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The neuropsychological functioning of men residing in a homeless shelter

Dissertation
Author: Sara Murray Hegerty
Abstract:
The number of homeless individuals in the U.S. has continued to increase, with men comprising the majority of this population. These men are at substantial risk for neuropsychological impairment due to several factors, such as substance misuse, severe mental illness, untreated medical conditions (e.g., diabetes, liver disease, HIV/AIDS), poor nutrition, and the increased likelihood of suffering a traumatic brain injury. Impairments in attention, memory, executive functioning, and other neuropsychological domains can result in poor daily functioning and difficulty engaging in psychological, medical, or educational services. Thus, knowledge of the neuropsychological functioning of homeless men is critical for those who work with this population. Yet data in this area are limited. This study aimed to describe the functioning of men residing in an urban homeless shelter across the domains of attention/concentration, memory, executive functions, language, sensory-motor abilities, general intelligence, and reading ability. Particular areas of impairment included attention, visual memory, cognitive flexibility, balance/coordination, and fine motor control. Correlational analyses found that educational background and ethnicity were linked to test performance, and the results of cluster analysis found two distinct subgroups based on neuropsychological functioning: an "average" group and a "low average/impaired" group. Caveats in interpreting test scores, particularly in the domain of language, are discussed, along with possible explanations for differences between African American and non-African American participants. Based on the findings of this study, it is recommended that clinicians and other service providers working with men residing in homeless shelters consider the possibility of neuropsychological impairment when developing treatment plans. Specific recommendations for each subgroup are discussed. Future research in this area might also explore the utility of offering skill-enhancing interventions within homeless shelters, such as workshops to improve organizational and planning skills. Further, the development of adequate norms for neuropsychological tests that are to be used with homeless individuals is recommended, given the possibility of low educational attainments and below average reading skills in this population.

iii TABLE OF CONTENTS

ACKNOWLEDGMENTS .........................................................................................

i

LIST OF TABLES .....................................................................................................

v

LIST OF FIGURES ...................................................................................................

ix

CHAPTER

I. INTRODUCTION .....................................................................................

1

Statement of the Problem ...................................................................

3

Purpose of the Study ..........................................................................

4

Definition of Terms ............................................................................

5

Importance of the Study .....................................................................

7

Note Regarding Person-First Language .............................................

7

II. REVIEW OF THE LITERATURE ..........................................................

8

Homeless Individuals in the United States ........................................

8

Factors Affecting the Neurobehavioral Status of Homeless

Individuals ..........................................................................................

17

Cognitive Functioning of Homeless Individuals ...............................

36

Neuropsychological Functioning of Homeless Individuals ...............

44

Conclusion .........................................................................................

94

III. METHOD ...............................................................................................

100

Research Design .................................................................................

100

Participants .........................................................................................

101

Instruments .........................................................................................

139

Procedure ...........................................................................................

175

iv IV. RESULTS ...............................................................................................

186

Cognitive and Neuropsychological Test Performance .......................

186

Post-Hoc Comparisons .......................................................................

248

Relationships Among Test Variables .................................................

250

Cluster Analysis .................................................................................

255

V. DISCUSSION ..........................................................................................

270

Summary of Results ...........................................................................

271

Interpretation of Results .....................................................................

275

Limitations .........................................................................................

292

Implications and Recommendations ..................................................

296

Recommendations for Shelter-Based Research .................................

305

Future Research .................................................................................

307

Conclusion .........................................................................................

308

BIBLIOGRAPHY ......................................................................................................

310

APPENDIX A ............................................................................................................

327

APPENDIX B ............................................................................................................

334

APPENDIX C ............................................................................................................

336

APPENDIX D ............................................................................................................

337

v LIST OF TABLES

Table 3.1: Participant Demographic Characteristics (N = 51)....................................

104

Table 3.2: Additional Sample Characteristics (N = 51)..............................................

106

Table 3.3: Comparisons Between African American and Non-African American Participants.................................................................................................................

108

Table 3.4: Educational Achievements of African American and non-African American Participants................................................................................................

109

Table 3.5: Current Health Concerns by Self-Report (N = 51)....................................

111

Table 3.6: Sleep-Related Concerns (N = 51)..............................................................

113

Table 3.7: Self-Reported Neurological Symptoms (N = 51)......................................

115

Table 3.8: Types of CNS Medications Reported by Participants (n = 20).................

117

Table 3.9: Comparisons Between Participants Taking and Not Taking CNS Medications.................................................................................................................

119

Table 3.10: List of Reported Medications, By Frequency (N = 51)...........................

121

Table 3.11: Description of Head Injuries (n = 43).....................................................

124

Table 3.12: Description of Loss of Consciousness (n = 43).......................................

125

Table 3.13: Psychological Disorders, Current and Lifetime, by eMINI (N = 51)......

128

Table 3.14: Number of Psychological Disorders, Current and Lifetime, by eMINI (N = 51).......................................................................................................................

130

Table 3.15: Self-Reported Adaptive Behavior Problems, Past Year (N = 51)...........

131

Table 3.16: Experiences With Homelessness in Adulthood (N = 51)........................

135

Table 3.17: Correlations: Background Factors and Length of Homelessness............

136

Table 3.18: Reasons for Current Homeless Status (N = 51).......................................

138

Table 3.19: Self-Report Symptom Assessment Results (N = 51)...............................

139

Table 3.20: Neuropsychological Tests by Functional Domain................................... 140

vi Table 4.1: WASI and WTAR Results.........................................................................

187

Table 4.2: Correlations: Sample Characteristics and Cognitive Test Performance................................................................................................................

189

Table 4.3: Racial/Ethnic Group Comparisons: WASI Estimated IQ and WTAR Score...........................................................................................................................

190

Table 4.4: Digit Span, Digit Symbol-Coding, and Letter-Number Sequencing Results.........................................................................................................................

191

Table 4.5: CPT-II Test Results...................................................................................

193

Table 4.6: Correlations: Sample Characteristics and Attention/Working Memory Test Performance........................................................................................................

195

Table 4.7: Racial/Ethnic Group Comparisons: Digit Span, Letter-Number Sequencing, and CPT-II............................................................................................. .

197

Table 4.8: Drug Use Disorder Comparisons: WAIS-III Subtests and CPT-II Confidence Index........................................................................................................

198

Table 4.9: WRAML2 Verbal Memory Results...........................................................

200

Table 4.10: WRAML2 Visual Memory Results.........................................................

202

Table 4.11: WRAML2 Screening Memory Index Results.........................................

203

Table 4.12: RCFT Memory Trial Results...................................................................

204

Table 4.13: Correlations: Sample Characteristics and Memory Test Performance................................................................................................................

206

Table 4.14: Racial/Ethnic Group Comparisons: Selected Memory Tests..................

207

Table 4.15: Boston Naming Test Results...................................................................

208

Table 4.16: Correlations: Sample Characteristics and Boston Naming Test Performance................................................................................................................

210

Table 4.17 : Boston Naming Test Performance (Raw Score) by Level of Education....................................................................................................................

212

Table 4.18: Performance on Selected BNT Items and Relationship With Reading Ability, Education.......................................................................................................

213

vii Table 4.19: Ethnic Group and Performance on Selected BNT Items.........................

214

Table 4.20: Trail Making Test Results........................................................................

215

Table 4.21: Trail Making Test: Contrast Measures, Scaled Scores...........................

218

Table 4.22: Verbal Fluency Test Results....................................................................

220

Table 4.23: Verbal Fluency Test: Contrast Measures, Scaled Scores........................

222

Table 4.24: Tower Test Results..................................................................................

223

Table 4.25: FrSBe Self-Report Results, T-scores.......................................................

224

Table 4.26: Correlations: Sample Characteristics and Trail Making Test Performance................................................................................................................

226

Table 4.27: Correlations: Sample Characteristics and Verbal Fluency Test Performance................................................................................................................

228

Table 4.28: Correlations: Sample Characteristics and Tower Test Performance.......

230

Table 4.29: Correlations: Sample Characteristics and FrSBe Results........................

232

Table 4.30: Correlations: DKEFS Test Performance and Self-Rated Executive Functioning.................................................................................................................

234

Table 4.31: Drug Use Disorder Comparisons: Verbal Fluency Tests and Executive Dysfunction Scale...............................................................................

236

Table 4.32: RCFT Copy Trial Results........................................................................

237

Table 4.33: Correlations: Sample Characteristics and RCFT Copy Task Performance................................................................................................................

239

Table 4.34: D-WSMB Sensory Tests Results: W-Diff Scores and Impairment Categories...................................................................................................................

241

Table 4.35: D-WSMB Motor Tests Results: W-Diff Scores and Impairment Categories...................................................................................................................

243

Table 4.36: Grooved Pegboard Test Results..............................................................

245

Table 4.37: Correlations: Sample Characteristics and Sensory-Motor Test Performance................................................................................................................

247

viii Table 4.38: Comparisons Between Participants With and Without Drug Use Disorders (DUD)........................................................................................................

249

Table 4.39: Correlations: Cognitive Ability and Performance on Select Neuropsychological Tests...........................................................................................

251

Table 4.40: Correlations: Symptomatology and Performance on Select Neuropsychological Tests...........................................................................................

252

Table 4.41: Intercorrelations Among Neuropsychological Tests...............................

253

Table 4.42: Comparison of Clusters on Cognitive and Neuropsychological Tests....

259

Table 4.43: Comparison of Clusters on Demographics, Background Characteristics, and Symptoms (Continuous Variables)............................................

264

Table 4.44 Comparison of Clusters: Demographics, Background Characteristics, and Symptoms (Categorical Variables).............................................

265

ix LIST OF FIGURES

Figure 4.1: Comparison of Cluster 1 (n = 38) and Cluster 2 (n = 13), in terms of performance on cognitive and neuropsychological tests.................................................261

1 CHAPTER I INTRODUCTION

Homelessness is not a new issue in the United States. For the past several decades, researchers and clinicians have been working to find answers to some very basic questions: What causes homelessness? Who is more likely to become homeless? Why do some people become “chronically” homeless? and What can we do to solve this problem? Research suggests that economic factors are often involved in the onset and continuation of homelessness, such as low wages, high unemployment rates, and a decline in low-cost housing (Milwaukee Continuum of Care, 2007; Koegel, Burnam, & Baumohl, 1996; The United States Conference of Mayors – Sodexho, Inc., 2006). Yet not all people who experience these conditions become homeless. Substance abuse/dependence, psychiatric disorders, and physical illness are all highly prevalent in the homeless population, compared to the general public (e.g., Koegel et al., 1996; Koegel, Sullivan, Burnam, Morton, & Wenzel, 1999; Reardon, Burns, Preist, Sachs-Ericsson, & Lang, 2003; Silver & Felix, 1999; Toro et al., 1995); however, whether these factors are causes or consequences of homelessness is unclear. The presence of a substance use or mental health disorder alone does not necessarily cause one to become homeless. It seems likely that the pathway to homelessness is built through person-environment interactions. One component of these person-environment interactions is neuropsychological functioning. Individuals who are homeless are often malnourished, which can produce short-term neuropsychological impairment (Silver & Felix, 1999). Compounding the situation is the longer-term neuropsychological impairment that can result from poorly managed chronic illnesses such as diabetes or HIV/AIDS, which are prevalent in the

2 homeless population (Falk, 2006; Silver & Felix, 1999). Also prevalent in this population are substance misuse and mental health disorders (e.g., Falk, 2006; Silver & Felix, 1999), and the neuropsychological sequelae of these conditions can be widespread and, in some cases, permanent (e.g., Knight & Longmore, 1994). The situation can be dire for those individuals with both psychiatric and substance use disorders, as they are often in very poor physical health, perhaps due to the multiple negative effects of alcohol and drugs on the body (e.g., Brust, 2004; Struening & Padgett, 1990). In addition to these factors, life on the streets or in shelters can be dangerous, as evidenced by the high rates of physical assault and traumatic brain injury in this population (Silver & Felix, 1999). Thus, individuals who are homeless are vulnerable to neuropsychological impairment on several fronts. While it seems logical – and intuitive – that some people who are homeless would evidence signs of cognitive or neuropsychological impairment, there has been very little empirical research to support this idea. For those who work with or develop programs for people who are homeless, this information is important. For example, research suggests that deficits in attention, concentration, and executive functioning are linked to health risk behavior (Hall, Elias, & Crossley, 2006). Further, psychotherapy and other types of psychosocial interventions are said to be learning situations that require attention, memory, problem solving, and abstract thinking (Fals-Stewart, Schafer, Lucente, Rustine, & Brown, 1994). At a very basic level, organized, planful thinking and goal-setting are necessary skills for managing money, running a household, and maintaining employment. Professionals who work with this population need to know which areas of neuropsychological functioning are likely to be impaired or are vulnerable to impairment.

3 Such information can be used to identify needed services and develop interventions tailored to the capacities of the individual. Further, a more accurate understanding of the lives of homeless persons can help improve the quality of interaction between provider and client by reducing inaccurate assumptions and stereotypes about the homeless (Backer & Howard, 2007). Thus, obtaining information about the neuropsychological functioning of homeless individuals is an important area of research with several useful applications. Statement of the Problem Currently, our knowledge of the neuropsychological functioning of homeless individuals is limited to a handful of studies based on the performance of less than 600 individuals who have experienced homelessness (Cotman & Sandman, 1997; Douyon et al., 1998; Duerksen, 1995; Foulks, McCown, Duckworth, & Sutker, 1990; Gonzalez, Dieter, Natale, & Tanner, 2001; Lo, 2001; Seidman et al., 1997; Solliday-McRoy, Campbell, Melchert, Young, & Cisler, 2004; Zlotnick, Fischer & Agnew, 1995). These studies have varied in terms of sample characteristics, instruments used, and coverage of the various domains of neuropsychological functioning. Even the definition of “homeless” is of concern when synthesizing the findings across several studies; some researchers have chosen to take a categorical approach (homeless vs. not homeless; sheltered vs. roofless) while others have utilized a continuous approach (e.g., length of homelessness). There may be important differences between individuals who have had one short episode of homelessness in his or her lifetime, and those who have been continuously homeless for several years. However, the extant research does not answer the question of how these groups may differ in terms of neuropsychological functioning.

4 Despite these drawbacks, research into the neuropsychological functioning of homeless individuals has produced some important initial findings. Although not found across the entire homeless population, there are at least some subgroups of homeless individuals who have anywhere from mild to severe deficits in various domains of neuropsychological functioning. A tentative conclusion from these data is that individuals who are or have been homeless may be more likely than non-homeless individuals to evidence impairments in attention span, processing speed, sustained and selective attention, verbal memory, prose recall, visuospatial memory, expressive language, motor- sensory functioning, and domains of executive functioning. However, some of these domains have been more extensively researched than have others. The domain of attention has been the most extensively examined in this population (Cotman & Sandman, 1997; Duerksen, 1995; Foulks et al., 1990; Gonzalez et al., 2001; Lo, 2001; Seidman et al., 1997; Solliday-McRoy et al., 2004), followed by memory and executive functions (Duerksen, 1995; Foulks et al., 1990; Gonzalez et al., 2001; Lo, 2001; Seidman et al., 1997; Solliday-McRoy et al., 2004). On the other hand, the areas of language and motor-sensory functions have received little attention. Further, some homeless individuals have performed in the average range on neuropsychological tests (e.g., Cotman & Sandman, 1997; Foulks et al., 1990; Zlotnick et al., 1995). These mixed results point to a need for further research. Purpose of the Study The purpose of the current study is to describe the neuropsychological functioning of a sample of men who are currently homeless and receiving services through the Guest

5 House of Milwaukee (GHOM), a comprehensive social services agency that also provides emergency shelter services. Three research questions will guide this study: 1. What do the results of a neuropsychological assessment battery reveal about the neuropsychological functioning of men who are homeless, specifically in the domains of attention, memory, language, motor-sensory abilities, and executive abilities? 2. How does neuropsychological functioning relate to the background/ demographic variables, psychosocial variables, and psychiatric diagnosis issues for these men? 3. Can men who are homeless be divided into subgroups on the basis of their neuropsychological functioning, and if so, what characterizes these subgroups? Definition of Terms Homeless In this study, “homeless” and “homelessness” are defined according to the Stewart B. McKinney Act (1987): (1) An individual who lacks a fixed, regular, and adequate nighttime residence; and (2) 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 mentally ill); (b) an institution 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, a regular sleeping accommodation for human beings.

Specific examples of living or sleeping arrangements that fit this definition include (1) staying in emergency shelters; (2) sleeping in places such as cars, parks, sidewalks, or abandoned buildings; or (3) transitional or supportive housing, when the individual came

6 from the streets or a shelter. Further, individuals who spend less than thirty days in an institution but typically sleep in shelters or other arrangements listed above are also considered homeless. “Episodes” of homelessness are defined in accordance with other research with this population (e.g., Kuhn & Culhane, 1998). An instance of homelessness must be separated by at least thirty days from another instance of homelessness in order to be classified as a unique episode. Neuropsychological Functioning Neuropsychology is defined as the study of brain-behavior relationships. In this study, neuropsychological functioning is based on the following: 1. Attention and concentration, as measured by the Conners’ Continuous Performance Test II (CPT-II; Conners & MHS Staff, 2000) and the Digit Span and Digit Symbol subtests of the Wechsler Adult Intelligence Scale – Third Edition (WAIS-III; The Psychological Corporation, 1997). 2. Working memory, as measured by the Digit Span and Letter-Number Sequencing subtests of the WAIS-III. 3. Construction ability, based on scores from the Copy trial of the Rey Complex Figure Test (RCFT; Meyers & Meyers, 1995). 4. Visual and verbal memory, as measured by the Visual and Verbal indices of the Wide Range Assessment of Memory and Learning – Second Edition (WRAML2; Sheslow & Adams, 2003) and the Immediate and Delayed Recall trials of the RCFT.

7 5. Language functioning, as measured by the Boston Naming Test (BNT; Goodglass, Kaplan, & Barresi, 2000). 6. Executive functioning, based on Trail Making, Verbal Fluency, and Tower tests from the Delis-Kaplan Executive Function System (D-KEFS; The Psychological Corporation, 2001), and the self-report version of the Frontal Systems Behavior Scale (FrSBe; Grace & Malloy, 2001). 7. Motor-sensory functioning, as measured by the Grooved Pegboard test (Lafayette Instrument Company, 2002) and selected subtests of the Dean- Woodcock Sensory Motor Battery (D-WSMB; Dean & Woodcock, 2003). Importance of the Study The importance of this study is twofold. First, the results will add to the normative databases for the tests used in the study. This is important given the limited normative data available for psychologists working with individuals who are homeless. Second, the information regarding the neuropsychological functioning of homeless men in shelter can be used to develop clinical and programmatic recommendations. It is believed that these recommendations could lead to improved services for homeless men in shelter. Note Regarding Person-First Language Person-first language has been used wherever possible in this document (i.e. “individuals who are homeless” versus “homeless individuals”). However, in some cases the nature of writing is such that a “shortened” phrase is preferred. In those cases where phrases such as “homeless individuals,” “homeless persons,” or “homeless men” are used, it should be noted that this has been done for writing style purposes and not to diminish the personhood of individuals who experience homelessness.

8 CHAPTER II REVIEW OF THE LITERATURE

Individuals who are homeless tend to be a heterogeneous group, with some experiencing short episodes of homelessness and others spending extended periods of time on the streets or in shelters. Research and programmatic efforts over the past several decades have aimed to understand the causes and consequences of homelessness in order to better serve this population. A primary focus of these efforts has been on the substance use and mental health concerns of homeless individuals. At the same time, it has been suggested that therapy – and perhaps psychosocial services in general – is a type of learning situation, one that requires cognitive and neuropsychological skills such as attention, memory, problem solving, and abstract thinking (Fals-Stewart et al., 1994, p. 756). Such skills can be impaired by the use of drugs/alcohol and the presence of mental and/or medical illnesses, all of which are concerns frequently found among homeless individuals. This review will discuss the current research on homelessness in the United States and factors that increase the likelihood of neurobehavioral impairment among homeless individuals, as well as critically review the empirical research regarding the cognitive and neuropsychological functioning of homeless individuals. Homeless Individuals in the United States Demographics Homelessness in the United States is a widespread problem and a national concern, as evidenced by the Bush Administration’s goal to end chronic homelessness by the year 2012 (McCarty, 2005). Estimating the number of people in the U.S. who are considered homeless is a difficult task. In 2005, 744,313 people were estimated to be

9 homeless at one point in time (National Coalition for the Homeless, 2007). Period prevalence counts, which estimate the number of homeless over a given period of time, suggest that approximately 3.5 million individuals in the U.S. will be homeless in a given year (National Coalition for the Homeless, 2007). These data were gathered from surveys of service providers in 1996; more recent statistics indicate that the homeless population in the U.S. is anywhere between 600,000 to 2.5 million persons (McCarty, 2005). Due to the reliance on shelters and service providers to count homeless persons, it is likely that these numbers underestimate the actual number of homeless people (National Coalition for the Homeless, 2007). Although an accurate period prevalence count is difficult to obtain, researchers have concluded that there has been a dramatic increase in the number of homeless persons in the U.S. over the past twenty years (National Coalition for the Homeless, 2007). The composition of the homeless population has been changing over the past several years (The United States Conference of Mayors – Sodexho, Inc., 2006; National Coalition for the Homeless, 2007), with more children and families experiencing homelessness. However, adult men continue to make up the majority of the homeless population. In the 2006 U.S. Conference of Mayors Hunger and Homelessness Survey, men comprised 51% of the homeless population across twenty-three major U.S. cities, and single women were estimated to make up 17% of the homeless population. Survey results also indicated that the U.S. homeless population is predominantly African American (42%) and Caucasian (39%), and that individuals remain homeless for eight months on average.

10 The homeless population in Milwaukee, Wisconsin, closely mirrors these national figures. A point-in-time count in 2007 estimated that there are 1,470 homeless adults and children on a given day in the city of Milwaukee (Milwaukee Continuum of Care, 2007). Survey data from a portion of this group indicated that nearly one third are between the ages of 41-50 (30.8%), and one in four is under the age of 30 years old. However, those considered to be “chronically” homeless tended to be older. The majority of Milwaukee’s homeless are men (55%), and nearly three-fourths of the chronically homeless are men. African Americans are over-represented among the homeless in Milwaukee (61.8% compared to 40.2% of the general population in Milwaukee). In terms of episodes of homelessness, the majority of Milwaukee’s homeless have at least one or two previous episodes of homelessness, and 80% of the chronically homeless have been homeless for longer than one year. While most individuals surveyed had spent the last night in a shelter or transitional housing, one-third were identified as unsheltered. Causes of Homelessness Research into the causes of homelessness has suggested myriad reasons. Two broad trends over the past two decades have received a great deal of attention: the decline in low-cost housing and increasing numbers of individuals living at or below the poverty line (Koegel, et al., 1996). Other economic factors that are cited as causes of homelessness are low wages and unemployment (e.g., The United States Conference of Mayors – Sodexho, Inc., 2006; Milwaukee Continuum of Care, 2007). In addition, certain risk factors have also been suggested, namely severe and disabling mental illness and substance abuse (Koegel et al., 1996). Certain early life conditions, such as physical or sexual abuse, parental mental illness or substance abuse, and time spent in out-of-home

11 placements, have also been tentatively linked to homelessness in adulthood (Koegel et al., 1996). Recent research tends to fall in line with these ideas. The majority of community- based providers surveyed for the 2006 U.S. Conference of Mayors study reported that mental illness coupled with a lack of needed services was the main cause of homelessness, followed by lack of affordable housing and substance abuse problems. A survey of homeless adults in the city of Milwaukee found that the most common responses to the cause of homelessness question were unemployment and low wages, eviction or loss of place to stay (i.e. with friends/family), drug/alcohol problems, and family breakup (Milwaukee Continuum of Care, 2007). Adults in Milwaukee classified as “chronically” homeless were more likely to cite drug/alcohol problems and mental illness as reasons for becoming homeless. While the statistics suggest that economic factors, drugs/alcohol, and mental illness are among the more common causes of homelessness, it is unclear as to how these factors interact. For example, it has been suggested that mental illness and substance abuse might precede homelessness – and thus be considered a causal factor – or be consequences of homelessness (Koegel et al., 1996). While research on the causes of homelessness is ongoing, there is a wealth of information on the problems faced by homeless adults in the U.S. Epidemiology Mental Illness As previously mentioned, mental illness has long been considered a concern and possible cause of homelessness in the United States (Koegel, et al., 1996). Older

12 estimates suggested that 20-25% of homeless persons had at one point suffered from a severe or disabling mental illness, such as schizophrenia or bipolar disorder (Koegel et al., 1996). More recent estimates suggest that 16% of homeless individuals have mental health problems (The United States Conference of Mayors – Sodexho, Inc., 2006). In the city of Milwaukee, 33% of homeless individuals interviewed self-reported a history of mental illness (Milwaukee Continuum of Care, 2007), while Solliday-McRoy et al. (2004) found that 50% of their sample of adults from a men’s homeless shelter in Milwaukee had received some form of mental health treatment in the past. A large-scale study in Colorado comparing formerly homeless and never homeless adults found that 47.3% of the formerly homeless had a DSM-III diagnosis in the past year, compared to 23% of the never homeless group (Reardon et al., 2003). Toro and colleagues (1995) also found that currently homeless individuals scored higher than did formerly homeless and never-homeless poor individuals in the areas of depression, anxiety, and paranoid ideation. Commonly found DSM-III diagnoses have been schizophrenia, mood disorders, dementia, and antisocial personality (Fischer & Breakey, 1991). More recently, Solliday-McRoy et al. found that nearly 30% of adult homeless men had received treatment for a mood disorder in the past. High rates of posttraumatic stress disorder have also been found among the homeless (North & Smith, 1992). Substance Misuse The prevalence of substance abuse among the homeless has long been studied, and is believed to be even more common than mental illness (Koegel et al., 1996). The most recent U.S. Conference of Mayors survey (2006) estimated that 26% of homeless individuals abuse drugs or alcohol. In one major U.S. city, approximately 59% of

13 homeless adults had received a diagnosis of alcohol dependence sometime in their life, with men comprising 64% of this group, and more men than women had currently met diagnostic criteria for alcohol or drug dependence (Koegel, et al., 1999). However, formerly homeless women have been found to have higher rates of alcohol disorders than never-homeless women (Reardon et al., 2003). A lifetime diagnosis of substance abuse has also been found to be more common among currently and formerly homeless individuals, compared to the never-homeless poor (Toro et al., 1995). Sixty percent of homeless individuals surveyed in the city of Milwaukee reported having problems with drugs or alcohol (Milwaukee Continuum of Care, 2007), and Solliday-McRoy et al. (2004) found that 93% of their Milwaukee-based participants had a history of substance abuse or dependence. Research also indicates that co-occurring mental health and substance use disorders are prevalent among the homeless (e.g., Drake, Osher, & Wallach, 1991; Reardon et al., 2003). While little information exists regarding the specific “drugs of choice” of homeless individuals, Solliday-McRoy et al. (2004) found that the majority of homeless men had a history of polysubstance abuse/dependence (74%), followed by cocaine (11%) and alcohol (7%). Health Problems Physical health problems are considered to be both a cause and consequence of homelessness (Wright, 1990). Conditions found in higher rates among the homeless include upper respiratory infections, malnutrition, hypertension, peripheral vascular disease, seizures, anemia, and liver disease (Silver & Felix, 1999; Wright, 1990). Other common conditions in this population include AIDS/HIV, tuberculosis, and diabetes

Full document contains 349 pages
Abstract: The number of homeless individuals in the U.S. has continued to increase, with men comprising the majority of this population. These men are at substantial risk for neuropsychological impairment due to several factors, such as substance misuse, severe mental illness, untreated medical conditions (e.g., diabetes, liver disease, HIV/AIDS), poor nutrition, and the increased likelihood of suffering a traumatic brain injury. Impairments in attention, memory, executive functioning, and other neuropsychological domains can result in poor daily functioning and difficulty engaging in psychological, medical, or educational services. Thus, knowledge of the neuropsychological functioning of homeless men is critical for those who work with this population. Yet data in this area are limited. This study aimed to describe the functioning of men residing in an urban homeless shelter across the domains of attention/concentration, memory, executive functions, language, sensory-motor abilities, general intelligence, and reading ability. Particular areas of impairment included attention, visual memory, cognitive flexibility, balance/coordination, and fine motor control. Correlational analyses found that educational background and ethnicity were linked to test performance, and the results of cluster analysis found two distinct subgroups based on neuropsychological functioning: an "average" group and a "low average/impaired" group. Caveats in interpreting test scores, particularly in the domain of language, are discussed, along with possible explanations for differences between African American and non-African American participants. Based on the findings of this study, it is recommended that clinicians and other service providers working with men residing in homeless shelters consider the possibility of neuropsychological impairment when developing treatment plans. Specific recommendations for each subgroup are discussed. Future research in this area might also explore the utility of offering skill-enhancing interventions within homeless shelters, such as workshops to improve organizational and planning skills. Further, the development of adequate norms for neuropsychological tests that are to be used with homeless individuals is recommended, given the possibility of low educational attainments and below average reading skills in this population.