Health Problems of Homeless Adolescents

Some of the key elements to this paper will be the physical and mental health problems of the homeless adolescent population. Physical problems such as frostbite, hypertension, and dental problems are discussed. Mental problems such as depression, schizophrenia, and mental retardation are also discussed. Counseling considerations are also discussed, which include counseling special populations , such as, the homeless. American Association of Mental Retardation give their view and definition of mental retardation. The literature review give the experts opinion of health problems of the homeless. Theories pertaining to the homeless are incorporated, and available health care resources are discussed.

Overview of Health Problems of the Homeless

There is an interaction of homelessness and health problems. Health problems can contribute to being homeless, and being homeless can decrease access to many health care facilities. Few homeless youth are housed in emergency shelters. The National Coalition for the Homeless (1999) says few homeless youth are housed in emergency housing, and because of their age, homeless youth have few legal means to earn money to meet their basic needs. The National Coalition for the Homeless (1999) says homeless adolescents exchange sex for food, clothing and shelter, which puts them at a greater risk for AIDS or HIV related illnesses. The National Network for Youth (1998) says homeless youth may be 2 to 10 at greater risk for HIV than other adolescents in the United States. Many homeless people face an extreme environment every day, such as, extreme hot temperatures, and very cold weather. Many homeless people do not utilize shelters. They live on streets, under bridges, in bus terminals, and in abandoned buildings.

Smeltzer & Bare (1992) says many homeless people get frostbite, hypothermia, heat strokes, pneumonia, infectious diseases from rodents, skin disorders, and serious injuries due to accidents, assault, or rape. Many communicable diseases and infections are spread inside shelters. These diseases are contracted because of the close sleeping quarters, showers, and dining areas. Health care is often inaccessible to the homeless because most of the homeless do not have health insurance. Smeltzer & Bare (1992) says co-morbidity, which is the existence of concurrent health problems, is especially prevalent among the homeless.Many of the health problems of the homeless are related to their living conditions. The lack of proper nutrition, clothing, and sleep compounds the risk to poor health. Bare, (1992) says over 50% of homeless single adolescents smoke cigarettes, which increase their health risk. The homeless have high rates of trauma, tuberculosis,upper respiratory infections, poor nutrition, anemia, lice, scabies, peripheral vascular problems, sexually transmitted diseases, dental problems, arthritis, hypothermia, and foot problems. Eye, cardiac, and genitourinary disorders. Some of the potentially fatal diseases of the homeless are HIV/AIDS, and TB.

Physical Problems

Many homeless adolescents have chronic health conditions. Hamner & Turner (1996) says these youths have chronic health conditions, such as, frequent serious upper respiratory problems, dehydration, and diarrhea. The American Academy of Pediatrics (1996) says many homeless youth have scabies, lice, tooth decay, ear infections, and conjunctivitis. Sinusitis, anemia, eczema, diabetes, and asthma are other chronic diseases that many homeless youth have endured. The anemia is found to be two to three times more common in homeless youth, and since refrigerator storage and cooking facilities are not available, fast-food restaurants and convenient stores are the most common source for food for homeless youth. The homeless have a high rate of chronic physical problems, such as, hypertension, gastrointestinal, vascular diseases, and poor dental problems. The study done by Gelberg, Andersen,& Leake, (2000) says homeless adults and children had high rates of functional visual impairment (3.7 percent) a rate of high blood pressure similar to that of the general public (81 percent). Skin for tuberculosis test positively (78 percent) skin/leg/foot problems were (44 percent) and visual problems (33 percent). In more severe homeless status, mental health problems, and substance abuse deter homeless individuals from obtaining better care. Tuberculosis is contagious and can be fatal if untreated. Clients with AIDS are particularly prone to tuberculosis. Treating tuberculosis is sometimes difficult because the homeless adolescent must take several medications over many months, and many homeless adolescents stop taking the medication before the full course of their treatment. If the homeless adolescent stops taking the medication, he/she can develop resistant strains of tubercule bacillus. The Center for Disease Control (CDC) recommends an intensive 6-month treatment of multi-drug medication. The CDC have protocols to treat tuberculosis on a three or five day a week schedule. Decreased overcrowding in shelters, sunlight, ventilation, and ultraviolet light will prevent the spread of the infection. Upper respiratory infections are the most common health problem that homeless youth have. Poor nutrition is a health problem for the homeless. The absence of adequate means to prepare and store food contribute to this. Many homeless adolescents panhandle, then buy "junk" food at fast food restaurants or delicatessens. Lice and scabies are sometimes an epidemic at the shelters. Inadequate access to bathing and washing facilities lead to poor hygiene.

Smeltzer & Bare (1992) says peripheral vascular diseases, such as, varicosity's, phlebitis, thrombosis, chronic edema, cellulitis, and gangrene were found to be 10 to 15 percent more prevalent among the homeless. Sexually transmitted diseases are also prevalent with the homeless besides HIV/AIDS. There is a high rate of syphilis and gonorrhea. There is no precise number, but the National Coalition for the Homeless (1990) estimates that between 12 to 30% of the homeless population was HIV infected. Dental problems is another health problem of many homeless youth. Smeltzer & Bare (1992) says 98 out of 100 homeless people need dental attention, and a large number have pain and infection.

Medical Emergencies

Trauma is a major reason for visits of homeless youth to the emergency room. Accidents are a major cause of death among the homeless, and many homeless youth are victims of crime. Hypothermia is considered a medical emergency. Hypothermia is caused when the body temperature drops below 95 F. Hypothermia is caused by cold weather and inadequate clothing. The homeless have been known to die from hypothermia. Some risk factors that increase the risk of hypothermia, are older people and intoxication. Frostbite - This is a cold related injury caused by exposure of the body to some sort of chemical, such as, dry ice or to cold weather. Frostbite most often attack the toes, fingers, nose, chin, and ears. Some of the physical problems a person may have that will increase the risk of getting frostbite are anemia, malnutrition, edema, poor circulation because of diabetes, peripheral vascular disease, smoking, alcohol and drug abuse. A person with first degree frostbite has red or bluish edemous skin. With third degree frostbite, the skin is purplish with purplish filled blisters. Persons with fourth degree frostbite has gangrene. The underlying tissue and the bone is dead in fourth degree frostbite. Homeless youth are sometimes exposed to very hot temperatures. These hot temperatures can cause the homeless to have Heat Edema. Heat Edema is the swelling that occurs when a person stands for a long period of time in the heat. This edema occurs in the legs. Also, extreme heat can cause dehydration in the homeless. Many homeless youth do not have immediate access to drinking water, especially those that live on the streets, in alleys, and in abandon buildings. Extreme temperatures in heat can also cause Heat Syncope ,which is fainting. In Heat Syncope, the blood is pulled from the brain to the skin surface in extremely hot weather. This causes the person to faint.
Heat Exhaustion is caused when the weather is very humid, such as, 103 to 106 degrees. Heat exhaustion can cause nausea, headaches, confusion. A heat stroke happens when the body temperature goes over 105 degrees. A person gets a heat stroke when they are unable to sweat enough. A lot of homeless people have Grand Mal Seizures due to brain tumors or alcohol. The homeless has an increase risk of exposure to Infectious diseases,
such as ,Hepatitis A+B+C, and AIDS. A lot of homeless youth who have Hepatitis or AIDS, are without resources to get treatment or care. Homeless youth with AIDS and Hepatitis has to deal with fatigue, diarrhea, dementia, and vision problems as well as their homelessness. There is an increase in Tuberculosis in the homeless, as well as infestations, such as, scabies and lice due to poor hygiene and contact with others.
Mental Disorders

Hamner & Turner (1996) says many adolescents are depressed and have suicidal thoughts. Jaffe (1998) says many teenagers in the United States run away from home because of conflict, rejection, neglect, and abuse. Jaffe (1998) says on the streets, these youths are exposed to drug use. Many homeless teenagers are withdrawn, have intense anxiety, and have low self-esteem.
Many homeless adolescents have mental problems, such as, psychiatric, drug, and alcohol disorders. Schzizophrenia, mood, and personality disorders are also mental problems of the homeless. Some homeless persons are dual-diagnosed. Substance abuse is a major problem of the homeless. Smeltzer & Bare (1992) says an estimated 50 percent of homeless youth have problems with alcohol, or drug dependency. Many studies have found high levels of serious mental illness among homeless single adults. Boston and Philadelphia studies identified schizophrenia, major affective disorders, clinical and manic depression, as high as 40% in the shelters in those cities (Responding To The Homeless, Russell Schultz, 1992.)

Types of Mental Illness

Schizophrenia - Distorted reality, with symptoms of hallucination, delusions, apathy.
Major Affective Disorders

1.) Major Depression - The person feels blue, difficulty in sleeping, eating, concentrating,
and physical acts.

2.) Bipolar Disorder - Involves manic episodes and major depression. In the manic phase the person is full of energy, rapid speech, may give way money, clothes. At other times, these persons are extremely depressed.

3.) Personality Disorders - The personality disorders most commonly found in shelters are
borderline personality and antisocial personality. Persons with a borderline personality are loners. They do not become involved in groups in the shelter. Their speech is a vague. They steer away from the main point.

Mental Retardation

There have been many definitions for mental retardation. Mental retardation has been defined as subaverage intellectual functioning with deficits in adaptive behavior (Goddard, 1916). Alfred Benet says in 1905 that the concept of adaptive behavior is when an individual is able to conduct his affairs of daily life without having need of others to supervise him. The American Association of Mental Retardation (1992) found four new ways to classify people with mental retardation. The AAMP defines mental retardation as a condition that develops before the age of 18, and there is subaverage intellectual functioning, with and I.Q. of 75 or less. The AAMR in 1992 replaced the labels referring to the degree of mental retardation. The labels were changed form mild, moderate, and
profound to intermittent, limited, time limited, and extensive. Covenant House New York (2001) says for the mentally ill adolescent, developmental tasks bring extreme anxiety. Adolescence is a time environmental demands increase, and many serious mental disorders have their onset. Bipolar 1, Schizophrenia, and suicide risk increase during adolescence, and preexisting mental disorders tend to worsen. Covenant House New York (2001) estimate that 5,400 homeless youth in New York are suffering from a neuropsychiatric disorder, and 1,700 of these youth are diagnosed with Axis-1 disorder. Covenant House New York's Psychiatric Day Program has served over 900 youth suffering from mental illness. The Citizens Committee for Children (1999) found between 15,370 and 42,400 foster children in New York had serious mental problems. Thousands of these children will eventually be too old for foster care, and will add to the mentally ill, 18-21 year old homeless population.

The TV series "Boston Public" has a teenage girl who is homeless and lives with her mother in a car.Some youths at the high school made fun of this teenager because of her clothes and poor grooming. This homeless adolescent was took under the wings by a female staff member at Boston Public, and attended the prom on a later series, looking like Cinderella. This teenager had been shy, withdrawn, and had low self-esteen. With the help of the staff member, all of these conditions improved. The teenager stated "She wanted to go to college and become a teacher."

Counseling Considerations

Sue & Sue (1999) says therapist should be aware of their own biases, assumptions, beliefs, and values when counseling homeless youth. An effective counselor must understand himself and his beliefs before he/she can effectively counsel someone else. The counselor should actively attempt to understand the worldview of his culturally different client. The culturally competent mental health professional must possess specific knowledge and information about the particular group he/she is working with (Sue & Sue, 1999). Many homeless youth have substance abuse problems. These clients may deny their problem, and try to manipulate others. Therapist should use "street smarts" when counseling these clients. Clients should be screened for drugs, and if positive, referred to drug rehabilitation programs. Smeltzer & Bare (1992) says it may be unsafe to be left alone with some addicted clients because they may be dangerous. Therapists should counsel clients in a non-judgmental way on the negative effects of substance abuse. For example, the therapist may say, your lab test show elevated liver enzymes, if you continue to drink, you may die. Money and medication management, crises intervention, activities, and services are important components of therapy for the homeless client. Therapists should have guidelines to assess the socioeconomic issues of homeless clients. This guideline may be a standard form for the client to fill out inquiring about health, employment, housing, etc.

Homeless clients should also be interviewed. The interview should be sensitive and unbiased. This interview is also used to determine the clients support system, and to make necessary referrals to the clients. The referral may be for a client to get food, housing, rehabilitation, medical, etc. Clients basic needs must be met before we can help them with their mental health needs. The article by Wendel (1997) Cultural bias among minority counselors says "In this country, regardless of whether a person is a member of the majority group, or one of the minority groups, he or she hold preconceived notions and stereotypical assumptions about who are different. The article says many counselor educators do not have the background necessary to teach cultural awareness, yet many do. Clients can sense bias in their counselors, just like counselors can detect bias in their clients. In counseling homeless youth, therapist and mental health workers should not have preconceived notions about their clients. Therapists and mental health professionals should be open to inquire about their homeless clients spiritual beliefs. This may be simply included on an intake form initially, then during a therapist session, more questions may be asked. Sue & Sue (1999) says just as the therapist might inquire about the physical condition of his client, he should feel free and comfortable to inquire about his clients values and beliefs as they relate to spirituality. However, regardless of the religious affiliation of a client, the therapist or mental health worker should realize that faith in a higher power can be therapeutic for the client. Therapists should be an active listener for the client to talk about his or her religion, and for spirituality. Spiritual values and beliefs direct a persons behavior, and their approach to health and mental problems. Smeltzer & Bare (1999). There should be guidelines that ask questions to determine the extent to which religion is a part of the clients life, and also questions to determine the clients religious practices.

A multidimensional approach should be used when counseling the homeless youth. This approach should include assessment and evaluation of the clients health and mental problems, appropriate referrals, housing, job training, and education. Working with homeles youth can be rewarding. The therapist should be a supportive listener, help resolve disputes, and build a rapport with his/her client. The article, Homelessness in America Today by National Health Care for the Homeless Council (1997) says multi-disciplinary teams work together to remedy the variety of problems that affect their clients health. These teams work with their clients to address issues of safe shelter and permanent housing, jobs and income, family relationships and substance abuse, in an effort to help people get well and move out of homelessness. Hoy, (2000) says homeless people with mental illnesses or substance abuse problems benefit greatly from community-based mental health services, according to researchers from New York University School of Medicine. The article says when homeless people with severe mental illness have access to safe, affordable housing, along with outpatient services, including case management, they can achieve long-term, stable ability.
Substance abuse has been a major factor affecting residential stability. There is a need for new strategies to improve housing for those homeless clients who are dually diagnosed.

Counseling Tips (Sue, D. W. & Sue, D., 1999)

1. Therapists should be aware of their own values, and biases, and be sensitive to how it may influence working with clients from other cultures.
2. Therapists should understand and develop an appreciation for diversity, accept it as a challenge, and satisfaction.
3. Therapists should always be aware of their own limitations when working with diverse cultures.

4. Therapists should seek to understand the values, history , and traditions of their clients.
5. Therapists should be aware of various cultural view of issues, such as, mental health, religion, counseling, adjustment, etc.
6. Therapists should utilize various therapy techniques, and match approaches to the needs of the client (Mult-therapy tecniques can be used.)
7. Therapists should be sensitive to institutional barriers and prejudices that their clients have to deal with.
8. Therapists should be flexible and sensitive while utilizing various approaches.
9.Therapists should communicate effectively with their clients by using appropriate language.
10. Therapists should be familiar with referral sources, programs, and agencies, so that appropriate referrals can be made to their clients.

Definitions

A. Individual counseling- There is a preferred orientation with individual counseling. An approach should be selected which is suitable for the client. Individual counseling is more structured.
B. Group Counseling -It has the advantages of maximizing the therapist time, as well as providing multiple interactions.
C. Special Types of Counseling- Includes family, leisure, and life-style.

Literature Review

In the book, Responding To the Homeless, Garrett (1992) have found that practical assistance may sometimes be the most appropriate form of health promotion. The experts have found that health promotion initiatives need to be connected with immediate and practical aid. For example, a heroin user may be more compliant to his other medical problems if he is given methadone. Experts have found, you have to use practical sense. Educating a homeless person about dental health may be pointless. Also educating a homeless person about hygiene will not sink in if the person has to live on the streets.
Wojtusik, (1998) says in her article, Health Status and Health Care Barriers among the homeless , (Journal of Health Care for the Poor and Undeserved, 1998, Vol. 8, 70-82) that the provision of appropriate and effective health care to the homeless is one of the most complex problems facing health care providers today. Wojtusik says the majority of homeless people have no forms of health insurance. Government assistance including Medicaid is hard to obtain if a person does not have a permanent residence. Wojtusis says other barriers the homeless have in obtaining healthcare are their inability to pay, mistrust and fear of health-care professionals, lack of transportation, and the lack of sensitivity of professional workers to homeless people. ( Wojtusik, 1998). People need basic health and welfare services so that they have enough energy to offer one another the support necessary for dealing with needs beyond safety and security. People with severe mental illness has been found to have low levels of social support. Drake & Buchanan (1999) says in their article, Social Support And Service Use Among Homeless Persons With Serious Mental Illness, (Journal of Social Psychiatry, 1999, 45, 13-28) find that homeless clients with more intact social supports will be better able, and more likely to access the health and social service system. A drop in health center is one type of facility that promotes rebuilding of social network. A research done in New York City by Ron Winslow found in the article Homeless Patients Are Found to Place Disproportionate Weight on Hospitals (Wall Street Journal, 1998; Health, B7) says that the homeless people admitted to a New York hospital stayed 4.1 days longer than other low income patients.

A group of homeless psychiatric patients stayed 70 days longer than the medical treatment called for because the doctors believed it would be more dangerous to their health to discharge them ( Winslow 1998). Homeless youth have a high rate of dental problems. The homeless population are at a greater risk for dental problems because of poor nutrition, alcohol, substance abuse, and the lack of personal hygiene facilities. Cousineau, (1997) in his article ,Health status of and access to health services by residents of urban encampments in Los Angeles ( Journal of Health Care for the poor and Undeserved, 1997, Vol. 8, 70-82) reports that few dental practices will take clients with Medical. Homeless people will most often not seek private practice medical or dental care because they say they are subject to judgmental and discriminatory treatment. Mental health problems can increase alcohol or chemical dependence when homeless people do not have adequate access to mental health care services. Cousineau (1997) found this in the article, Health status of and access to health services by residents of urban encampments in Los Angeles. Nordhaus-Bike (1998) in the article, Street - Smart Health Care from the (Journal of Hospitals & Health Networks, 1998, Vol. 71, 26) says the residential social service program Northwestern helps the homeless put their lives back together. Northwestern has
several programs for the homeless, poor, and uninsured. Northwestern address health care problems of the homeless such as nutritional deficiency, hypertension, and glaucoma.

Hosking (1997) in the article, Hospice of Spokane hopes to open its own facility ( Journal of Business, 1997, Vol. 12, 23) says the Hospice of Spokane's goal is to provide palliative care for the terminally ill who are homeless or who can't stay with family members. This facility will serve to help the homeless die with dignity in the company of others, and not alone. The Hospice of Spokane uses a team of staff nurses, counselors, social workers, nurses aides, physicians, and volunteers. (Hosking, 1997). When homeless youth have a minor physical problem, it can escalate to a serious problem if it is not treated in a reasonable period of time. There is a need to provide on-site health care to homeless people in places where they gather to reduce barriers to care, increase compliance with treatment, and to reduce the cost of emergency room services. In my research, I read the article Mobile Units deliver health care to the homeless, I learned that in the state of Florida the Department of Social Services has operated a Mobile Medical Unit to provide medical and dental care to the homeless. I feel this is a
necessary service for the homeless, and that it is needed . I would like to see vision service added to the mobile unit. Sometimes homeless clients have severe toothaches, and they have to suffer all day because they have to have an appointment to get dental care. My hope is that the Mobile Medical Units will start providing regular preventive care nationwide This will be saving tax payers if the homeless are allowed regular preventive care, because it would decrease non-emergency visits to the emergency room.

I have been a witness to ahomeless person seeking medical treatment at a doctors office where I worked several years ago. There was a homeless man who came in limping, and pointed to his foot which was bandaged in newspaper. He said that he heard that the doctor was a good doctor and he wanted him to look at his foot. The homeless young man did not have any insurance and was told the doctor was not taking walk-ins. He was referred to a clinic around the corner. The homeless young man insisted he wanted to talk to the doctor. He was informed the doctor was busy with other clients, and was again advised to go to the clinic around the corner. The homeless man refused to leave and became so loud that ther receptionist, said okay, have a seat, I'll go get the doctor. The doctor came out, examined the homeless man's foot. The doctor sanitized and dressed the man's foot. He also gave the homeless man a prescription for antibiotics. This homeless man insisted on seeing Dr. Agra because he had heard that the doctor had given care before to homeless people. Sad to say, but some health care workers do not want to wait on homeless people. We must remember that just because a person is homeless does not mean they don't have feelings. A homeless person is especially sensitive to demeaning remarks, gestures, and
attitudes, I thank my parents every day for bringing me up to respect others. Just because a person is homeless does not mean that they should be shunned, talked about or disrespected.

Theories

A theory that I feel is appropriate for homeless adolescents is the theory, Maslow's Hierarchy of needs. This theory was used because it addresses health, safety, shelter, health, and health coverage. In this theory, the above needs are considered safety needs once the physiological needs are met. I feel it is important for mental health workers and therapists to assess their clients health care needs as part of the intake assessment. clients should be asked if they have any health care problems, or to list their health care problems. We as therapists should ask clients where do they go for health care, and make referrals if the client does not know where to go. Another theory I felt appropriate to use is the Family Stress theory or Crises Model, which was developed by Reuben Hill in 1949. Hill saw reactions between the A-stressor which creates a demand, B-resources for meeting demands C-how a person view or define a situation. and X-crisis which may or may not occur as a result of the interactions of A, B, C. An example of this theory would be a adolescent getting kicked out or leaving home.
As a result, the adolescent no longer has medical insurance. The youth may have a medical emergency, such as, a Grand Mal Seizure, or faint. Many homeless youth are in the Stress Theory.

Many adolescents run away from home, they end up on the streets or in shelters with acute or chronic health problems.I will continue to seek ways to improve the health care of the homeless by attending seminars , workshops, whenever I can. I will keep current my license for the Basic Cardiac Life Support and Standard First Aid. As therapists and mental health workers, these skills may help to save a life or limb of one of my clients. I will continue to volunteer whenever I can, and continue to read current literature on how to help the homeless and anyone seeking medical care. I feel gaining insight on the health problems of the homeless will help me to be understanding of this populations problems and to seek out better and effective ways to help them obtain health care. Access to health care is extremely limited for the homeless, and therapist and counselors need to be aware of the resources available to help the homeless with health care. Therapists and mental health workers may participate in campaigns to promote better health care for the homeless, participate in Health Fairs, and other community health promotion events. Therapists can help the homeless teenagers recognize the need for medical attention, to keep doctors appointments, and to follow the prescribed medical regimen. An agency I have worked for in the past was a homeless shelter for men, women, and children. This agency provided employment assistance, counseling, housing assistance, food, and spiritual guidance. This agency operated a day program as well as a night program where homeless men, women, and children sought help. This agency , in my opinion, is culturally competent. This agency they have weekly staff meetings to discuss how to better understand, and help clients. This agency provides guidance and counseling for individuals, families, persons with disabilities, mental illness, ex offenders, and the elderly.

The staff and group leader of the agency were multicultural and multilingual, consisting of Anglo, Afro, Asian and Hispanic Americans.
This agency offered continuing education for its staff. Volunteers and internships from students majoring in Humanities, such as, social work, Psychology students, etc. The staff was able to communicate and handle cultural diversity issues. The mission of this non-profit agency was to uplift all people and bring them to God. This agency also provided emergency food and clothing to clients at the shelter if they are in school or at work. Some of the classes were life skills classes. There were coping classes, AA meetings, church meetings. Some of the areas this agency handled were classes on family issues and parental responsibilities. The area of human sexuality was addressed by the safe sex classes held. There were stress and conflict management classes. Some of the clients in this agency utilized services of other social service agencies, such as FIA, social security, etc. There were also classes on Family Resource management which included decision making, setting goals, and consumer decisions. There were defined rules at this agency. If the rules were broken, there was a progressive disciplinary action ranging from a Behavior contract, extra detail, a write up, to suspension from the shelter.

Prevention of Homelessness

I feel that therapist and mental health workers can improve the homeless youth population by helping them to sort out their daily struggles. We should clarify what is real or realism in their life. Therapist and mental health workers must develop communication and support from political leaders, directly and indirectly. Therapist and Counselors should put forth their best effort in helping all families to cope and adapt to change in a modern world, especially the homeless. This includes single, foster, step, etc. Therapist should continue to seek training and be more assertive in working with families. Therapists and
mental health workers should be creative and be able to engage in problem solving. We as therapist and counselors should focus on individual attitudes and behavior, and also teach our youth how to cope, and how to use information in a productive manner. I feel that by building supportive relationships with homeless youth, and encouraging them to build supportive relationships with their families and others, can help lessen the misery and loneliness they so often experience. Each homeless teenager should have someone with whom to share problems in a non-clinical setting. This relationship may be with a case manager, nurse, or other staff members. I feel that counselors, case managers, and shelter workers should become familiar with the health care emergencies that are common with homeless clients. At least one person per shift should be certified in CPR and basic first aid. The American Red Cross, local hospitals and the American Heart Association offers CPR and Standard First Aid certification.

References

American Association on Mental Retardation (1992) Mental Retardation: Definition, classification, and systems of efforts (9th ed.) Washington, DC: Author.

Citizens Committeee for Children of New York, Inc. (1999) Before it's too late: Ending the Crisis in Children's Mental Health: New York.

Committee on Community Health Services (1996) Health needs of homeless children and families. American Academy of Pediatrics, 98, 351-353.

Cousineau, M. R. (1997) Health status of and access to health services by residents of urban encampments in Los Angeles.
Journal of Health Care for the Poor and Underserved, 8,70-82.

Covenant House New York (2001) Mental health care of homeless older adolescents. Mental Health Policy. New York: Covenant House.

Golden, S. (1992) The women outside. California: University of California Press.

Hamner, T. J. & Turner, P. H. (1996) Parenting in contemporary society (3rd ed.) Massachusetts: Allyn and Bacon.

Hoskins, S. (1997) Hospice of Spokane hopes to open its facility. Journal of Business.

Hoy, L. J. (2000) Homeless benefit from mental health services: Insight and developments in counseling (On-line) Available: http://www.holyweb.com.

Jaffe, M. L. (1998) Adolescence. New York: John Wiley and Sons, Inc.

Lam, J.A. & Rosenbeck, R. (1999) Social support service use among homeless persons with mental illness. Journal of Social Psychiatry, 45, 13-28.

National Health Care for the Homeless (1997) Homeless in America: Washington: Pentium Press.

National Network for Youth (1998) Homeless youth. Washington: Author.

Nordhaus-Bike, A. M. (1998) Street smart health care. Hospitals & Health Networks, 2, (2) 26-27.

Power, R., French-James, R. & Connelly, S. (1999) Education and debate: Health promotion and homelessness.
British Medical Journal, 318, 590-592.

Rosenthall, R. (1994) Homeless in paradise. Philadelphia: Temple University.

Schutt, R. K. & Garrett, G. R. (1992) Responding to the homeless. New York: Pentium Press.

Sue, D. W. & Sue, D. (1999) Counseling the culturally different: Theory and practice (3rd ed.) New York: John Wiley and Sons, Inc.

Wendell, P. (1997) Cultural bias among minority counselors. Counseling Today,
40,4.

Winsow, R. (1998) Homeless patients are found to place disproportionate weight on hospitals. Wall Street Journal: Health, B 7.

Wojusik, L. M. (1998) Health status, needs and health care barriers among the homeless. Journal of Health Care for the Poor and Undersereved, 9, 140- 152.

Maurine J