history of TBI after becoming homeless, respectively, whereas no differences were observed during other time points. Previous studies have documented an increased risk of injury attributable to victimization or risk-taking behavior among sexual minority homeless youths,22 and these finding may suggest that this increased risk also applies to TBI. Differences related to educational achievement were observed when TBI was stratified by onset of homelessness. Participants who
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RESEARCH AND PRACTICE
110
Participants Who Reported a TBI, No.
100 90 80 70 60 50 40 30 20 10 0
≥ 20
15
10
5
Years Prior to First Homeless Episode
0
5
10
15
≥ 20
Years Since First Homeless Episode
Note. The sample size was n = 1081 (information was missing for 64 respondents). Adapted from Hwang et al.14
FIGURE 1—Number of years before or after their first homeless episode that participants reported experiencing their first traumatic brain injury (TBI): Wilder Homelessness Study, Minnesota, 2006 and 2009. experienced a TBI after becoming homeless were significantly less likely to have educational attainment commensurate with or higher than the level expected for their age. Youths who experienced their first TBI after becoming homeless were, on average, younger (i.e., 12.9 years) than the other groups. Those who reported sustaining a TBI after becoming homeless were 40% more likely to report a past suicide attempt than those who did not report a history of TBI. Time on the streets may weaken coping abilities, leading to selfdirected violence,23 although further research is necessary to explain this relationship.
Clinical Implications Our findings add support to previous research suggesting that TBI often precedes loss of housing12,13 and that injury risk peaks near the time homelessness begins.14 Stabilization efforts during this critical time frame may be valuable in reducing injury prevalence, and studies examining mechanisms of TBI among homeless individuals are needed so that effective prevention strategies can be developed.
A first step in improving care may be identification of young people who are homeless and documentation of TBI. Documenting injury and illness among homeless individuals is challenging. Homeless individuals, particularly youths, may have difficulty accessing health care services or may be reluctant to seek medical care owing to shame or fear of discrimination by providers.24 Thus, unlike domiciled individuals, they may not seek care even when it is warranted. When homeless individuals do seek health care, hospitals do not typically have a standard way of documenting housing instability.25 Admissions screenings to effectively identify individuals who are homeless should be implemented, as should protocols to screen for victimization. Personnel who provide health care and social services to homeless individuals are often not trained to identify or respond to people who may have cognitive impairments, which are common sequelae of TBI.26 Consequently, service providers may be unaware that an individual could function reasonably well in social conversation but still exhibit notable
1990 | Research and Practice | Peer Reviewed | Mackelprang et al.
difficulties in cognitive functioning that preclude effective engagement in daily activities or result in challenges in treatment adherence. Increasing providers’ knowledge may promote empathy for the often-frustrating behavioral problems (e.g., late or missed appointments, emotional dysregulation) sometimes associated with TBI. In addition, homeless youths with TBI may be eligible for services offered to individuals with acquired brain injury (e.g., Social Security disability income), although access to these resources may be limited by lack of objective evidence of injury. Seeking medical care has been linked with efforts by homeless young people to gain housing,27 and interactions with health care providers should be conceptualized as valuable opportunities to empower homeless young people.28 Brief interventions in emergency department settings have shown promise for modifying risk-taking behaviors among adolescents,29,30 suggesting that they may be a viable means of reaching high-risk youths. When possible, creating avenues for continuity of care is valuable in fostering a sense of trust among young people whose past experiences with adults may have been coercive or abusive. If health care providers are to deliver patientcentered care for homeless individuals, they need to shift away from traditional approaches of care to optimize engagement and adherence.31,32
Limitations and Strengths Our study involved several limitations that warrant discussion. For example, our data were cross sectional, thereby limiting our ability to infer causality between our exposures of interest and TBI. Also, history of TBI was based on a positive response to a single selfreport question, and objective data to substantiate participants’ injury recall were not available. Similar questions have been used to assess TBI in previous studies of homeless adults.14,15 Future studies of TBI among homeless individuals should include validated screening tools. At the same time, the nature of the item focusing on history of TBI may have failed to detect some of the common but milder postconcussive symptoms that might emerge after the injury and prompt diagnosis.33,34 As a result, recall bias may have introduced error into our estimates of the prevalence of TBI,
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893 (33.5)
48.4
22.4
1.83 (1.62, 2.06)
584 (65.7)
69.1
60.3
1.22 (1.01, 1.47)
especially given that TBI may yield deficits in memory. Nevertheless, among another group of vulnerable individuals, prisoners, accurate recall of TBI has been corroborated through the use of medical records, suggesting that self-reports may be an adequate, albeit not ideal, means of assessing history of TBI.35 Given that homelessness among a subset of participants was recurrent and chronic, some of our respondents may have participated in the study during both 2006 and 2009. To address this concern, we conducted sensitivity analyses of the 2009 cohort only, and these analyses yielded similar findings with respect to our primary outcomes. Finally, our sample was recruited from a single midwestern state with unique health and social service policies. Thus, it is unclear whether our findings generalize to regions that have a different socioeconomic or cultural composition. Strengths of this study include recruitment of participants from multiple communities (i.e., rural and urban) and in various locations (e.g., streets, shelters), yielding the largest homeless sample to date in which TBI has been examined. Our sample also included a sizable number of female respondents, which is important given that female participants are often underrepresented in studies of homelessness. Moreover, to our knowledge, this study represents the first effort to ascertain populationbased estimates of TBI among adolescents and young adults who are homeless.
Childhood physical abuse
1153 (43.2)
57.2
32.7
1.80 (1.59, 2.02)
Conclusions
Childhood sexual abuse
799 (29.9)
38.9
23.4
1.74 (1.53, 1.98)
Childhood neglect
809 (30.3)
38.8
23.8
1.47 (1.30, 1.66)
Homeless adolescents and young adults face adversity that often includes recurrent exposure to physical, sexual, and psychological trauma. Our findings suggest that TBI may be both an antecedent and a consequence of homelessness among young people and may be an indicator of other difficulties (e.g., mental illness, suicidality, risk taking, exposure to violence, and academic difficulties). Future research is necessary to determine the most effective ways of identifying homeless individuals who have sustained TBIs and connecting them to appropriate services that will promote community integration. Our results indicate that TBI is common among homeless young people and may be an important factor in identifying youths possibly at risk for adverse outcomes. j
TABLE 2—Associations Between Mental Health and Substance Use, Exposure to Violence, and Limitations in Activities of Daily Living Among Adolescents and Young Adults With and Without Traumatic Brain Injury (TBI): Wilder Homelessness Study, Minnesota, 2006 and 2009 History of TBI,a % Variable
Total, No. (%)
Yes (n = 1145)
No (n = 1549)
PRb (95% CI)
Type of mental health diagnosis, past 2 y Schizophrenia
107 (4.0)
6.6
2.0
1.50 (1.18, 1.90)
Other psychotic disorder
139 (5.2)
8.7
2.4
1.62 (1.31, 2.00)
Bipolar disorder
523 (19.5)
28.3
12.8
1.60 (1.40, 1.82)
Major depression
790 (29.4)
40.7
20.8
1.66 (1.47, 1.88)
Posttraumatic stress disorder
420 (15.7)
24.6
9.1
1.77 (1.54, 2.03)
Alcohol use disorder
289 (10.7)
16.7
6.4
1.41 (1.20, 1.66)
381 (14.2)
20.2
9.6
1.34 (1.15, 1.56)
0
1463 (55.5)
39.9
67.0
1.00 (Ref)
1
454 (17.2)
19.3
15.8
1.51 (1.28, 1.78)
2
346 (13.1)
18.1
9.6
1.84 (1.56, 2.19)
‡3
373 (14.1)
22.8
7.6
2.10 (1.79, 2.47)
Drug use disorder No. of mental health diagnoses, past 2 y
Substance use in past 30 d Alcohol
867 (32.1)
38.1
27.8
1.18 (1.05, 1.34)
Marijuana Crack or cocaine
580 (21.5) 71 (2.6)
27.2 3.9
17.2 1.6
1.30 (1.14, 1.50) 1.39 (1.03, 1.89)
Heroin
23 (0.9)
1.4
0.5
1.38 (0.84, 2.28)
Inhalants
23 (0.9)
1.1
0.7
1.25 (0.69, 2.27)
Methamphetamines
49 (1.8)
2.2
1.4
1.14 (0.75, 1.72)
Hallucinogens
36 (1.3)
1.8
1.0
1.30 (0.84, 2.03)
Lifetime suicidal behavior Suicidal ideation Suicide attempt (among those with suicidal ideation) History of trauma
Intimate partner violence in past 12 mo
803 (29.8)
36.1
24.9
1.54 (1.35, 1.75)
Physical or sexual assault during homeless episode
570 (21.2)
32.3
13.0
1.88 (1.66, 2.14)
Survival sex during homeless episode
421 (15.6)
21.7
11.0
1.51 (1.31, 1.74)
623 (23.4)
32.4
16.8
1.51 (1.33, 1.72)
168 (6.2)
9.0
4.1
1.43 (1.16, 1.77)
715 (26.7)
41.2
15.9
1.87 (1.66, 2.11)
Activities of daily living Condition that limits type or amount of work done Condition that limits bathing, eating, getting dressed, or getting around independently Condition that leads to confusion, trouble remembering things, or problems making decisions
Note. CI = confidence interval; PR = prevalence ratio. Percentages may not equal 100% because of rounding. Unless otherwise specified, the reference group for each variable is no diagnosis or no exposure. a Data regarding history of TBI were missing for 38 respondents. b Comparison adjusted for age, gender, race, and education.
October 2014, Vol 104, No. 10 | American Journal of Public Health
Mackelprang et al. | Peer Reviewed | Research and Practice | 1991
RESEARCH AND PRACTICE
About the Authors Jessica L. Mackelprang is with the Harborview Injury Prevention and Research Center and the Department of Pediatrics, University of Washington School of Medicine, Seattle. Scott B. Harpin is with the College of Nursing, Anschutz Medical Center, University of Colorado, Aurora. Joseph A. Grubenhoff is with the Department of Pediatrics, University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora. Frederick P. Rivara is with the Harborview Injury Prevention and Research Center and the Department of Pediatrics, University of Washington School of Medicine. Correspondence should be sent to Jessica L. Mackelprang, PhD, University of Washington, Harborview Injury Prevention and Research Center/Department of Pediatrics, 401 Broadway, Suite 4075, Patricia Bracelin Steel Memorial Building, Seattle, WA 98104 (e-mail: jlmack11@uw. edu). Reprints can be ordered at http://www.ajph.org by clicking on the “Reprints” link. This article was accepted May 8, 2014.
Contributors J. L. Mackelprang, S. B. Harpin, and F. P. Rivara originated and designed the study. J. L. Mackelprang, S. B. Harpin, and J. A. Grubenhoff drafted the article. J. L. Mackelprang was responsible for the statistical analyses. F. P. Rivara contributed to critical revision of the article. All of the authors contributed to interpretation of the data analyses.
Acknowledgments Jessica L. Mackelprang received fellowship support from the National Institute of Child Health and Human Development (grant T32-HD057822) during the preparation of this article. We are grateful to Wilder Research (St. Paul, MN), especially project director Greg Owen and Ellen Shelton, for sharing data with us. We also acknowledge the contributions of the study participants and the many volunteers who conducted the interviews. Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Human Participant Protection
homelessness: a systematic review. Am J Public Health. 2013;103(6):e24---e37. 6. Ensign J, Bell M. Illness experiences of homeless youth. Qual Health Res. 2004;14(9):1239---1254. 7. Ensign J, Gittelsohn J. Health and access to care: perspectives of homeless youth in Baltimore City, USA. Soc Sci Med. 1998;47(12):2087---2099. 8. Ensign J, Santelli J. Health status and service use: comparison of adolescents at a school-based health clinic with homeless adolescents. Arch Pediatr Adolesc Med. 1998;152(1):20---24. 9. Cauce AM, Paradise M, Ginzler JA, et al. The characteristics and mental health of homeless adolescents: age and gender differences. J Emot Behav Disord. 2000;8(4):230---239. 10. Parks RW, Stevens RJ, Spence SA. A systematic review of cognition in homeless children and adolescents. J R Soc Med. 2007;100(1):46---50. 11. Coronado VG, Xu L, Basavaraju SV, et al. Surveillance for traumatic brain injury-related deaths: United States, 1997---2007. MMWR Surveill Summ. 2011;60(5):1---32. 12. Topolovec-Vranic J, Ennis N, Colantonio A, et al. Traumatic brain injury among people who are homeless: a systematic review. BMC Public Health. 2012;12(1):1059. 13. Hux K, Schneider T, Bennett K. Screening for traumatic brain injury. Brain Inj. 2009;23(1):8---14. 14. Hwang SW, Colantonio A, Chiu S, et al. The effect of traumatic brain injury on the health of homeless people. CMAJ. 2008;179(8):779---784.
5. Hodgson KJ, Shelton KH, van den Bree MB, Los FJ. Psychopathology in young people experiencing
30. Zatzick D, Russo J, Lord SP, et al. Collaborative care intervention targeting violence risk behaviors, substance use, and posttraumatic stress and depressive symptoms in injured adolescents. JAMA Pediatr. 2014;168(6):532--539. 31. Barry PJ, Ensign J, Lippek SH. Embracing street culture: fitting health care into the lives of street youth. J Transcult Nurs. 2002;13(2):145---152. 32. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician. 2006;74(7):1132---1138. 33. Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126(2):e374---e381.
35. Schofield P, Butler T, Hollis S, D’Este C. Are prisoners reliable survey respondents? A validation of self-reported traumatic brain injury (TBI) against hospital medical records. Brain Inj. 2011;25(1):74---82.
17. Dworsky A, Napolitano L, Courtney M. Homelessness during the transition from foster care to adulthood. Am J Public Health. 2013;103(suppl 2):S318---S323. 18. Kidd SA, Carroll MR. Coping and suicidality among homeless youth. J Adolesc. 2007;30(2):283---296.
20. Ferguson KM. Exploring family environment characteristics and multiple abuse experiences among homeless youth. J Interpers Violence. 2009;24(11):1875---1891.
4. Hwang SW, Wilkins R, Tjepkema M, O’Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ. 2009;339:b4036.
29. Walton MA, Chermack ST, Shope JT, et al. Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: a randomized controlled trial. JAMA. 2010;304(5):527---535.
16. Edidin JP, Ganim Z, Hunter SJ, Karnik NS. The mental and physical health of homeless youth: a literature review. Child Psychiatry Hum Dev. 2012;43(3): 354---375.
References
3. Roy E, Haley N, Leclerc P, Sochanski B, Boudreau JF, Boivin JF. Mortality in a cohort of street youth in Montreal. JAMA. 2004;292(5):569---574.
28. Thompson SJ, Ryan TN, Montgomery KL, Lippman ADP, Bender K, Ferguson K. Perceptions of resiliency and coping: homeless young adults speak out. Youth Soc. 2013;Epub ahead of print.
15. Oddy M, Moir JF, Fortescue D, Chadwick S. The prevalence of traumatic brain injury in the homeless community in a UK city. Brain Inj. 2012;26(9):1058---1064.
19. Hadland SE, Marshall BD, Kerr T, Qi J, Montaner JS, Wood E. Suicide and history of childhood trauma among street youth. J Affect Disord. 2012;136(3):377---380.
2. Roy E, Haley N, Boudreau JF, Leclerc P, Boivin JF. The challenge of understanding mortality changes among street youth. J Urban Health. 2010;87(1):95---101.
27. Carlson JL, Sugano E, Millstein SG, Auerswald CL. Service utilization and the life cycle of youth homelessness. J Adolesc Health. 2006;38(5):624---627.
34. Babcock L, Byczkowski T, Wade SL, Ho M, Mookerjee S, Bazarian JJ. Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr. 2013;167(2):156---161.
No protocol approval was necessary for this study because de-identified data were used.
1. US Department of Housing and Urban Development. 2013 annual homeless assessment report to Congress. Available at: https://www.onecpd.info/ resources/documents/AHAR-2013-Part1.pdf. Accessed July 1, 2014.
26. Backer TE, Howard EA. Cognitive impairments and the prevention of homelessness: research and practice review. J Prim Prev. 2007;28(3---4):375---388.
21. Walls NE, Bell S. Correlates of engaging in survival sex among homeless youth and young adults. J Sex Res. 2011;48(5):423---436. 22. Cochran BN, Stewart AJ, Ginzler JA, Cauce AM. Challenges faced by homeless sexual minorities: comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. Am J Public Health. 2002;92(5):773---777. 23. Cleverley K, Kidd SA. Resilience and suicidality among homeless youth. J Adolesc. 2011;34(5):1049---1054. 24. Hudson AL, Nyamathi A, Greengold B, et al. Healthseeking challenges among homeless youth. Nurs Res. 2010;59(3):212---218. 25. Tsai M, Weintraub R, Gee L, Kushel M. Identifying homelessness at an urban public hospital: a moving target? J Health Care Poor Underserved. 2005;16(2):297---307.
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American Journal of Public Health | October 2014, Vol 104, No. 10
Adverse Outcomes Among Homeless Adolescents and Young Adults Who Report a History of Traumatic Brain Injury Jessica L. Mackelprang, PhD, Scott B. Harpin, RN, PhD, MPH, Joseph A. Grubenhoff, MD, and Frederick P. Rivara, MD, MPH
Homelessness is a serious public health problem that emerges at the intersection of complex socioecological factors. According to US Department of Housing and Urban Development estimates, at least 200 000 children, adolescents, and young adults were homeless on the night of a survey conducted in January 2013, representing one third of all homeless people in the United States.1 Homeless youths may be counted along with families but are often unaccompanied and moving between shelters or living on the streets. The unpredictable and often dangerous circumstances that accompany homelessness leave homeless individuals vulnerable to injury, illness, and victimization. Homeless individuals experience poorer health than people with stable housing and have a shorter life expectancy,2---4 and homeless young people experience high rates of internalizing (e.g., depression), externalizing (e.g., conduct disorder), and substance use disorders.5 A number of studies have documented cognitive difficulties, health problems, and violence exposure among homeless youths6---10; however, traumatic brain injury (TBI) has garnered minimal empirical attention. TBI is a leading cause of death and disability in the United States.11 However, a 2012 systematic review showed that only 8 studies have investigated TBI among homeless populations.12 The lifetime prevalence of TBI in these samples ranged from 8% to 53%, with all but 1 investigation reporting a rate above 20%. Five of the 8 studies were conducted in North America, with each recruiting from a single urban area and only one sampling multiple shelters. Most were limited by modest sample sizes, with only 2 exceeding100 participants.13,14 Moreover, although 2 studies included adolescents, the samples were small and the prevalence of TBI among youths was not separated
Objectives. We examined the prevalence of self-reported traumatic brain injury (TBI) among homeless young people and explored whether sociodemographic characteristics, mental health diagnoses, substance use, exposure to violence, or difficulties with activities of daily living (ADLs) were associated with TBI. Methods. We analyzed data from the Wilder Homelessness Study, in which participants were recruited in 2006 and 2009 from streets, shelters, and locations in Minnesota that provide services to homeless individuals. Participants completed 30-minute interviews to collect information about history of TBI, homelessness, health status, exposure to violence (e.g., childhood abuse, assault), and other aspects of functioning. Results. Of the 2732 participating adolescents and young adults, 43% reported a history of TBI. Participants with TBI became homeless at a younger age and were more likely to report mental health diagnoses, substance use, suicidality, victimization, and difficulties with ADLs. The majority of participants (51%) reported sustaining their first injury prior to becoming homeless or at the same age of their first homeless episode (10%). Conclusions. TBI occurs frequently among homeless young people and is a marker of adverse outcomes such as mental health difficulties, suicidal behavior, substance use, and victimization. (Am J Public Health. 2014;104:1986–1992. doi:10. 2105/AJPH.2014.302087)
from that of adults.13,14 Hwang et al.14 and Oddy et al.15 reported that injuries tend to occur in late adolescence, with 70% or more occurring prior to the onset of homelessness. Hwang et al.14 also found that TBI was associated with mental health, substance use, and other difficulties. To date, no studies to our knowledge have reported TBI prevalence specifically among homeless adolescents and young adults. We sought to determine the prevalence of selfreported TBI among homeless adolescents and young adults in a population-based study and to investigate whether sociodemographic characteristics, mental health history, exposure to violence, and ability to perform routine activities of daily living (ADLs) differ between young people who report a history of TBI and those who do not. We hypothesized that homeless young people with a history of TBI would report greater difficulties in the domains assessed and that most respondents’ first TBI would precede their first episode of homelessness.
1986 | Research and Practice | Peer Reviewed | Mackelprang et al.
METHODS The Wilder Homelessness Study (conducted by Wilder Research, St. Paul, MN) is a crosssectional survey in Minnesota completed triennially during a single evening in October. We used data from the 2006 and 2009 cohorts because these were the only cohorts in which questions about exposure to TBI and age at first injury were included. In both 2006 and 2009, homeless individuals of all ages were recruited from homeless shelters and drop-in centers, shelters for domestic violence survivors, and streets in approximately 80 communities across Minnesota. Surveys required approximately 30 minutes to complete and were administered by a team of trained volunteers who read the questionnaire aloud to each participant individually. Responses were anonymous, and respondents were provided a $5 honorarium for participating. Findings from the study have
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been used to inform local and state policies on housing, employment, and social service delivery for homeless individuals.
Exposures of Interest Sociodemographic variables. Information was obtained on respondents’ age, gender, race, sexual orientation, marital status, and education. The difference between age and years of education was calculated to determine whether educational attainment was lower than, commensurate with, or higher than the level expected relative to a respondent’s age. Among those aged 19 years or older, more than 12 years of education was considered higher than expected. The survey also ascertained respondents’ history of having an individual education plan (IEP), receiving special education services, being in foster care, being involved in the juvenile justice system, and serving in the military. Variables documenting the age at which respondents experienced their first homeless episode, the number of times they had been homeless, and the duration of their current homeless episode were included. Mental health, substance use, and exposure to violence. To assess mental health history, respondents were asked whether they had been told by a doctor or nurse in the preceding 2 years that they had any of 8 mental health diagnoses (e.g., major depression, posttraumatic stress disorder). Those who reported a history of suicidal ideation were asked whether they had ever attempted suicide. In addition, the survey asked about substance use in the preceding 30 days, including use of alcohol, marijuana, crack or cocaine, heroin, inhalants, methamphetamine, and hallucinogens. Responses to both mental health and substance use questions were dichotomous. Respondents were asked whether they had been physically or sexually abused during childhood and whether their parents ever neglected to provide them with food, shelter, or medical care. Intimate partner violence was assessed with the question “During any time in the last 12 months, have you been in a personal relationship with someone who hit you, slapped you, or pushed you around or threatened to do so?” A pair of questions were used to assess exposure to violence during a homeless episode and participation in survival sex: “Have you ever been physically or sexual attacked or
beaten while you have been without a regular place to stay?” and “Have you ever been sexual with someone only for the purpose of getting shelter, clothing, food, or other things?” Activities of daily living. Participants were asked 3 questions regarding ADLs: “Do you have any physical, mental, or other health condition that limits the kind or amount of work you can do?” “Do you have a physical, mental, or other health condition that makes it hard for you to bathe, eat, get dressed, get in or out of bed or a chair, or get around by yourself?” and “Do you often feel confused or have trouble remembering things, or have problems making decisions, to the point that it interferes with daily activities?”
We also conducted exploratory analyses to determine whether participants differed with respect to sociodemographic and mental health characteristics, depending on whether they reported sustaining a TBI before the age at which they first became homeless, the same age at which they became homeless, or after their first homeless episode. Finally, because some respondents may have participated at both study points (i.e., as a result of recurrent or chronic homelessness), we conducted sensitivity analyses by rerunning our primary analyses with only the larger of the 2 cohorts (the 2009 cohort). Stata version 12.1 (StataCorp LP, College Station, TX) was used in these analyses, which were conducted on unweighted data.
Outcome Variable
RESULTS
Our dependent variable was self-reported history of TBI, which was assessed with the question “Have you ever been hit in the head so hard that you saw stars or were knocked unconscious—for example, from a blow, a fall, or a motor vehicle accident?” Similar self-report questions have been used in prior studies to assess TBI among homeless adults.14,15 Participants who reported a history of TBI were asked “After your head injury, did you start having problems with headaches, concentration or memory, understanding, excessive worry, sleeping, or getting along with people?” Age at first injury was also ascertained, allowing us to determine the temporal relationship between TBI and the first episode of homelessness (i.e., prior to homelessness, at the same age as the first homeless episode, after becoming homeless).
The 2732 participating homeless adolescents and young adults were between the ages of 11 and 28 years, with a mean age of 21.8 years (SD = 3.6; Table 1). Most participants were female (63.3%) and self-identified either as White (37.9%) or as Black or African Native (35.3%). Approximately 10% identified as being gay or lesbian, bisexual, or unsure of their sexual orientation. The majority of participants had never been married (88.8%). Forty percent had less education than would be expected given their age, and 36.8% reported a history of receiving special education services or having an IEP. Three fourths were unemployed. Nearly 32% had been in foster care, and 28.9% had been detained in a juvenile justice center for 1 week or longer; only 2.3% had served in the military.
Statistical Analyses We used Poisson regression models with robust standard errors to determine associations between the exposures of interest and self-reported TBI, as well as to obtain prevalence ratios (PRs) and their corresponding confidence intervals (CIs). Initially, we constructed bivariate Poisson regression models to examine unadjusted associations between sociodemographic characteristics and history of TBI. We then investigated the association among respondents’ history of homelessness, mental health diagnoses, substance use, exposure to violence, and ADL difficulties, all of which were adjusted for age, gender, race, and education.
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Prevalence of Traumatic Brain Injury and Correlates of Injury Forty-three percent of the respondents reported a history of a TBI. The average age at first injury was 15.0 years (SD = 5.7). TBI was more common among male (PR = 1.47; 95% CI = 1.31, 1.65) and bisexual (PR = 1.26; 95% CI = 1.00, 1.59) respondents. A history of TBI was significantly less common among participants who self-identified as Black or African Native than among those who self-identified as White (PR = 0.73; 95% CI = 0.63, 0.84). Lower education than expected for age was associated with a higher prevalence of TBI, as was having a history of an IEP or special
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RESEARCH AND PRACTICE
TABLE 1—Sociodemographic Characteristics of Homeless Adolescents and Young Adults With and Without Traumatic Brain Injury (TBI): Wilder Homelessness Study, Minnesota, 2006 and 2009 (n = 2732)
Variable
Total, No. (%) or Mean (SD)
History of TBI,a % or Mean (SD) Yes (n = 1145)
No (n = 1549)
PRb (95% CI)
Age, y 11–15
69 (2.5)
1.9
3.0
0.77 (0.50, 1.18)
16–18 19–24
794 (29.1) 1107 (40.5)
26.6 40.2
30.7 40.9
0.93 (0.80, 1.07) 1.00 (Ref)
25–28
762 (27.9)
31.4
25.4
1.13 (0.99, 1.30)
1730 (63.3)
54.2
70.2
1.00 (Ref)
990 (36.2)
45.4
29.3
1.47 (1.31, 1.65)
12 (0.4)
0.4
0.5
0.92 (0.34, 2.45)
952 (35.3) 372 (13.8)
29.4 14.9
39.5 13.2
0.73 (0.63, 0.84) 0.93 (0.78, 1.11) 0.70 (0.43, 1.13)
Gender Female Male Transgender Race/ethnicity Black/African Native American Indian/Native American Asian/Pacific Islander
53 (2.0)
1.5
2.2
1022 (37.9)
43.5
33.9
1.00 (Ref)
Other (including multiracial)
297 (11.0)
10.8
11.2
0.85 (0.70, 1.04)
Hispanicc
273 (10.4)
9.7
11.1
0.91 (0.75, 1.11)
2363 (90.2)
88.0
91.9
1.00 (Ref)
75 (2.9) 149 (5.7)
3.7 7.0
2.2 4.7
1.33 (0.98, 1.82) 1.26 (1.00, 1.59)
33 (1.3)
1.4
1.2
1.09 (0.66, 1.82)
White
Sexual orientation Heterosexual/straight Gay/lesbian Bisexual Unsure Marital status Single, never married
2407 (88.8)
88.0
89.5
Married
114 (4.2)
4.2
4.1
1.00 (Ref) 1.02 (0.77, 1.37)
Separated, divorced, or widowed
191 (7.0)
7.8
6.5
1.12 (0.90, 1.39)
Lower than expected for age Commensurate with age
1074 (39.9) 1024 (38.0)
43.4 36.3
37.3 39.3
1.00 (Ref) 0.88 (0.77, 1.00)
Higher than expected for age
596 (22.1)
20.3
23.5
0.84 (0.72, 0.98)
Educational attainment in relation to aged
Employment statuse Unemployed
education, foster care involvement, juvenile justice detainment, and military service (Table 1). Fifty-one percent of the respondents sustained their first injury prior to becoming homeless for the first time, and 10% experienced their first TBI at the same age they became homeless (Figure 1). Forty-five percent of the respondents reported onset of headaches, concentration or memory difficulties, excessive worry or sleeping, or difficulty getting along with others after their injury. Adjusted analyses showed that respondents who reported a history of TBI became homeless at a younger age (16.2 vs 17.4 years) and reported a greater number of episodes of homelessness (4.4 vs 3.4; Table 1) than did their noninjured counterparts. Few differences were observed with regard to the duration of the current episode of homelessness. A history of TBI was associated with a higher prevalence of reporting all of the mental illnesses that were assessed, with rates 34% to 77% greater than among those without a history of TBI. Prevalence of TBI increased with comorbidity; participants who reported having 3 or more mental health diagnoses were more than twice as likely as those with no diagnoses to report a TBI (PR = 2.10; 95% CI = 1.79, 2.47). Alcohol use, marijuana use, and crack or cocaine use in the preceding 30 days were more common among participants who reported a history of TBI, as were lifetime suicidal ideation and attempts. A history of TBI was associated with a history of childhood physical and sexual abuse, childhood neglect, and intimate partner violence. Exposure to violence during a homeless episode was more prevalent among participants with a history of TBI; participants with a TBI were 88% and 51% more likely to report physical or sexual assault and survival sex, respectively. In addition, a history of TBI was associated with difficulties in all of the ADLs assessed (Table 2). The sensitivity analyses showed no substantive differences in the magnitude or pattern of findings.
1969 (73.1)
74.4
71.9
1.00 (Ref)
Part time
573 (21.3)
20.4
22.1
0.94 (0.81, 1.08)
Full time
152 (5.6)
5.2
6.0
0.90 (0.69, 1.17)
1689 (63.2)
55.8
68.3
1.00 (Ref)
985 (36.8)
44.2
31.7
1.35 (1.20, 1.52)
No
1848 (68.1)
62.5
72.5
1.00 (Ref)
Yes
865 (31.9)
37.5
27.6
1.29 (1.14, 1.45)
Traumatic Brain Injury in Relation to Onset of Homelessness
No
1924 (71.1)
62.9
77.2
1.00 (Ref)
Yes
783 (28.9)
37.1
22.9
1.45 (1.29, 1.63)
We conducted stratified analyses among the 1081 individuals who had a history of TBI and data on age at first injury to determine whether the relationships between the different TBI risk factors differed by the age at which
History of individualized education plan or special education services No Yes History of foster care
History of juvenile justice detainment
Continued
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TABLE 1—Continued History of military service No
2650 (97.7)
96.0
99.0
Yes
62 (2.3)
4.0
1.0
1.80 (1.34, 2.42)
16.9 (5.4)
16.2 (5.5)
17.4 (5.3)
0.98 (0.97, 0.99)
3.9 (2.7)
4.4 (2.7)
3.4 (2.6)
1.08 (1.06, 1.10)
Age at first homeless episode Lifetime no. of homeless episodes Duration of current homeless episode £ 6 mo
1.00 (Ref)
1356 (50.7)
48.1
52.6
1.00 (Ref)
7–12 mo
285 (10.7)
11.3
10.3
1.11 (0.92, 1.35)
1–3 y
676 (25.3)
24.7
26.0
1.02 (0.88, 1.18)
3–5 y
227 (8.5)
9.7
7.4
1.22 (0.99, 1.50)
‡5 y
132 (4.9)
6.3
3.8
1.36 (1.07, 1.75)
Note. CI = confidence interval; PR = prevalence ratio. Percentages may not equal 100% because of rounding. a Data regarding history of TBI were missing for 38 respondents. b Unadjusted comparison. c Data on Hispanic ethnicity were collected separately from data on race to enable participants to represent most accurately their ethnoracial identity; thus, tallies for race and ethnicity exceed the total sample size. d The difference between age and years of education was calculated to determine whether educational attainment was lower, commensurate with, or higher than the level expected relative to respondents’ ages. Among those aged 19 years or older, more than 12 years of education was considered higher than expected. e 6.3% (n = 4) and 22.1% (n = 47) of respondents 11–15 and 16–17 years of age reported being employed, respectively. Consistent with Minnesota child labor laws specific to school years, no respondents younger than 16 years were employed more than 18 hours per week.
participants sustained their first TBI (i.e., prior to the first homeless episode, at the same age as the first homeless episode, after the first homeless episode). The findings were similar to those reported in our primary analyses, with some exceptions (Table A, available as a supplement to the online version of this article at http://www.ajph.org). Individuals who reported a TBI after their first homeless episode became homeless at a younger age (mean = 12.9; SD = 5.4) than did respondents who had been injured prior to becoming homeless (mean = 18.6; SD = 4.4) or at the same age of the first homeless episode (mean = 17.4, SD = 4.6). Also, they were more likely to self-identify as gay or lesbian or as bisexual. Finally, they were less likely to have completed a level of education commensurate with or higher than that expected relative to their age, less likely to have been employed on a parttime basis at the time of their study participation, and more likely to report a suicide attempt.
DISCUSSION To our knowledge, this is the first study to examine TBI among homeless young people. The lifetime prevalence of TBI in our sample (43%) was comparable to the prevalence
observed in the few studies that have examined TBI among homeless adults,12 indicating that young people who are homeless are as likely as individuals in older cohorts to have sustained a TBI. Fifty-one percent of participants who reported a history of TBI reported sustaining their injury prior to becoming homeless. The proportion of participants who reported sustaining a TBI after becoming homeless was greater than the proportions reported in the 2 adult studies that examined the temporal relationship between TBI and homelessness.14,15 Our findings might be explained by sample differences. The mean age of participants in the Hwang et al. Toronto study was 37.4 years, and the first homeless episode occurred at a mean age of 28.5 years.14 On average, our respondents were 15 years younger (i.e., 21.8 years) and became homeless considerably earlier in their lives (i.e., 16.9 years); thus, it is possible that the reasons for becoming homeless were also distinct. Becoming homeless at a younger age may point to greater early life instability (e.g., a chaotic family life, an unsafe or abusive home), to engagement in risk-taking behavior (e.g., substance use),16 or to aging out of the foster care system.17 Consistent with the results of Hwang et al.,14 the age at which the greatest percentage of
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TBIs was sustained was the same age at which participants became homeless (7% in the Hwang et al. study and 10% in our study). This finding suggests that, among young people and adults alike, the time at which a person becomes homeless is a point of particular vulnerability to sustaining potentially life-altering injuries. This may signify a peak period of risk-taking behavior or of vulnerability to victimization associated with the loss of stable housing, although risk-taking behavior is increased among adolescents with stable housing as well. Mental illnesses were common in our sample, and increased mental health comorbidities were associated with reporting a TBI, as were use of alcohol, marijuana, and crack or cocaine in the preceding month. Suicide attempts are disproportionately high among homeless young people.18,19 Participants with a history of TBI were 83% more likely to report lifetime suicidal ideation, and those who reported suicide ideation were 22% more likely to have attempted suicide. In addition, respondents with a history of TBI were 47% to 80% more likely to report exposure to violence during childhood (physical or sexual abuse, neglect), intimate partner violence, victimization during a homeless episode (physical or sexual assault), or engagement in survival sex. Although these difficulties have been documented in previous research,5,9,20,21 this is the first study to associate them with TBI. Given the cross-sectional nature of our data, we cannot speculate regarding causal relationships between the aforementioned variables; nonetheless, a self-reported history of TBI among homeless young people may be an indicator of risk-taking activities or other difficulties. Several findings in our exploratory analyses merit mention. Relative to heterosexual respondents, participants who identified as gay or lesbian or as bisexual were 80% and 51% times more likely to report a history of TBI after becoming homeless, respectively, whereas no differences were observed during other time points. Previous studies have documented an increased risk of injury attributable to victimization or risk-taking behavior among sexual minority homeless youths,22 and these finding may suggest that this increased risk also applies to TBI. Differences related to educational achievement were observed when TBI was stratified by onset of homelessness. Participants who
Mackelprang et al. | Peer Reviewed | Research and Practice | 1989
RESEARCH AND PRACTICE
110
Participants Who Reported a TBI, No.
100 90 80 70 60 50 40 30 20 10 0
≥ 20
15
10
5
Years Prior to First Homeless Episode
0
5
10
15
≥ 20
Years Since First Homeless Episode
Note. The sample size was n = 1081 (information was missing for 64 respondents). Adapted from Hwang et al.14
FIGURE 1—Number of years before or after their first homeless episode that participants reported experiencing their first traumatic brain injury (TBI): Wilder Homelessness Study, Minnesota, 2006 and 2009. experienced a TBI after becoming homeless were significantly less likely to have educational attainment commensurate with or higher than the level expected for their age. Youths who experienced their first TBI after becoming homeless were, on average, younger (i.e., 12.9 years) than the other groups. Those who reported sustaining a TBI after becoming homeless were 40% more likely to report a past suicide attempt than those who did not report a history of TBI. Time on the streets may weaken coping abilities, leading to selfdirected violence,23 although further research is necessary to explain this relationship.
Clinical Implications Our findings add support to previous research suggesting that TBI often precedes loss of housing12,13 and that injury risk peaks near the time homelessness begins.14 Stabilization efforts during this critical time frame may be valuable in reducing injury prevalence, and studies examining mechanisms of TBI among homeless individuals are needed so that effective prevention strategies can be developed.
A first step in improving care may be identification of young people who are homeless and documentation of TBI. Documenting injury and illness among homeless individuals is challenging. Homeless individuals, particularly youths, may have difficulty accessing health care services or may be reluctant to seek medical care owing to shame or fear of discrimination by providers.24 Thus, unlike domiciled individuals, they may not seek care even when it is warranted. When homeless individuals do seek health care, hospitals do not typically have a standard way of documenting housing instability.25 Admissions screenings to effectively identify individuals who are homeless should be implemented, as should protocols to screen for victimization. Personnel who provide health care and social services to homeless individuals are often not trained to identify or respond to people who may have cognitive impairments, which are common sequelae of TBI.26 Consequently, service providers may be unaware that an individual could function reasonably well in social conversation but still exhibit notable
1990 | Research and Practice | Peer Reviewed | Mackelprang et al.
difficulties in cognitive functioning that preclude effective engagement in daily activities or result in challenges in treatment adherence. Increasing providers’ knowledge may promote empathy for the often-frustrating behavioral problems (e.g., late or missed appointments, emotional dysregulation) sometimes associated with TBI. In addition, homeless youths with TBI may be eligible for services offered to individuals with acquired brain injury (e.g., Social Security disability income), although access to these resources may be limited by lack of objective evidence of injury. Seeking medical care has been linked with efforts by homeless young people to gain housing,27 and interactions with health care providers should be conceptualized as valuable opportunities to empower homeless young people.28 Brief interventions in emergency department settings have shown promise for modifying risk-taking behaviors among adolescents,29,30 suggesting that they may be a viable means of reaching high-risk youths. When possible, creating avenues for continuity of care is valuable in fostering a sense of trust among young people whose past experiences with adults may have been coercive or abusive. If health care providers are to deliver patientcentered care for homeless individuals, they need to shift away from traditional approaches of care to optimize engagement and adherence.31,32
Limitations and Strengths Our study involved several limitations that warrant discussion. For example, our data were cross sectional, thereby limiting our ability to infer causality between our exposures of interest and TBI. Also, history of TBI was based on a positive response to a single selfreport question, and objective data to substantiate participants’ injury recall were not available. Similar questions have been used to assess TBI in previous studies of homeless adults.14,15 Future studies of TBI among homeless individuals should include validated screening tools. At the same time, the nature of the item focusing on history of TBI may have failed to detect some of the common but milder postconcussive symptoms that might emerge after the injury and prompt diagnosis.33,34 As a result, recall bias may have introduced error into our estimates of the prevalence of TBI,
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RESEARCH AND PRACTICE
893 (33.5)
48.4
22.4
1.83 (1.62, 2.06)
584 (65.7)
69.1
60.3
1.22 (1.01, 1.47)
especially given that TBI may yield deficits in memory. Nevertheless, among another group of vulnerable individuals, prisoners, accurate recall of TBI has been corroborated through the use of medical records, suggesting that self-reports may be an adequate, albeit not ideal, means of assessing history of TBI.35 Given that homelessness among a subset of participants was recurrent and chronic, some of our respondents may have participated in the study during both 2006 and 2009. To address this concern, we conducted sensitivity analyses of the 2009 cohort only, and these analyses yielded similar findings with respect to our primary outcomes. Finally, our sample was recruited from a single midwestern state with unique health and social service policies. Thus, it is unclear whether our findings generalize to regions that have a different socioeconomic or cultural composition. Strengths of this study include recruitment of participants from multiple communities (i.e., rural and urban) and in various locations (e.g., streets, shelters), yielding the largest homeless sample to date in which TBI has been examined. Our sample also included a sizable number of female respondents, which is important given that female participants are often underrepresented in studies of homelessness. Moreover, to our knowledge, this study represents the first effort to ascertain populationbased estimates of TBI among adolescents and young adults who are homeless.
Childhood physical abuse
1153 (43.2)
57.2
32.7
1.80 (1.59, 2.02)
Conclusions
Childhood sexual abuse
799 (29.9)
38.9
23.4
1.74 (1.53, 1.98)
Childhood neglect
809 (30.3)
38.8
23.8
1.47 (1.30, 1.66)
Homeless adolescents and young adults face adversity that often includes recurrent exposure to physical, sexual, and psychological trauma. Our findings suggest that TBI may be both an antecedent and a consequence of homelessness among young people and may be an indicator of other difficulties (e.g., mental illness, suicidality, risk taking, exposure to violence, and academic difficulties). Future research is necessary to determine the most effective ways of identifying homeless individuals who have sustained TBIs and connecting them to appropriate services that will promote community integration. Our results indicate that TBI is common among homeless young people and may be an important factor in identifying youths possibly at risk for adverse outcomes. j
TABLE 2—Associations Between Mental Health and Substance Use, Exposure to Violence, and Limitations in Activities of Daily Living Among Adolescents and Young Adults With and Without Traumatic Brain Injury (TBI): Wilder Homelessness Study, Minnesota, 2006 and 2009 History of TBI,a % Variable
Total, No. (%)
Yes (n = 1145)
No (n = 1549)
PRb (95% CI)
Type of mental health diagnosis, past 2 y Schizophrenia
107 (4.0)
6.6
2.0
1.50 (1.18, 1.90)
Other psychotic disorder
139 (5.2)
8.7
2.4
1.62 (1.31, 2.00)
Bipolar disorder
523 (19.5)
28.3
12.8
1.60 (1.40, 1.82)
Major depression
790 (29.4)
40.7
20.8
1.66 (1.47, 1.88)
Posttraumatic stress disorder
420 (15.7)
24.6
9.1
1.77 (1.54, 2.03)
Alcohol use disorder
289 (10.7)
16.7
6.4
1.41 (1.20, 1.66)
381 (14.2)
20.2
9.6
1.34 (1.15, 1.56)
0
1463 (55.5)
39.9
67.0
1.00 (Ref)
1
454 (17.2)
19.3
15.8
1.51 (1.28, 1.78)
2
346 (13.1)
18.1
9.6
1.84 (1.56, 2.19)
‡3
373 (14.1)
22.8
7.6
2.10 (1.79, 2.47)
Drug use disorder No. of mental health diagnoses, past 2 y
Substance use in past 30 d Alcohol
867 (32.1)
38.1
27.8
1.18 (1.05, 1.34)
Marijuana Crack or cocaine
580 (21.5) 71 (2.6)
27.2 3.9
17.2 1.6
1.30 (1.14, 1.50) 1.39 (1.03, 1.89)
Heroin
23 (0.9)
1.4
0.5
1.38 (0.84, 2.28)
Inhalants
23 (0.9)
1.1
0.7
1.25 (0.69, 2.27)
Methamphetamines
49 (1.8)
2.2
1.4
1.14 (0.75, 1.72)
Hallucinogens
36 (1.3)
1.8
1.0
1.30 (0.84, 2.03)
Lifetime suicidal behavior Suicidal ideation Suicide attempt (among those with suicidal ideation) History of trauma
Intimate partner violence in past 12 mo
803 (29.8)
36.1
24.9
1.54 (1.35, 1.75)
Physical or sexual assault during homeless episode
570 (21.2)
32.3
13.0
1.88 (1.66, 2.14)
Survival sex during homeless episode
421 (15.6)
21.7
11.0
1.51 (1.31, 1.74)
623 (23.4)
32.4
16.8
1.51 (1.33, 1.72)
168 (6.2)
9.0
4.1
1.43 (1.16, 1.77)
715 (26.7)
41.2
15.9
1.87 (1.66, 2.11)
Activities of daily living Condition that limits type or amount of work done Condition that limits bathing, eating, getting dressed, or getting around independently Condition that leads to confusion, trouble remembering things, or problems making decisions
Note. CI = confidence interval; PR = prevalence ratio. Percentages may not equal 100% because of rounding. Unless otherwise specified, the reference group for each variable is no diagnosis or no exposure. a Data regarding history of TBI were missing for 38 respondents. b Comparison adjusted for age, gender, race, and education.
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RESEARCH AND PRACTICE
About the Authors Jessica L. Mackelprang is with the Harborview Injury Prevention and Research Center and the Department of Pediatrics, University of Washington School of Medicine, Seattle. Scott B. Harpin is with the College of Nursing, Anschutz Medical Center, University of Colorado, Aurora. Joseph A. Grubenhoff is with the Department of Pediatrics, University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora. Frederick P. Rivara is with the Harborview Injury Prevention and Research Center and the Department of Pediatrics, University of Washington School of Medicine. Correspondence should be sent to Jessica L. Mackelprang, PhD, University of Washington, Harborview Injury Prevention and Research Center/Department of Pediatrics, 401 Broadway, Suite 4075, Patricia Bracelin Steel Memorial Building, Seattle, WA 98104 (e-mail: jlmack11@uw. edu). Reprints can be ordered at http://www.ajph.org by clicking on the “Reprints” link. This article was accepted May 8, 2014.
Contributors J. L. Mackelprang, S. B. Harpin, and F. P. Rivara originated and designed the study. J. L. Mackelprang, S. B. Harpin, and J. A. Grubenhoff drafted the article. J. L. Mackelprang was responsible for the statistical analyses. F. P. Rivara contributed to critical revision of the article. All of the authors contributed to interpretation of the data analyses.
Acknowledgments Jessica L. Mackelprang received fellowship support from the National Institute of Child Health and Human Development (grant T32-HD057822) during the preparation of this article. We are grateful to Wilder Research (St. Paul, MN), especially project director Greg Owen and Ellen Shelton, for sharing data with us. We also acknowledge the contributions of the study participants and the many volunteers who conducted the interviews. Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Human Participant Protection
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