THE United States is a powerful and resource-rich nation, but it does not adequately provide for the healthy development of its most precious resource: children and adolescents. An alarming number of American youth are leaving homes and communities that are detrimental to their health and well-being. Some are fortunate enough to connect with caring adults administering model programs to meet their survival and developmental needs. Some connect with other homeless individuals who care about each other's welfare. Others, however, are part of a growing number of homeless citizens who struggle daily to survive, much less thrive. To address the many needs of increasing numbers of homeless Americans, policies and programs have been developed in both public and nonprofit sectors. To promote optimal health and development among homeless adolescents, policies and programs must incorporate principles of caring.

The purpose of this article is to assert that social policy for homeless adolescents should be implemented by communities guided by a philosophy, ethic, and theory of caring and connectedness. I begin with a brief overview of theories of caring situated in the disciplines of nursing and education, and follow this with a description of the scope of homelessness in American adolescents, including pathways to homelessness, how these adolescents meet their survival needs, and the ways in which several programs address these needs. I have also presented the findings of several research studies showing that social connectedness is a primary protective factor in the lives of adolescents.

THEORIES OF CARING

The discipline of nursing has a long history of caring, a concept that helps define its unique perspective.1 Several nurse theorists have advanced theories of care and caring.2-4 In their book titled The Primacy of Caring, Benner and Wrubel5 asserted that "caring" is another term for being connected and that caring means that people and events matter. These nurse theorists differentiated a theory of caring from a theory of motivation in which the focus is merely on meeting a person's needs. They argue that caring is "always specific and relational" and that it is "primary because it sets up the possibility of giving help and receiving help."5^(pp3) In an essay about nursing theories, Saewyc6 cited theories of caring as fundamental to the promotion of adolescent health around the world. She further noted that these caring theories not only defined a scope of practice for nursing but also are useful as philosophies and mission statements for programs and organizations working with adolescents.

More recently, Noddings,7 a reflective educator, also cites care theory as an alternative to social liberalism, particularly as it relates to policies directed at providing care for homeless adults. She argues that care theory begins with the premise that persons do not come into the world as rational decision makers, but rather as helpless individuals who are totally vulnerable and in need of care from others. This premise shifts the focus from the isolated individual to the relational connectedness of one human being with another. Noddings7 points out that current social policy concerning the homeless is based on preservation of life and that programs are directed at providing food and shelter, but that they fail to address the fundamental need for human beings to have a "home," or a place that is intimately tied to an individual's identity. She further asserts that if social policy for the homeless were driven by care theory, finding a place to call home would become the first priority and the second priority would be to ensure that having a home would not be a tenuous situation for the homeless.7^(p445)

Noddings' argument for social policy regarding adults who are homeless can also be extended and modified to address the increasing numbers of adolescents who are homeless. We know a great deal about factors that protect adolescents from engaging in behaviors that place them at risk for adverse health and social outcomes. High on this list of factors is having caring adults in their homes, schools, and communities. But what happens to youth in America who do not have caring parents or other adults in their lives? Many of these young people become homeless, virtually without a place to live, without the sense of identity that comes from having an address, and without an environment where they experience happiness and security. It is curious that the term "homeless" is used to label these youth, but social policy primarily focuses on the fact that they are "houseless." Because policy is implemented by people, the context of home is critical when translating policy into programs. Home is a place where people care about one another and are connected in ways that ensure happiness, security, and optimum development. Housing can provide shelter from inclement weather and meals can provide nourishment for the body, but human beings need so much more to thrive. They need homes that provide a sense of identity where they can give and receive care and where they can be connected to other human beings.

HOMELESSNESS IN ADOLESCENCE

Although the US Census Bureau cannot count the number of citizens who are homeless in this country, persons living in emergency and transitional shelters as well as those living outdoors were included in the 2000 census.8 Unfortunately, this census does not include the number of adolescents who run away from home and are homeless for 1 or more nights on 1 or more occasions, nor does this census reflect the number of youth who are thrown away by families unable to cope with them. The US Department of Justice estimates that in 1999 nearly 1.7 million youngsters younger than 18 years had at least 1 runaway or throwaway episode.9 Congressional research reports cite annual estimates of 0.5 million to 2.8 million homeless youth in the United States.10

Analyzing data from a representative national sample of adolescents attending schools (National Longitudinal Study of Adolescent Health or Add Health), Sanchez et al11 concluded that 6.4% of youths had run away from home in the previous 12 months. Characteristics of those who ran away included older age (>15 years), more females than male, more likely to live in urban rather than suburban or rural areas, and more likely to live in a single parent family. These researchers suggested that older youth might be more likely than younger youth to run away owing to increased resistance to parental authority, conflict with parents over health-risk behaviors such as substance use, and the individuals' increased confidence in being able to take care of themselves. Clearly, homeless youth do not come only from lower socioeconomic levels of American society.

REASONS FOR HOMELESSNESS

For the majority of homeless adolescents, disrupted family relationships are at the root of this phenomenon. In an ethnographic study of 50 homeless youth aged 18 to 23 years, Hyde12 found that the majority of these youth left home owing to intense family duress and physical abuse. Other researchers have found that an adolescent's or family member's drug use provided a major pathway to homelessness.13 Whitbeck et al14 concluded that homeless youth as well as their caretakers reported a lack of parental monitoring, warmth, and support. These researchers also reported high levels of violence within the home, some originating with parents and some originating from disturbed youth.

Reasons for leaving home given by a nonprobability sample of homeless adolescents in Texas included parent's disapproval of the youth's drug use (28%), emotional abuse (18.6%), youth's sexual orientation (18%), physical abuse (16.2%), and sexual abuse (12.1%).15^(p140) Similarly, in a nonprobability sample of 329 homeless adolescents in Seattle, reasons given for leaving home were nonviolent conflict (22%), violence (18%), physical abuse (11%), neglect (10%), family member's drug use (5%), and sexual abuse (4%).16 In a study of 428 runaway and homeless adolescents in 4 midwestern states, researchers found that participants who self-identified as gay, lesbian, or bisexual reported being thrown out of their homes owing to conflict about sexuality or sexual behaviors more than heterosexual participants.17

NEEDS OF HOMELESS ADOLESCENTS

The most salient need of runaway and homeless youth is to survive; to survive, they must find food and shelter.18 Over time, these adolescents must either find a job or some other way to earn money, often through risky or illegal behaviors.19 Runaway and homeless youth face legion challenges to stay alive and maintain their health and well-being. Some of the challenges derive from factors that contributed to their homelessness such as physical and sexual abuse in their families of origin,20,21 academic difficulties,22,23 substance use and misuse,24,25 and mental health problems such as conduct disorder.26-28

Other challenges derive from factors the homeless youth face on the streets, many of which may exacerbate problems that contributed to their running away or being thrown out of their homes. As many as 83% of samples of homeless youth report physical or sexual victimization after leaving their homes.29 To survive, many engage in sexual practices that increase their risk for human immunodeficiency virus infection and sexually transmitted disease.30-32 Some of the survival sex practices also increase their risk for sexual victimization and other forms of violence.33-35

As noted above, most adolescents who are runaways or throwaways leave home to seek relief from stress and conflict within their families.12 With a lack of role models in the home, these youth may gravitate toward deviant peers and engage in health-risk behaviors associated with drug and alcohol use.36 Substance use may also be a way of coping with previous trauma and with the stress of being homeless.12 As one 16-year-old homeless male stated, "You get high together-that's basically how you establish friendships."37^(p239) Substance use is also highly correlated with risky sexual behavior in homeless and runaway youth.38

Homeless youth experience higher rates of pregnancy than their housed peers.39,40 In this environment, homeless youth are prone to symptoms of depression41 and suicide.32,42,43 Many more have mental health problems, which may be exacerbated by substance use and risky sexual behavior.44 In a longitudinal study of 428 homeless and runaway adolescents in the midwest, researchers found that homeless and runaway youth were 6 times as likely as a national representative sample of youth to have 2 or more mental disorders.45 Females were more likely than males to meet diagnostic criteria for posttraumatic stress disorder, whereas males were more likely than females to meet diagnostic criteria for conduct disorder. In addition to these mental and social problems, homeless youth experience high levels of sexually transmitted infections, uncontrolled asthma, tuberculosis, and skin disorders.19,46 Up to half of street and sheltered youth do not have a regular source of healthcare.47

In a grounded theory study of homeless youth, Auerswald and Eyre48 described a life cycle model of homelessness. In this model, youth in their sample, who were primarily White males in San Francisco, became acculturated to street life through an apprenticeship that connected them to street mentors who helped them master the street economy. By adapting to a street ethic of feeling like an outsider, "rejected by mainstream culture," sharing adversity, feeling free, and believing in a "magical provision of basic needs," these marginalized youth perceived myriad obstacles in finding their way back to connecting with the larger society.48^{(pp1505-1506)}

In summary, homeless adolescents face multiple obstacles during a phase of life when they should be developing skills and patterns of behavior that will contribute to being productive members of American society. But because they have become disconnected from the usual socializing institutions of home and school, they may attempt to connect with other youth from similar backgrounds. Homelessness not only poses a threat to the public health but also, more importantly, the nation suffers the loss of human potential as the numbers of homeless youth grow.

STRENGTHS OF HOMELESS YOUTH

Far less is known about the strengths of homeless youth than about their deficits and needs. Building on a philosophy of self-care found in the revolutionary work of Florence Nightingale, Rew37 conducted a grounded theory study of a multiethnic sample of 15 homeless adolescents. The basic social process identified by the participants was "taking care of oneself in a high-risk environment."37^(p236) This process linked experiences of (1) gaining self-respect, (2) increasing self-reliance, (3) engaging in self-preservation, (4) planning for self-protection, (5) interacting with other people, and (6) confronting obstacles in handling their own health. These findings suggest that in the absence of caring adults, homeless adolescents engage in self-care behaviors that support their survival.

In a secondary analysis of 3 qualitative studies, including the grounded theory cited above, Rew and Horner49 noted that in addition to self-care practices, homeless youth described numerous examples of connecting with others. They developed a community of peers, a street family, from whom they realized unconditional acceptance and acquired information to ensure their survival. This phenomenon of caring and connectedness was described in contrast to the estrangement they felt from their families of origin and other adults in institutions such as hospital emergency departments. Rew and Horner49 concluded that community responses to the needs of homeless adolescents should focus on their strengths and not merely their deficits.

POLICIES FOR THE HOMELESS

US federal policies address at least 3 major aspects of adolescent homelessness: juvenile justice, healthcare, and education. The Juvenile Justice and Delinquency Prevention Act (JJDPA) of 1974 was developed to prevent children and adolescents from being placed in jails or other institutions with adults. It also ensured that status offenders (ie, children who run away, skip school, possess and/or use alcohol, or break curfew) would not face secure detention in jails or prisons.50 The act states that such children should receive community-based services that include mentoring, alternative education, counseling, job skills training, and day treatment. The JJDPA was amended in 2003 by the Runaway, Homeless, and Missing Children Protection Act (Pub L No. 108-96), legislation that provides funding for food, shelter, counseling to reunite runaways with their families, and extends residential or transitional living shelters for youth up to 21 years of age.51

The best known omnibus legislation offering services to homeless adolescents is the Stewart B. McKinney Homeless Assistance Act of July 1987 (Pub L No. 100-77m, 101 Stat 484). It was renamed the McKinney-Vento Homeless Assistance Act in 2000. This act clearly defines the homeless as an individual who lacks a fixed, regular, and adequate nighttime residence, or an individual who has a primary nighttime residence, or an individual who has a primary nighttime residence that is (a) a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the person with mental illness); (b) a public or private place that provides a temporary residence for individuals intended to be institutionalized; or (c) a public or private place not designed for, or ordinarily used as regular sleeping accommodations, for human beings.52^(p5)

The McKinney-Vento Homeless Assistance Act originally consisted of 15 programs that included emergency shelter and transitional housing, job training, education, primary healthcare, community mental health and drug abuse treatment programs, and limited permanent housing. Funding for programs initiated by the McKinney-Vento Act has been uneven over time and recent analyses showed that these programs are "insufficient to meet demand, and that lack of adequate funding limits the programs' success."53^(p4) Moreover, this analysis also showed that the act was an emergency measure that responded only to the symptoms of homelessness and failed to address its causes. While this legislation provides for limited housing and programs that meet basic requirements for survival, adolescents who are homeless need homes with a caring environment in which they can thrive by learning to care for themselves and others.

POLICY LIMITATIONS AND RESEARCH EVIDENCE

A number of federal laws have been passed to develop and deliver programs that address food, housing, education, and healthcare needs of homeless adolescents. A major limitation of many programs is that they are based on a deficit model, emphasizing the lack of the necessities of daily survival and the adolescent's lack of skills. Could policies based on a model of caring and connectedness be developed to promote thriving in addition to surviving? Time and time again, researchers have shown that adolescents who have caring adults in their lives are less likely in comparison with other youth to engage in behaviors that are harmful to their health. Researchers have found that family connectedness protects adolescents from disordered eating,54 early onset of sexual activity,55 perpetration of violence,56 and other health-risk behaviors such as smoking, and alcohol use.57 Moreover, researchers who conducted a comprehensive review of recent literature also showed that youth who form positive relationships with nonparental adults, outside school and other formal institutions, experience improved health and well-being.58 Few studies of connectedness among homeless youth have been published. However, in a small study of 59 homeless youth, social connectedness, defined as having caring adults in their lives, was significantly and inversely related to hopelessness.59

Unfortunately, youth who run away or are thrown out of their homes are not likely to have strong connections with caring parents or other adults. Not only do many of these youth feel hopelessness about their lives but also those who do so engage in life-threatening behaviors, including suicide attempts.59 Clearly, these adolescents need caring adults in their lives long before their status becomes that of "homeless." Caring, as conceptualized in nursing, is a moral ideal that is an integral part of the concept of community. As Bent asserted, "[it] is not an isolated variable in community: it is interactive, with ties to economics, politics, policy and law."60^(p30) Caring is necessary to sustain both the human race and the social institutions that bind us together. It allows us to preserve each one's dignity while alleviating each other's vulnerabilities.4

In response to a crisis related to increasing rates of emotional distress and mental disorders among American children and adolescents, a 33-member Commission on Children at Risk reported that the cause of this crisis was the lack of connectedness. More specifically, they noted that children and youth lack connectedness to other people as well as "deep connections to moral and spiritual meaning."61^(p5) The commission recommended that instead of using medication and psychotherapy to respond to this crisis at the level of the individual, America as a whole needs to respond by developing "authoritative communities," which are warm and nurturing social institutions that include children and youth and where children's development and thriving is a major goal. Such multigenerational communities establish clear limits and expectations, have a long-term focus, and carry out their work by nonspecialists. These communities also reflect and transmit a "shared understanding of what it means to be a good person, encouraging spiritual and religious development, and philosophically oriented to equal dignity of all persons and to the principle of love of neighbor."61^(p52) Authoritative communities might end the crisis caused by the lack of connectedness felt by too many youngsters in this country by intentionally creating ways for youth to contribute directly to the welfare of the community.

The Search Institute uses the term "asset-building communities" in which residents and organizations form caring relationships with adolescents.62 Such communities are devoted to providing external assets for youth, which include support, empowerment, clear expectations and boundaries, and constructive use of time. These assets derive from youths' interactions with caring adults who provide prosocial role models. Researchers using this model show that adolescents who live in environments with greater assets tend to "thrive," or enjoy an enhanced state of well being.63 Such communities have many characteristics in common with authoritative communities and might also contribute to ending a crisis related to lack of connectedness.

Adolescents living in homes and communities with few external assets lack connections to caring adults including parents, teachers, and neighbors. These are the youth who are more likely than others to run away or be thrown out of their homes. Researchers have noted that runaway behavior, particularly in early adolescence, is a critical time to intervene in a positive way because it is often the gateway to serious criminal behavior, substance abuse, and chronic homelessness.64 Policy that requires mandatory return of runaways to parental custody, however, may not always be the best solution. When youth have fled highly violent circumstances, presumably homes devoid of caring and connectedness, such returns may place these youth at high risk for further adverse outcomes.21 Authoritative or asset-building communities might then provide a safety net where such youth can find safe haven away from a dysfunctional family but still within the larger, caring, and connected village.

There is a large gap between what we know about adolescents who thrive and those who are the beneficiaries of US policies for the homeless. The overwhelming research evidence is that youth need to be personally connected to caring adults to thrive, but when such connections are lacking, these youth fail to thrive and the larger society addresses this gap through social policy, which is inherently generic, universal, and impersonal. Despite this gap, several programs highlight the positive outcomes that result when policy reflects what we know about caring and connectedness. For example, Big Brothers Big Sisters of America, which has some 500 agencies throughout the nation, a prevention program emanating from the JJDPA of 1974, has shown that children who have mentors are "46% less likely to initiate drug use, 27% less likely to initiate alcohol use, and 32% less likely to commit assault."65^(p2) This mentoring program clearly has outcomes demonstrating that caring adults outside a child's family and outside a social institution can have a significant impact on the development and well-being of at-risk youth. The focus here is not on supplying material needs but rather on developing a one-on-one, personal relationship between a caring adult and a vulnerable child, even preventing some youth from becoming homeless. Moreover, through the mentoring process, adult volunteers in Big Brothers Big Sisters of America model the kind of caring and connectedness that youngsters can then pass down to the next generation.

Seattle's YouthCare project is an example of a program that focuses on case management wherein services are flexible and tailored to meet the needs of individual clients.66 YouthCare is a nonprofit organization that originated in 1974 and received its original federal funding from the Runaway and Homeless Youth Act. The mission of the organization is to provide services to adolescents who are in crisis. It is based on a philosophy of respectful responsiveness wherein youth are encouraged to develop an awareness of choices in their lives and to accept responsibility rather than becoming dependent upon a social institution. The project includes a research department that allows for close collaboration with the University of Washington, thus providing an exemplar of closing the gap between evidence and policy in a community setting.

The 45th Street Youth Clinic, also in Seattle, describes itself as "youth centric" rather than "youth friendly." Their model is based on creating public health services where homeless adolescents can connect with caring adults. Armed with an understanding of adolescent development and the unique culture of homeless youth, the mission of this clinic is "to incorporate the services of the program into their [homeless youth] lives rather than having them adjust to us."67^(p147) Clinic staff take their clients seriously and are committed to customer service, providing a waiting area where youth can feel safe and relax and employing staff and volunteers who express an attitude of acceptance for homeless youth. In this waiting area, homeless youth can help themselves to supplies such as toothpaste and socks, which the staff provides as a sincere expression of caring for these young folks. This clinic shows that a successful program for homeless adolescents can be developed on the basis of principles of caring and connectedness wherein guidelines for conduct are developed through communication between staff and clients.

Another program is that of the Larkin Street Youth Center in San Francisco. This program was initiated in 1996 to provide residential living arrangements for adolescents infected with human immunodeficiency virus, many of whom were homeless. Creating a residential care program involved a collective recognition of the needs of these youth by the program staff and directors as well as local businesses, city government, and public health officials, including those responsible for developing policy. The Larkin Street Youth Center staff and board of directors intentionally used social marketing to alter the perceptions of other stakeholders about the unique needs of this vulnerable population of youth. A hallmark of this program is the emphasis on developing youths' competence, independence, and self-regulation. Moreover, a key variable in the success of this program was identified as positive interpersonal relationships.44

CONCLUSIONS

A very large number of American adolescents run away or are thrown out of their homes daily. Although this may be a situation for many, for others this becomes a chronic, if not permanent, condition. The needs of these youth for shelter, food, clothing, education, and protection from illness and injury are great and several policies have evolved to provide for these basic survival needs. However, the need for a home in which these youngsters feel safe, develop an identity, and are cared for and learn to care for others may never be fully met. Social policy is designed to address the common problems of a population such as homeless adolescents. When the programs that result from policies are based on human relational qualities of caring and connectedness, we can expect these youth not only to survive but also to thrive. As a nation, we need to understand more about how to teach adults and communities to be caring and then to connect at-risk youth to caring adults within authoritative communities. Can America afford not to make this investment?

REFERENCES