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Objectives. We investigated the links between homelessness associated with serious mental and physical healthy disparities and adverse childhood experiences (ACEs) in nationally representative data, with Axis I and II disorders as potential mediators.
Methods. We examined data from the National Epidemiologic Survey of Alcohol and Related Conditions in 2001-2002 and 2004-2005, and included 34 653 participants representative of the noninstitutionalized US population who were 20 years old or older. We studied the variables related to 4 classes of Axis I disorders, all 10 Axis II personality disorders, a wide range of ACEs, and a lifetime history of homelessness.
Results. Analyses revealed high prevalences of each ACE in individuals experiencing lifetime homelessness (17%-60%). A mediation model with Axis I and II disorders determined that childhood adversities were significantly related to homelessness through direct effects (adjusted odd ratios = 2.04, 4.24) and indirect effects, indicating partial mediation. Population attributable fractions were also reported.
Conclusions. Although Axis I and II disorders partially mediated the relationship between ACEs and homelessness, a strong direct association remained. This novel finding has implications for interventions and policy. Additional research is needed to understand relevant causal pathways. (Am J Public Health. 2013;103:S275-S281. doi:10.2105/AJPH.2013.301323)
Homelessness is a serious societal problem. Approximately 12% to 14% of adults in the United States report a history of homelessness. 1-3 In addition to poverty, homelessness has been associated with the deterioration of mental and physical health, social isolation, and exposure to traumatic events.4-6 Furthermore, those who have experienced homelessness have significantly elevated mortality rates and high rates of suicidal behavior.7,8 Worldwide, homelessness has been found to be overrepresented in men and those groups that traditionally experience discrimination.2
Although systemic societal factors (e.g., lack of affordable housing) affect how many individuals are homeless at any given time, demographic characteristics and life histories put specific individuals at risk for this detrimental experience.9 Childhood adversities are found to be substantially overrepresented in homeless samples, and a history of childhood adversity has been related to particularly poor outcomes among the homeless.9,10 Previous research, however, has a number of limitations. Nearly all studies used interview methodology of currently sheltered homeless or clinical populations, who might have elevated risk factors or be chronically homeless.10,11 These studies generally lacked a suitable sociodemographic comparison group...