July 10, 1998

To:Board of Health

From:Dr. Sheela V. Basrur, Medical Officer of Health

SubjectNo Fixed Address: Young Parents on the Street

Purpose:

Recent increases in the numbers of pregnant and parenting teens without stable housing is of urgent concern. The working committee Young Parents, No Fixed Address (NFA) was convened in December, 1997 by Toronto Public Health at the request of workers at local agencies (see Appendix 1), to help coordinate existing services for the growing numbers of young parents and children without homes. The committee's concerns for the health and welfare of these young families are discussed in this paper, along with recommendations for addressing the situation, based upon available data and information collected by the group.

Source of Funding:

Not applicable.

Recommendations:

It is recommended that:

(1)the Board of Health support the working committee on Young Parents, No Fixed Address to ensure ongoing co-ordination amongst youth serving agencies, and the continued development of flexible, alternative approaches that address the urgent needs of this population;

(2)the Board of Health urge City Council to ensure an increased supply of safe, affordable transitional and permanent housing stock and to eliminate barriers to access housing in both the public and private sector for this population;

(3)the Board of Health urge the provincial and federal Minsters of Housing to develop an increased supply of safe, affordable, transitional and permanent housing stock and to eliminate barriers to access housing in both the public and private sector for this population;

(4)the Board of Health direct Toronto Public Health to continue as a partner in the group, participating in programs that will include: a) food access and supplementation; b) development of a youth advisory board; c) further development of parent relief programs; d) development of responses to mental and emotional health problems; and e) continued data collection and monitoring;

(5)the Board of Health continue to support existing programs and services essential to street youth such as provision of classes outside schools in the community and advocate to the Minister of Education, the Toronto District School Board and the Catholic School Board to ensure these programs;

(6)the Board of Health advocate to the Minister of Community and Social Services for adequate provincial funding for child welfare and protection in order to ensure that caseloads are manageable and realistic for the protection of children and the prevention of abuse and neglect;

(7)the Board of Health advocate to the Minister of Health and to the Minister of Community and Social Services for the development of pro-active, early intervention strategies to prevent the rise in numbers of street youth and children;

(8)the Board of Health forward this report to the Assistant Deputy Minister - Integrated Children's Services, the Toronto District School Board, the Catholic School Board, the Children's Action Committee, and the Toronto Child Advocate;

(9)the Board of Health refer this report to Community and Neighbourhood Services for information and to City Council for adoption; and

(10)the Board of Health forward this report to the Premier of Ontario to urge him to ensure that the growing needs of young parents on the street be addressed through coordinated action of the part of the relevant Ministries.

Background:

Why are there youth without homes in Toronto?

The reasons young people trade their homes for the streets are confirmed in a number of studies.^13,14,15,21 A 1992 study of street youth in Toronto described "a population of adolescents in special circumstances, more than 70% of whom leave home because of physical and/or sexual abuse."¹⁴ Confirmation of the high prevalence of chaotic childhood experiences and serious emotional problems among these youth are found in several local data sources (see Tables 1A, 2A, Appendix 2).

Estimates of the number of homeless youth in Toronto are extremely wide-ranging^13,15,21,29 and the source of considerable debate. The statistics available indicate that between 5,000 and 20,000 teens spend time on the streets each year. Studies which attempt to enumerate homeless populations are exceptionally difficult to complete due to the transient lifestyles of this group. ²⁵ A 'census' of homeless persons has not been undertaken in Toronto.

Youth Hostel utilization figures provide one "official" indicator of the size of the street youth population in Toronto. According to statistics from Hostel Division, Community and Neighbourhood Services, approximately 325-340 youth between the ages of 16-24 use hostels nightly in Toronto³¹. In addition, there are youth who avoid these services and make alternative arrangements. Discussions with front-line professionals indicate that the number of youth in this latter group may equal the number of youth registered in hostels. Overall, Hostel Division statistics record over 5,000 youth using their facilities annually (see Table 3, Appendix 2).

There is strong evidence that the total number of street youth in Toronto has increased over the past several years. Utilization data from the Second Base Youth Shelter, one of nine hostels for youth between the ages 16 and 24, indicate a steady increase in the number of youth seeking shelter, from just over 500 in 1994 to nearly 900 in 1996 (see Table 4, Appendix 2). This 70% increase is particularly noteworthy, as it has been recorded in a facility located outside of Toronto's downtown core. Along with the increasing number of homeless youth, the growing number of homeless families sheltered outside of the inner city is significant, given the relatively few resources available in these areas. Of particular concern is the lack of accessible medical care for homeless individuals outside of the city's central core.

The number of children of homeless young parents, growing up without permanent homes, is another concern. Records from local maternity homes and shelters in downtown Toronto are the only data available regarding numbers of births among homeless women (see Tables 5A-6C, Appendix 2). The most recent figures, from the mid-1990's, document more than 200 births annually to residents in these facilities, with approximately 30% to teens.^1,2,3,4. The addition of women living in other circumstances at the time of delivery would likely bring this total to over 300 annually. More recent information regarding increases in pregnancies among homeless teens suggest this figure may still underestimate the number of children born to young mothers on the streets^5,6,7 (see Tables 7-9, Appendix 2).

Discussion:

Health Issues

The erratic nature of street life poses obvious threats to the health of this growing homeless population. Of all the risks they face, one of the most prominent fears among street youth is that of assault. Crime and violence ranked second among the ten most important problems cited by Toronto street youth in a 1990 survey, exceeded only by homelessness. The great majority have been physically and/or sexually assaulted at least once.¹³ Some youth report that sleeping during the day and walking all night allows them greater peace of mind.

The danger of sexual assault is heightened by common practices of "survival sex" and prostitution. Street youth are constantly in need of money and find that exchanging sex for housing, and other favors, are among their limited options.^23,26,28 Several young women involved in prostitution have been murdered over the past several years in Toronto, although the precise figures are not readily available.

A recent study of homeless young women in Toronto indicates that more than half become pregnant. Multiple pregnancies are also common, with 118 pregnancies among the 93 women interviewed . Lack of adequate prenatal care adds to the inflated risks for homeless young women and babies and results in extremely high rates of premature delivery. It is estimated that more than 10% of these babies do not survive.²⁸

Substance abuse on the street is another serious concern. In an extensive study of Toronto street

youth in 1992, more than 25% reported problems with one or more drugs. Rates of alcohol use

were exceptionally high, with an average reported weekly consumption of 15 drinks. Over

one quarter of those interviewed had injected drugs at some point in their lifetime; four percent had shared needles with others.¹⁴ The rate of HIV among street youth was reported as seven-times that expected in this age group.²¹

In addition, further serious health risks are related to inadequate nutrition, lack of rest, and limited opportunities for good hygiene and prevention practices^29,30,37. These factors further complicate high risk pregnancies while increasing susceptibility to serious acute and chronic infections. Not surprisingly, these significant physical risks, coupled with an often traumatic past, result in high levels of mental health problems as well. Estimates of clinical depression among street youth range between 35-50%¹⁴. The number who attempt suicide is also disturbing. Of the 217 street youth interviewed by the Addiction Research Foundation in 1992, 43% indicated at least one such attempt at some point in their lives. Females were significantly more likely to report such attempts (61% vs 37%). Other studies confirm these alarming rates.^21,27,28

These critical health concerns naturally extend to the children of these youth. Numerous acute and chronic health risks are associated with lack of access to adequate nutrition and to a clean, safe, and secure living environment in childhood.^15,27 In addition, many of these children suffer developmental delays, a result of low birth weight, as well as lack of attention and stimulation. Added to these problems are increased risks of physical abuse and neglect, as well as high levels of parental substance abuse, stemming from the often overwhelming levels of stress experienced by their parents.^20,32

Given these serious physical and emotional risks, it is not surprising that about one-half of the babies born to homeless teens are no longer in their mother's custody by the time they are two years old. ³⁸ Loss of custody is generally a devastating failure to these young women, leading to further serious emotional problems for themselves and the children.³² This is often a cyclical process; many of these women become pregnant again to try and replace this loss, with further impact on their emotional state.

Addressing the Needs

The most urgent need of these young parents and their children is safe, affordable housing. Unfortunately, formidable obstacles stand in the way. Of primary concern is the inadequate income on which these families must exist. Appendix 3 displays a sample monthly budget for a teenage mother on welfare. Based on the $957.00 stipulated by social assistance, the maximum shelter allowance of $575.00 leaves only $382.00 to pay for food, transportation, and all other needs each month. Those who are forced to pay more than the rent allowance provides must take additional money from other items in the budget.

Compounding the problem is the very limited availability of affordable housing. Waiting lists for subsidized units in social housing have tripled since 1990.¹⁷ As of February, 1998 the combined waiting lists for MTHA, MTHCL, and Cityhome stood at approximately 41,000.¹⁸ A vacancy rate of well below 1% in the private market further limits availability.

The absence of a centralized system allowing applicants to access information on a range of housing units has been a further impediment. The system of advertising and filling vacancies is often informal. Homeless youth, generally without telephones or mailing addresses, have limited access to information regarding upcoming vacancies. The new Toronto Social Housing Connections system has been designed to simplify the process, with information on 800 buildings, as well as other social services. However, the supply of affordable units will not be increased by this project.

Additional complications exist for mothers under 18 years of age. Often considered too young to sign a lease by private landlords, some temporarily use rooming houses. These accommodations are often dirty and unsafe, and not appropriate for infants and children. Shelters and other shared

accommodations are additional options, but are often overcrowded, and unsuitable for young children, intensifying the young mother's feelings of loneliness, vulnerability, and despair.¹⁹

Along with the urgent need for stable housing, homeless teen parents require strong, ongoing support with parenting. The conditions which bring youth to the streets generally imply a severing of ties with their own parents. While friends on the street may provide a surrogate family, they generally cannot provide support in terms of parenting responsibilities. As a result, these teens are generally caring for small children 24 hours a day, without a permanent residence, and with little money. Front line workers note that assistance with parenting is vital in preventing crises of desperation that do occur³³. 'Hot' lines for these emergency situations are another urgent need. In addition to crisis services, programs which offer information on parenting are vital in insuring the well-being of the children of street youth. Education for males, to help them assume their responsibilities as fathers, is crucial. Because their own childhood experiences generally leave these teens without positive role models in caring for their own children, programs which incorporate information on parenting with a wide range of other basic health services, including information on child health and nutrition, are vital to ensuring child protection.

The prevalence of serious addiction problems among street youth call attention to another critical need. The birth of a child is a life changing experience, which can provide the motivation for a new parent to overcome drug dependency and work toward a more stable lifestyle for themselves and their children. ^22,26,32 Numerous studies have identified the lack of treatment programs with provisions for day care as a major barrier in addressing are addiction problems in young mothers over the past several years.^32,33 Unfortunately, however, the gap remains. Reports of increasing numbers of babies born in Toronto with evidence of prenatal drug exposure further emphasize the need for maternal addiction treatment.³³ Long-term counseling and other supports, to prevent relapse in these vulnerable new parents, is an essential part of drug addiction treatment.

Conclusions:

Despite limited access to food, shelter, and health care for themselves and their children, youth on the street are often "service-shy". Early experiences with child welfare agencies can be traumatic, often resulting in a lack of trust in authority. Fear of losing their children to these same authorities creates perhaps the most difficult barrier to overcome in working with homeless teens, transcending all areas of need. This dilemma clearly illustrates the cyclical nature of the problems of child abuse, neglect, homelessness, and early pregnancy. Further stigmatization resulting from life on the streets can be an additional disincentive to receiving urgently needed food and shelter or attending to medical and dental emergencies. Local agencies, including Public Health, devote considerable efforts to "outreach," which involves identifying individuals in need of assistance and encouraging them to accept help. Discussions with outreach staff indicate that beyond the fear of these young women is often a tremendous desire to provide a better life for their children. A number of local programs have demonstrated how these many of these young women can draw upon the strengths they use to survive on their own to achieve this goal.^32,38

The network of agencies formed through Young Parents No Fixed Address has, in its first six months of existence, demonstrated the importance of inter-agency collaboration in working with resistant yet needy clients. Modifications to the system of identifying high risk parents and children, expanded case conferencing, use of designated teams and coordination of services and data collection have been initiated through this partnership. Such collaboration is seen as vital in helping to ensure that these youth and their children do not "fall between the cracks."

Significant increases in child welfare rolls over the past several years virtually guarantee a continued growth in the street youth population in Toronto (see Tables 10A - 11, Appendix 2). The promise of an expanding population of young families living without permanent homes underscores the urgent need for increased attention to this tragedy on Toronto's streets.

Contact Name:

Dr. Jack Lee, Regional Director

Toronto Public Health

Tel:(416) 392-7467

Fax:(416) 392-0713

E-mailjlee1@city.toronto.on.ca

Dr. Joyce Bernstein, Epidemiologist

Health Information & Research

Toronto Public Health

Tel:(416) 392-6788

Fax:(416) 392-7418

E-mail: jbernste@city.toronto.on.ca

Appendix 1

Agencies Participating in Young Parents No Fixed Address

Catholic Children's Aid Society

Children's Aid Society of Metropolitan Toronto

City of Toronto, Community and Neighbourhood Services

City of Toronto, Public Health

Covenant House

Jewish Family and Child Services

Evergreen Health Centre

Humewood House Association

Inner City, Youth Link

Jessie's Centre for Teenagers

Massey Centre

Hostel Services

Native and Child Family Services

Robertson House

Rosalie Hall

Ryerson University

SHOUT Clinic

St. Michael's Hospital

Street Outreach Services

Appendix 2

1. From a file review at the Children's Aid Society (CAS) - Division of Long Term Care, 1998

A profile of 41 young mothers, formerly in care of the CAS. These women were between 16 and 24 years old.

TABLE 1A:Past abuse experienced by mothers*

* Out of the 41 women, 17 experienced all 3 forms of abuse

TABLE 1B:Highest Grade Level Achieved:

Currently 17 of the 41 women are enrolled in school, 24 are not

2. From a file review at Covenant House , Profile of 41 Mothers, 1995.

TABLE 2:Past abuse experienced by mothers

3. From Hostels Division, Community and Neighbourhood Services

TABLE 3:Number of Youth Aged 16-24 Staying in a Metro Hostel, 1992-1996

4. From Second Base Youth Shelter

TABLE 4:Number of Clients Requesting Shelter, Ages 16-21, January, 1, 1994-December 31,1997

5. From City of Toronto Birth Records 1990-1995 ("Old" city of Toronto only, not Metro):

TABLE 5A:Live Births to Mothers living in Hostels

TABLE 5B:Age of Mothers Living in Toronto Shelters by Year:

6. Maternity Homes:

TABLE 6A:Number of Residential Clients Served - Rosalie Hall, 1996-1998

TABLE 6B:Selected Annual Program Statistics - Massey Centre for Women, East York

TABLE 6BB:Massey Hall, Additional Services

TABLE 6C: From Humewood Centre, York

7. Evergreen Health Centre

TABLE 7:Pregnancy and Follow up visits treated at Evergreen from 1994 to 1997 (Per 1000 visits)

8. SHOUT clinic

TABLE 8:No. Of visits with children under 5 years of age

*1996 data incomplete

9. Ontario Ministry of Health, Selected Newborn Diagnoses, 1986-1997

TABLE 9:Selected Newborn Diagnoses among babies born in Toronto

*A newborn may appear in more than one category, with the resulting effect on the total.

10. From Catholic Children's Aid Society (CCAS)

TABLE 10A:Child Admissions and Re-admissions to Care

TABLE 10B:Reasons for Admissions & Re-admissions, 1997

11. Children's Aid Society of Metropolitan Toronto

TABLE 11:Number of Children in Care, 1995-1997

Appendix 3

Sample Budget for Single Mother with One Child

INCOME:$957.00

EXPENSES:

Rent 575.00

Food 130.00

Diapers 60.00

Baby food and supplies 65.00

Telephone 30.00

Clothing 25.00

Household Supplies 20.00

Transportation 30.00

Miscellaneous 22.00

TOTAL: $957.00

References:

1. Birth registrations, 1990-1995, City of Toronto, Department of Public Health, Health Information Section.

2. Annual Program Statistics, Massey Centre, Housing and Resource Centre for Pregnant Young Women and Single Mothers, April 1, 1992 - March 31, 1997.

3. Statistical Summary, Rosalie Hall, 1996-1998.

4. Statistical Summary, Humewood House, 1995-1997

5. Summary of Utilization Statistics, Hostel Division, Community and Neighbourhood Services, 1992-1996.

6. Conditions Seen Per 1000 Visits, Evergreen Health Centre, 1994-1997.

7. Encounters with Children under 5 years of age, SHOUT Clinic, 1995-1997.

8.Case file Review, Covenant House, 1995.

9. Case File Review, Children's Aid Society of Metropolitan Toronto, 1998.

10.Child Admissions/Re-admissions, Monthly and Accumulative report on Services, Catholic Children's Aid Society, December, 1997, page 27.

11. Client Statistics, January 1, 1994 - March 23, 1998, Second Base Youth Shelter.

12.Children in Care, telephone conversation with Bruce Leslie, Children's Aid Society of Metropolitan Toronto.

13.Smart, R.G. et al (1990) Drugs, Youth, and the Street, Addiction Research Foundation.

14. Smart, R.G. (1992), Drifting and Doing, Changes in Drug Use Among Toronto Street Youth, 1990-1992, Addiction Research Foundation.

15.Fitzgerald, Michael(1995), "Homeless Youth and the Child Welfare System:Implications for Policy and Service", Child Welfare, v. 74, May/June, 1995, pp.717-730.

16. Ambrosio, E., et al, The Street Health Report, Street Health, 1992.

17.ONPHA, Quick Connections, March, 1998.

18. Personal Communication, Sheryl Pollock, City of Toronto, Housing, May 6, 1998.

19.Jessie's Housing Program, Jessie's Centre for Teenagers, October, 1997.

20. Crack Use Among Families Seen By the Children's Aid Society of Metropolitan Toronto, Metro Research Group on Drug Use, Children's Aid Society of Metropolitan Toronto, 1992.

21.Read, S., D. DeMatteo, and B. Bock (1993), HIV Prevalence in Toronto Street Youths, The Hospital for Sick Children, 1993.

22. Report of the Task Force into Illicit Narcotic Overdose deaths in British Columbia, Office of the Chief Coroner, 1994.

23.Butters, J., A. Hallgreen, and P. McGillicuddy (1997), "Poor Women and Crack Use in Downtown Toronto", Street Health and the Addiction Research Foundation.

24. Presentation to the City of Toronto Alternative Housing Subcommittee, M. Surbeck, May 30, 1997.

25.Patychuk, D., J. Phillips and D. McKeown, "Draft Report: Deaths Among the Homeless in the City of Toronto, 1979 to 1993," City of Toronto, Department of Public Health, July, 1996.

26. Focus group with former Street Youth, Toronto Dept. Of Public Health, April 6, 1998.

27.A Study of Young Mothers in Metro Toronto, Young Mothers Resource Centre, April, 1993.

28. Findlay, Sheri, Karen Leslie, Reuven Jhirad, Derek Stephens, "Pregnancy in Toronto's Street Youth," presented at the Pediatric Academic Society Meeting, New Orleans, May, 1998.

29.Lee, J., S. Gaetz, and F. Goettler, "The Oral Health of Toronto's Street Youth," Journal of the Canadian Dental Association, v. 60, #6, June/July, pp. 545-548.

30. Pennbridge, J. R. MacKenzie and A. Swofford, "Risk Profile of Homeless Pregnant Adolescents and Youth," Journal of Adolescent Health, v. 12, pp.534-538.

31.Commissioner of Community Services, "Status Report on Hostel Services", November 8. 1996, Report to the Human Services Commissioner,

32. Drug Use In Toronto, 1997, Research Group on Drug Use.

33.FAX on Drugs, "Need to Address Substance Abuse Problems in Approximately 25% of Child Welfare Cases in Metropolitan Toronto," vol. 2, No.7, Research Group on Drug Use, July 24, 1997.

34. Drug Use in Toronto, 1998, Research Group on Drug Use.

35.Radford, Joyce L., Stay in School: An Evaluation of the Ambassador Dropout Prevention Program, Toronto, Drug Abuse Prevention Centre, June, 1993.

36. Martin, Fay E., Reflection to Action: The Ambassador Program, Toronto: Drug Abuse Prevention Centre, February, 1997.

37.Killion, Cheryl M.(1995), "Special Health Care Needs of Homeless Pregnant Women," Advanced Nursing Science, vol. 18(2), pp.44-56.

38. Breaking the Cycle, The Evaluation Report, February, 1998.