30 Years – More homeless youth, But few other changes Mary Jane Rotheram-Borus

Declaration of the Rights of the Child UN Document Series Symbol: ST/HR/ UN Issuing Body: Secretariat Centre for Human Rights Proclaimed by General Assembly resolution 1386 (XIV) of 20 November 1959

The numbers of homeless youth are rising over time 1987 2016/17 Los Angeles 12,000 63,000 NYC 12,000 23,110

Youth go to where the services are – Downtown Hollywoood Venice

Homeless shelters are congregated in high risk neighborhoods 5

Homeless shelters are congregated in high risk neighborhoods: LA Type of sex Where Gay-for-pay Hollywood Straight –sex-for-pay Sunset Sex-for-drugs Santa Monica 6

Yet, who, where, & when youth are homeless is clear & consistent over time. Lesbian, gay, bisexual, & transgendered youth Psychiatrically disturbed girls having sex at 12 years Children in foster care Children whose families go homeless Youth with serious mental illness Youth with contact with criminal justice

Problems the same 30 years later, at similar rates 25% attempt suicide 25% sexually abused 27% psychiatrically disordered 40% jail (93% if LGBTY 80% some drug use 40% problems at school 80% boy-girl-boy troubles

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2018, Adolescent Trials Network

2018 Adolescent Prevention Trials Network

Over the last 20 years, the numbers of EBI have been substantial & all similar HIV+ Family HIV- HIV+ Miscellaneous Street Smart TLC TALC N.Y. Safety Counts, IDU Street Smart Computer CLEAR TALC L.A. Promise Street Smart Uganda TALC South Africa Healthy Living CPOL China Project LIGHT Project LIGHT TALC Thailand STRIVE SUUBI HIV+ Testing, Churches TALC China Teen LIGHT MD For Life ATN, #2 Philani, SA Zithulele, SA Men’s soccer, SA SMI LIGHT

HIV Interventions TLC 31 CLEAR 18 SUUBI 18 HEALTHY LIVING 15 # of Sessions Facilitators Site N TLC Clinic Staff NYC, LA, Miami, SF 31 310 NYC, LA, SF CLEAR 18 MA Level 253 CBO Staff Kampala, Uganda SUUBI 18 100 HEALTHY LIVING NYC, LA, SF, Wisconsin 15 MA Level 936

Common Life Challenges Parenting / Family / Relationships for PWA Health Transmission Quality of Life Parenting / Family / Relationships

Outcomes 24 15 24 25 TLC CLEAR SUUBI HEALTHY LIVING Substance Abuse Follow-up, months Sex 45% sex partners 31% weighted use index TLC 50% HIV- sex partners 24 82% unprotected sex 21% alcohol, mar., hard drugs CLEAR 59% HIV- sex partners 15 SUUBI in # sexual partners N/A 24 condom use alcohol, mar., hard drugs, days of use HEALTHY LIVING 53% sex acts with HIV- or unknown status 25

Common Effective Learning Model Same Theory, All Interventions Change occurs … slowly, over time with small steps in supportive relationships with opportunities & rewards

Identified Common Robust Factors in EBI Selected successful programs Obtained reliable category definition Identified common principles & processes Validated principles, re-review

Common Processes Behavior & cognitive focus Structural activities Goals Cohesiveness

Common Rules Be prepared Have + alternatives Make explicit plans Judge on facts Practice self-control

Common Factors in Interventions Health-Specific Information Feel/Think/Do Skills Frame Issue Supportive Relationships Environmental Barriers NIMH Workgroup on Behavior Change, 2001

Common Components for Reducing HIV Risk among runaway & homeless youth (I) EBFT* CRA** SBCM*** STRIVE Street Smart Frame the Issue & Assess Current Status failures of service system, family, & RHY. Assess each. Increase happiness: enhance motivation, gather history of risks, functionaly Analyze risk behaviors. Validate + normalize experience & feelings. Evaluate strengths & current functioning in multiple life domains. Family has poor conflict resolution skills: increased skills will reduce risk. Pursuing life goals requires a decrease in risk acts; evaluates risk knowledge, attitudes, & behaviors. Information/ Education Parents: limit-setting & monitoring, strategies to decrease substance use. Protection strategies that reward pro-social acts Normalize behaviors, ↑ protection strategies, conflict resolution Strategies aimed at conflict resolution. ↑ Protection strategies. Coping Skills ↑ Problem-solving, communication skills. Reward positive behaviors, punish or ignore negative behaviors. ↑ Problem-solving, including feelings, thoughts, & actions.

Common Components for Reducing HIV Risk among runaway & homeless youth (II) EBFT* CRA** SBCM*** STRIVE Street Smart Social Support /Relationships Improve relationship with parents & other key persons to support change. Involve “concerned others” in the intervention , encourage positive social activities. Build strong relationship with the case manager, non-deviant peers, & supportive adults. Improve relationships with parent/guardian & family members. Relationships with group members & the facilitator reduce risk. Environmental Barriers Mobilize resources of service system. Authoritative adults do not act contingently. Replacing “entrapping niches” that do not support the child’s strengths & goals with supportive settings. Develop a referral method for early access to runaways. Provide access to ongoing health care, STD treatment, & condoms.

Generic, Stepped Care Interventions; heavy mobile emphasis Automated Messaging & Monitoring Peer Support (Muut) Coaching

Progressing through Steps Stepped-Care for Youth Living with HIV

EBI Practice Elements Used by Coaches % of Utilization

Target Areas Discussed by Coaches % of Utilization

Our current approach is counter the prevailing scientific norms of EBI.

If you provide STABLE HOUSING, mental health disabilities are reduced. people remain housed & substance abuse & mental health disabilities are reduced.

$47.5 billion dollar industry Privatization of $47.5 billion dollar industry $32 billion special education $12-15 billion child welfare $ 3.5 billion juvenile justice

Thank You