Community-Built Occupational Therapy Services for Those Who Are Homeless

Home , Occupational apartheid, Occupational injustice

Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. Community-Built Occupational Therapy Services for Those Who Are Homeless

Winifred Schultz-Krohn, PhD, OTR/L, BCP, SWC, FAOTA and Urban Development [HUD], 2017). Although there is no Professor and Chairperson of Occupational Therapy definitive cause of homelessness, the National Coalition for San Jose State University the Homeless (2009) reported that substance abuse; mental San Jose, CA illness; domestic violence; and recent economic factors, such as decreases in public assistance programs and loss of jobs, are the Quinn Tyminski, OTD, OTR/L most prevalent causes of homelessness. Homelessness has been Occupational Therapist identified as an issue within the United States for more than 8 Washington University in St. Louis decades, but the composition of the homeless population has St. Louis, MO changed dramatically in the past 40 years. In the 1950s to 1970s, the overwhelming majority of those who were homeless were This CE Article was developed in collaboration with AOTA’s single men (Burt et al., 2001). During the 1980s, more families Home & Community Health Special Interest Section. were experiencing homelessness, and currently more than a third (35% to 37%) of the homeless population are members of homeless families (National Alliance to End Homelessness, ABSTRACT 2018). This change in the homeless population created the need More than 500,000 people experience homelessness on any for new services and supports. In 2017, approximately 65% of given night in the United States (U.S. Department of Hous- the total homeless population was living in emergency shelters ing and Urban Development, 2017). Even with the large need or transitional housing programs, and more than 184,000 were for services to support occupational engagement, health, and homeless individuals in families with children (HUD, 2017). well-being, the National Coalition for the Homeless (2009) Nearly 30% of the total sheltered homeless population is indi- reported that the majority of homeless individuals have access to viduals in homeless families (HUD, 2017). Homeless families few supportive services. Individuals experiencing homelessness typically consist of a single mother younger than 30 years of often do not have access to housing, health-related, or trans- age and with two or three children younger than 5 years of age portation resources, and are not provided education for health (Bassuk Center on Homeless and Vulnerable Children & Youth, maintenance, skills attainment, or home management. Often, 2015). Homeless mothers experience higher levels of mental underserved populations are not covered by traditional medical health issues, poor physical health, increased stress, loss of or educational services, yet they still have occupational needs. social supports, and deterioration of parental roles than housed This article outlines the theoretical foundation for occupational low-income mothers (Helfrich et al., 2006; Schultz-Krohn et al., therapy treatment for homeless individuals as well as treatment 2006). options for occupational therapy practitioners working with this Even with the large need for services to support occupational population. engagement, health, and well-being, the National Coalition for the Homeless (2009) reported that the majority of homeless LEARNING OBJECTIVES individuals has access to few supportive services. Individuals After reading this article, you should be able to: experiencing homelessness often do not have access to housing, 1. Identify barriers preventing full occupational engagement health-related, or transportation resources and are not provided among various populations experiencing homelessness with education for health maintenance, skills attainment, or 2. Discuss the role of occupational therapy within the homeless home management. Although many organizations exist within population the community to provide health care and supportive services 3. Identify the differences between community-based and com- to people without housing, the lack of funding for these services munity-built services results in strict inclusion criteria, long wait times, and stringent 4. Identify the occupational needs of various subgroups in the availability (National Alliance to End Homelessness, 2017). homeless population Other barriers to accessing services for individuals experiencing homelessness include lack of transportation to attend appoint- INTRODUCTION ments, job interviews, or educational classes outside of their More than 500,000 people experience homelessness on any immediate area; poor literacy skills, resulting in the inability given night in the United States (U.S. Department of Housing to complete necessary paperwork; lack of material resources

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(e.g., telephone access); and concern about stigma from staff at occupational participation because of race, religion, and/or support organizations (National Alliance to End Homelessness, sexual orientation are examples of occupational apartheid. 2017; Roy et al., 2017). Occupational imbalance refers to excessive engagement in one Research findings have indicated that individuals experi- occupation or group of occupations to the exclusion of other encing homelessness are provided with limited opportuni- occupations. This imbalance can compromise health, such as ties to engage in meaningful occupations and therefore have when parents need to work two to three jobs to support the decreased health outcomes, social interactions, and well-being family. Occupational alienation is when individuals or pop- (Glass et al., 2006). The element of personal choice is essential ulations are not able to engage in meaningful activities and to deriving meaning from occupations, yet the institutional instead engage in tasks whose requirements do not reflect nature of the homeless shelter environment requires individuals their full capabilities. An example of occupational alienation seeking services to abide by strict curfews, mealtime sched- could be when a woman living on the streets rummages ules, and mandatory check-ins, resulting in few opportunities through garbage cans to find plastic bottles to recycle for cash. to make choices about occupational participation (Glass et al., Occupational deprivation is a common form of occupational 2006). Additionally, one study attributed the high prevalence of injustice where illness or disability prohibits engagement substance abuse within the homeless population to the minimal in meaningful occupations. An example could be when a opportunities available for occupational engagement (Brad- musician with severe arthritis is no longer able to play the ley et al., 2011). Similarly, homeless shelters do not provide piano. Occupational marginalization is the injustice seen when opportunities for functional skill development (Illman et al., everyday options or choices are not available to every member 2013). Based on the current literature available, it is evident that of the society or community. An example could be persistent within the homeless population many barriers exist that prevent gender roles that restrict an individual’s options. full engagement in meaningful occupations, therefore requiring Occupational therapy services are continuing to evolve to occupation-based intervention services. meet the occupational needs of an ever-expanding number of client groups. The American Occupational Therapy Associa- THEORETICAL FOUNDATION tion’s (AOTA’s) Vision 2025 calls for the profession to “maximize The model of occupational justice was described by Townsend health, well-being, and quality of life for all people, populations, and Wilcock (2004) as a right of all individuals to participate in and communities” (AOTA, 2017, p. 7103420010p1). To help meaningful everyday occupations. The concept of occupational achieve this vision, practitioners can identify not only the occu- justice was built on a foundation of client-centered services, pational needs of current groups served, but also the needs of engagement in occupations as health promoting, and social underserved people, populations, and communities. justice. Specific elements of occupational justice include the concepts of enabling fairness and equal opportunity, removing Community Built, Not Community Based discriminatory practices that are based on age or other factors, a When attempting to address the occupational needs of new clear commitment to universal design, and providing a contex- and underserved populations and communities, a commu- tual position that enables everyone to individually flourish as nity-built model offers guidance and structure. Although a member of a community. Marginalized populations seldom many occupational therapy services are provided within have opportunities to engage in meaningful occupations, and a community-based setting, there is a distinct difference this is where occupational therapy services can diminish the between a community-based and a community-built model of occupational injustices by facilitating occupational participation service delivery (Schultz-Krohn, 2012). In a community-based (Townsend & Whiteford, 2005; VanLeit et al., 2006). model, the occupational therapist determines what services Although occupational justice is often compared to social will be provided and the frequency of services. Although the justice, it is considered a distinct entity (Stadnyk et al., 2010). services are physically provided within a community setting, Where social justice uses the lens of social relationships and presumably close to the client’s living situation, the control citizenry, occupational justice focuses on engaging and partic- and focus of the services primarily lies with the practitioners. ipating in occupations to support health and well-being. When This model is contrasted with a community-built model, which occupational engagement is diminished or compromised, occu- begins with an occupational analysis of needs within the set- pational injustices are seen (Durocher et al., 2014). ting (i.e., people, populations, community) and is a collabo- Durocher and colleagues (2014) outlined five distinct forms rative effort (Elliot et al., 2001; Herzberg & Finlayson, 2001). of occupational injustice that can serve as a guide to provide The foundation of community-built services is clearly aligned occupational therapy services to underserved populations and with AOTA’s Vision 2025 to promote “health, well-being, and communities. Occupational apartheid is the form of occupa- quality of life.” The control for determining services’ focus, tional injustice encountered when specific groups of people frequency, and outcome is located in the population and/ are restricted from occupational pursuits because of personal or community and derived through collaborative interac- characteristics. Societies and communities that prohibit tions. This allows the services to meet occupational needs

CE-2 ARTICLE CODE CEA0618 JUNE 2018 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. prioritized by the recipients of services, combined with the ness of occupational therapy services in shelters to develop expertise of occupational therapy practitioners. This does work readiness skills (Thomas, Gray, & McGinty, 2011). require careful balancing of various community partners and However, occupational therapy practitioners are addressing occupational concerns. When providing services to home- the need to help homeless parents with children transition to less families residing in an emergency shelter, for example, work. In a program involving faculty and students from San practitioners need to consider not only the occupational Jose State University (SJSU), for example, a family shelter priorities of the parents and children, but also the priorities runs work readiness programs for all parents at the shelter. and mission of the shelter (Schultz-Krohn, 2009). The foun- Parents design individual goals related to work readiness dation of this approach is broadly client-centered to simulta- skills, and programs are developed to help them reach those neously engage all participants. goals, which include expanding job search skills, developing a résumé, or improving interviewing skills, which are often INTERVENTIONS FOR INDIVIDUALS IN A HOMELESS SHELTER particularly useful if the parent has been incarcerated. Parents Along with always allowing their clients to embody the role have reported that the individual and group support has been of the “expert” in being homeless, occupational therapy critical in taking the initial steps to finding employment. practitioners providing interventions within the homeless population must focus on increasing occupational engage- INTERVENTION FOR PARENTS ment through large-scale environmental modification and Homelessness entails specific and unique risk factors that occupational exploration (Illman et al., 2013). Interventions make effective parenting especially difficult, including pro- addressed at a personal and institutional level may achieve the viding a safe and stable home for children to learn and play greatest effect on occupational performance. Institutionally, (David et al., 2012; Schultz-Krohn, 2004). Over the last sev- occupational therapists can assist in reviewing shelter policies, eral years, occupational therapists have responded to the crisis such as intake processes, curfews, and access to resources, to in homelessness by developing interventions and research integrate occupational engagement and the safety of all staff to explore how to facilitate the occupational participation of and residents. On an individual level, practitioners can address homeless individuals (Grandisson et al., 2009; Herzberg et al., occupational engagement through group and individual 2006; Roy et al., 2017; Thomas, Gray, & McGinty, 2011). For skill-building opportunities, as well as community-based expe- example, because homeless parents experience high stress and riences that explore free and local resources (e.g., libraries, a lack of leisure time, it would be valuable to offer occupa- museums, parks). tional therapy craft groups to parents living in a homeless As an example of skill-building group intervention, Helfrich shelter. Studies have shown that engaging in crafts offers par- and colleagues (2006) described a 4-week module consisting ticipants a vehicle for choice, provides purpose, restores the of four individual and four group interventions targeted solely balance between work and leisure, encourages the construc- at addressing skills for employment. Group sessions focused on tion of new routines and roles, and reduces stress (Adams- identifying career interests, searching for jobs, and developing Price & Steinman, 2007; Griffiths, 2008; Thomas, Gray, pre-employment skills and skills for maintaining a job. Individ- McGinty, & Ebringer, 2011). To meet this need, SJSU occu- ual sessions were designed to supplement the group material pational therapy faculty and students provide low- to no-cost and encourage self-exploration of job interests and skills. Other craft activities that are free for participants. Participants group-based interventions described in the occupational therapy receive the materials and instruction on how to complete the literature for this population include creating a client advisory project. During the group, the occupational therapy graduate board within a homeless shelter; implementing art and drama students and faculty member identify the process of planning classes to improve socialization and self-concept; and imple- the project, collecting needed materials, beginning the project, menting a structured life skills module designed to address monitoring progress, and completing the project. This process hygiene, clothing care, money management, leisure, and work to some degree mirrors the actions needed to find housing or (Fieldhouse et al., 2011; Herzberg & Finlayson, 2001; Shoredike employment and helps participants develop related skills. In & Howell, 2002). participating in such projects, parents (typically the mothers have shown the most interest in participating) have formed INTERVENTIONS FOR FAMILIES supportive relationships with other group members and have Homeless families comprise nearly half of the total sheltered encouraged each other in job and housing searches. homeless population (HUD, 2017), and like the homeless Shelters provide basic needs for parents and their families population in general, parents within these families face but often have a negative effect on parental authority and add various barriers to obtaining employment that occupational stressors to the maternal role (Roy et al., 2017; Schultz-Krohn, therapy practitioners can help address (Lloyd & Bassett, 2012). 2004, 2009). The role of occupational therapy is to establish Although the profession has a history of working with the or re-establish occupations. This includes parenting and infant homeless, there is limited research addressing the effective- occupations (Mindell et al., 2018). Occupational therapy

JUNE 2018 ARTICLE CODE CEA0618 CE-3 Continuing Education Article Download the CE Exam Click here to purchase and take the exam for CE credit. practitioners are able to teach mothers how to use infant pre-employment, job finding, and job maintenance skills massage to enhance their roles as caregivers. Infant massage is through activity- and discussion-based groups. Feedback from known to decrease levels of stress, improve depressive moods, the participants and staff at the shelter noted that interven- increase confidence levels in parenting, and enhance bonding tions were effective in creating job skills for future employ- (Cheng et al., 2011; Feijó et al., 2006). Infant massage is also a ment (Helfrich & Rivera, 2006). safe and cost effective intervention for both mothers and their infants (Feijó et al., 2006; Mindell et al., 2018). In the program CASE EXAMPLE: FAMILY “A” designed collaboratively by SJSU and a local family shelter, The “A” family was a two-parent family living in a small infant massage was taught to mothers on a weekly basis, with an apartment with two young boys, one in first grade and the emphasis on how to incorporate the massage strokes into daily other in a Headstart preschool program. The father was a day routines, such as bedtime, bath time, and meals. Additional laborer, often working 7 days a week, and the mother worked weekly parenting groups were held to foster and support posi- at a convenience store for fewer than 20 hours per week. tive parenting approaches to manage behaviors, establish family The school-aged boy had asthma and the youngest boy had fun routines using no-cost or low-cost games and activities, and developmental delays. The father had a history of drug abuse teach stress management techniques that could be used with the as a teenager and had been incarcerated in juvenile hall after entire family. a conviction for selling a controlled substance. He had not completed high school and did not have a general education INTERVENTIONS FOR DOMESTIC VIOLENCE SURVIVORS diploma (GED). The mother had been in several different Among mothers with children experiencing homelessness, foster care settings throughout her teenage years and met more than 80% have been shown to have experienced domes- the father after he was released from juvenile hall. The mom, tic violence (National Center for Children in Poverty, 2009). who did not use drugs or alcohol, also did not have a high Survivors of domestic violence demonstrate a decreased ability school degree or a GED. to maintain friendships and function appropriately within After being injured on a job, resulting in severe back pain, social environments (Helfrich et al., 2008). Additionally, the dad had been unable to work for more than 4 months, survivors of domestic violence experience mental health dis- leading to the family’s eviction from their apartment for failure orders, such as depression, posttraumatic stress disorder, and to pay rent. Occupational therapy services were provided at anxiety, at a higher rate than the general population (Phillips, the shelter and were designed to support the family during this 2014). Such disorders may affect every aspect of the indi- challenging period. Services were individualized for each parent vidual’s occupational performance. In fact, 44% of domestic to meet their various needs. Back safety techniques became violence survivors residing in homeless shelters reported con- an important part of the services provided for the father, cerns about their ability to function in work, social, and social particularly in caring for the children. The mother welcomed environments (Helfrich et al., 2008). The women reported the opportunity to participate in the craft program as a way difficulty managing daily responsibilities, poor self-concept, to diminish the stress of looking for full-time employment. the inability to develop new relationships, and concerns with Sessions were also designed to guide and support the parents in caring for children. selecting games and activities to engage both children during Interventions for survivors of domestic violence should “family time,” giving the dad a way to play with the kids besides focus on enabling participation in new and previously held the more physical type of rough-and-tumble play he primarily roles, adapting the person’s environment, building indepen- did before his injury. dent living skills, and engaging in vocational or education Support was provided to both parents to help obtain their related activities (Helfrich & Aviles, 2001). For example, one GEDs. The parents also participated in the shelter’s work read- program for female survivors of domestic violence experienc- iness program to search for new employment, with the mom ing homelessness delivered a 6-month curriculum of group seeking a full-time job and the dad searching for less physically and individual interventions targeted at addressing life skills taxing employment. As part of his employment search, the dad (Gutman et al., 2004). Interventions were focused on IADLs expressed concerns about his previous incarceration—he did (i.e., cooking, money management, nutrition) paired with not know that juvenile records could be sealed if requested maintaining healthy relationship and communication skills. after completing probation. The occupational therapist and After the program, 21 out of 26 female participants achieved case manager at the shelter supported the father in making at least one goal, as measured by the Goal Attainment Scale, a this request, and his juvenile court records were successfully method of scoring goal attainment through numeric represen- sealed. tation (Gutman et al., 2004). Another program implemented The children participated in the occupational therapy ser- at a homeless shelter for survivors of domestic violence vices provided at the shelter. The older boy participated in the focused on increasing job skills using a 4-week group module. Handwriting Without Tears program, which led to substantial Over the course of the program, participants were taught gains in his writing skills. The youngest boy participated in the

CE-4 ARTICLE CODE CEA0618 JUNE 2018 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. occupational therapy imaginative play group and displayed gains ished development of academic, play, and social skills (Jozefo- in problem-solving and decision-making skills. wicz-Simbeni & Israel, 2006). Homeless children frequently After 3 months at the shelter, the dad was in the midst of change schools within a single school year, often causing them seeking new job opportunities and the mom had found a full- to miss school for long periods of time or to miss key parts of time position at a local grocery store that provided employee the curriculum (Darden, 2009). As a result, these children benefits. She was also pursuing her GED. With financial support are at high risk for educational deficits. Homeless children are from the family shelter in the form of an initial rent deposit, the included as an identifiable eligible population to receive educa- family found a small apartment close to the grocery store and tional services under the Individuals with Disabilities Education within walking distance of the school. Improvement Act of 1990. This at-risk population may need additional educational services to meet their academic needs INTERVENTIONS FOR YOUTH (Peterson & Nelson, 2003). Approximately 1.6 million youth, ages 12 to 17, experience Studies have indicated that occupational therapy inter- homelessness within the United States in a given year vention in handwriting improves the academic outcome of (National Alliance to End Homelessness, 2018). For these children who are socio-economically disadvantaged (O’Ma- adolescents, basic necessities of survival, such as food, shel- hony et al., 2008). Although poor handwriting is frequently ter, and safety, are compromised. This can result in threats to addressed by school-based occupational therapy practitioners, physical, cognitive, and psychological development during a homeless children often do not have access to these services critical time associated with learning and acquiring the living at school because of inconsistent school attendance (Darden, skills needed to transition into adulthood (Oliveira & Burke, 2009; Peterson & Nelson, 2003). Schultz-Krohn and col- 2009). Homeless adolescents have self-reported they lack leagues (2008) provided occupational therapy services at a the important skills of managing money, locating safe and family shelter to foster handwriting skills for early elementary permanent housing, and searching for employment. Devel- children. The Handwriting Without Tears (Learning Without oping financial literacy and money management skills is Tears, 2017) program was provided three times per week for best done using a collaborative model to support acquisition 15- to 20-minute sessions for 4 consecutive weeks over the of these vital skills (Ssewamala et al., 2012). For teens who course of 3 months to support children in first and second experience homelessness, developing the habits and routines grade (Schultz-Krohn et al., 2008). Although only a small to support financial literacy and money management is an number (15) of the children completed the 12 sessions, major important need. In the collaborative program between SJSU gains were noted in their handwriting skills after this brief and a local family shelter, group sessions were provided intervention. The results demonstrated that improvements can twice weekly to help teens practice decision-making and be made using a short-term intervention for homeless children budgeting skills for an intended goal. At the beginning of whose education has been disrupted by frequent changes in the week, the session focused on selecting an activity, such school attendance. as making English muffin pizzas, smoothies, or cookies, or Currently, 1 in 30 U.S. children experience homelessness doing a craft activity, such as making duct tape wallets. The each year (American Institutes for Research, 2014). Children teens were then guided to select low- to no-cost activities living in high-stress contexts, such as homelessness, are at risk using materials available at the family shelter or that could for developing hopelessness and have decreased opportunities be purchased using a small fund provided by the shelter. to participate in developmentally appropriate activities, such as Teens formed small groups to identify materials and a budget play (Savina, 2014). This lack of access to play and developmen- for the selected group activity. The groups competed to find tal activities can negatively affect a child’s cognitive, emotional, the least expensive way to obtain the items needed for the social, and physical development (Gilpin et al., 2015; Hoffman activity. During the second session, the teens completed the & Russ, 2012). The weekly group occupational therapy sessions activity. Teens also developed individualized goals regarding provided by graduate occupational therapy students and a pro- money management and financial literacy skills and were fessor from SJSU to a local family shelter fostered imaginative introduced to basic financial literacy skills, such as differ- play skills to counteract the negative effects of homelessness. entiating “wants” versus “needs” and potential problems in Materials used included low- and no-cost items, such as plastic using credit cards to make purchases. Teens and parents have milk bottles that were converted into astronaut gear and paper commented on the helpfulness of these sessions in reduc- towel rolls converted into a spy glass. Children were offered ing arguments about items teens “want” versus those they materials to build on an imaginative story line while construct- “need.” ing and decorating their items. Children gained various play skills exhibited during a standardized play observation period. INTERVENTIONS FOR CHILDREN Parents and other caregivers noted the ability of the children to Children who experience homelessness are faced with many consider different options and alternative solutions for playing challenges. Deficits caused by homelessness lead to impover- with the materials.

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INTERVENTIONS FOR INDIVIDUALS EXPERIENCING MENTAL Copeland, M. E. (2002) Wellness recovery action plan: A system for monitoring, reducing, and eliminating uncomfortable or dangerous physical symptoms ILLNESS and emotional feelings. Occupational Therapy in Mental Health. 17, 127–150. The National Coalition for the Homeless (2009) reported that https://doi.org/10.1300/J004v17n03_09 nearly 26% of the homeless population experience symptoms of Darden, E. C. (2009). Handling homeless students. American School Board severe and persistent mental illness, further noting that mental Journal, 196(10), 43–44. illness is the third largest cause of homelessness for single David, D. H., Gelberg, L., & Suchman, N. E. (2012). Implications of homeless- adults. Research demonstrates the benefits of mental health ness for parenting young children: A preliminary review from a developmental attachment perspective. Infant Mental Health Journal, 33, 1–9. self-management programs in reducing psychiatric symp- Durocher, E., Gibson, B. E., & Rappolt, S. (2014). Occupational justice: A con- toms and increasing hopefulness and quality of life, including ceptual review. Journal of Occupational Science, 21, 418–430. https://doi.org/1 Wellness Recovery Action Plans (WRAPs; Cook et al., 2012). A 0.1080/14427591.2013.775692 WRAP is a self-directed plan the occupational therapist and cli- Elliot, S., O’Neal, S., & Velde, B. P. (2001). Using chaos theory to understand ent create together to provide daily maintenance, find triggers, a community-built occupational therapy practice. Occupational Therapy in and identify steps to take during a mental health crisis (Cope- Health Care, 13(3–4), 101–111. land, 2002). Occupational therapists attempting to address Feijó, L., Hernandez-Reif, M., Field, T., Burns, W., Valley-Gray, S., & Simco, E. (2006). Mothers’ depressed mood and anxiety levels are reduced after mental health concerns with individuals experiencing homeless- massaging their preterm infants. Infant Behavior & Development, 29, 476–480. ness can assist them in creating WRAP plans that may be used Fieldhouse, J., Parmenter, V., Peregrine, D., & Barham, R. (2011). Places for daily and in cooperation with their available community-based People OTIS Report: Evaluation of an occupational therapy intervention service resources (Gibson et al., 2011). within homeless services in Bristol. Retrieved from http://www1.uwe.ac.uk/hls/ ahp/aboutus/serviceevaluations.aspx Gibson, R. W., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational CONCLUSION therapy interventions for recovery in the areas of community integration There is an increasing need for occupational therapy services for and normative life roles for adults with serious mental illness: A systematic people experiencing homelessness (Roy et al., 2017; Thomas, review. 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Employment skills and domestic violence sur- infant massage. Journal of Perinatal Education, 20, 200–209. vivors: A shelter-based intervention. Occupational Therapy in Mental Health, Cook, J. A., Copeland, M. E., Jonikas, J. A., Hamilton, M. M., Razzano, L. A., 22, 33–48. https://doi.org/10.1300/J004v22n01_03 Grey, D. D., … Carter Sherry Boyd, T. M. (2012). Results of a randomized Herzberg, G., & Finlayson, M. (2001). Development of occupational therapy in controlled trial of mental illness self-management using wellness recovery a homeless shelter. Occupational Therapy in Health Care, 13(3–4), 131–144. action planning. Schizophrenia Bulletin, 38, 881–891. https://doi.org/10.1093/ https://doi.org/10.1080/J003v13n03_11 schbul/sbr012

CE-6 ARTICLE CODE CEA0618 JUNE 2018 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See below for details.

Herzberg, G. L., Ray, S. A., & Miller, K. S. (2006). The status of occupational therapy: Addressing the needs of people experiencing homelessness. Occupa- tional Therapy in Health Care, 20(3–4), 1–8. How to Apply for Hoffmann, J., & Russ, S. (2012). Pretend play, creativity, and emotion regulation in children. Psychology of Aesthetics, Creativity, and the Arts, 6, 175–185. https://doi.org/10.1037/a0026299 Continuing Education Credit Illman, S. C., Spence, S., O’Campo, P. J., & Kirsh, B. H. (2013). Exploring the occupations of homeless adults living with mental illnesses in Toron- A. To get pricing information and to register to take the exam to. Canadian Journal of Occupational Therapy, 80, 215–223. https://doi. online for the article Community-Built Occupational Therapy org/10.1177/0008417413506555 Services for Those Who Are Homeless, go to Individuals with Disabilities Education Act of 1990, Pub. L. 101-476, renamed http://store.aota.org, or call toll-free 800-729-2682. the Individuals with Disabilities Education Improvement Act, codified at 20 U.S.C. §§ 1400-1482. B. Once registered and payment received, you will receive instant Jozefowicz-Simbeni, D., & Israel, N. (2006). Services to homeless students and email confirmation. families: The McKinney–Vento Act and its implications for school social work practice. Children & Schools, 28, 37–44. C. Answer the questions to the final exam found on pages CE-8 & Learning Without Tears. (2017). Learning Without Tears for occupational thera- CE-9 by June 30, 2020. pists. Retrieved from https://www.lwtears.com/occupationaltherapists Lloyd, C., & Bassett, H. (2012). The role of occupational therapy in working D. On successful completion of the exam (a score of 75% or more), with the homeless population: An assertive outreach approach. New Zealand you will immediately receive your printable certificate. Journal of Occupational Therapy, 59(1), 18–23. Mindell, J. A., Lee, C. I., Leichman, E. S., & Rotella, K. N. (2018). Mas- sage-based bedtime routine: Impact on sleep and mood in infants and Schultz-Krohn, W., Boener, A, Dinh, H, & Phelan, M. (2008). Handwriting mothers. Sleep Medicine, 41, 51–57. Without Tears: A short-term intervention for children living in a homeless National Alliance to End Homelessness. (2017). Unsheltered homelessness: shelter. Journal of Occupational Therapy, Schools, & Early Intervention, 1, Trends, causes, and strategies to address. Retrieved from https://endhomeless- 271–282. ness.org/wp-content/uploads/2017/07/unsheltered-brief-final-7.26.pdf Schultz-Krohn, W., Drnek, S., & Powell, K. (2006). Occupational therapy inter- National Alliance to End Homelessness. (2018). The state of homelessness in vention to foster goal setting skills for homeless mothers. Occupational Thera- America. Retrieved from https://endhomelessness.org/homelessness-in-amer- py in Health Care, 20(3–4), 149–166. https://doi.org/10.1080/J003v20n03_10 ica/homelessness-statistics/state-of-homelessness-report/ Shoredike, A., & Howell, D. (2002). The reindeer of hope: An occupational National Center for Children in Poverty. (2009). Homeless children and youth: therapy program in a homeless shelter. Occupational Therapy in Health Care, Causes and consequences. Retrieved from http://www.nccp.org/publications/ 15(1–2), 57–68. https://doi.org/10.1080/J003v15n01_07 pdf/text_888.pdf Ssewamala, F. M., Sperber, E., Blake, C. A., & Ilic, V. P. (2012). Increas- National Coalition for the Homeless. (2009). Why are people homeless? Retrieved ing opportunities for inner-city youth: The feasibility of an economic from http://www.nationalhomeless.org/factsheets/why.html empowerment model in East Harlem and the South Bronx, New York. Children and Youth Services Review, 34, 218–224. https://doi.org/10.1016/j. Oliveira, J. O., & Burke, P. (2009). Lost in the shuffle: Culture of homeless childyouth.2011.10.003 adolescents. Pediatric Nursing, 35, 154–161. Stadnyk, R., Townsend, E., & Wilcock, A. (2010). Occupational justice. In C. H. O’Mahony, P., Dempsey, M., & Killeen, H. (2008). Handwriting speed: Duration Christiansen & E. A. Townsend (Eds.), Introduction to occupation: The art and of testing period and relation to socio-economic disadvantage and handed- science of living (2nd ed., pp. 329–358). Upper Saddle River, NJ: Pearson. ness. Occupational Therapy International, 15, 165–177. Thomas, Y., Gray, M., & McGinty, S. (2011). A systematic review of occupational Peterson, C. Q., & Nelson, D. L. (2003). Effect of an occupational intervention therapy interventions with homeless people. Occupational Therapy in Health on printing in children with economic disadvantages. American Journal of Care, 25, 38–53. https://doi.org/10.3109/07380577.2010.528554 Occupational Therapy, 57, 152–160. https://doi.org/10.5014/ajot.57.2.152 Thomas, Y., Gray, M., McGinty, S., & Ebringer, S. (2011). Homeless adults’ Phillips, R. (2014). Addressing barriers to housing for women survivors of engagement in art: First steps towards identity, recovery, and social inclu- domestic violence and sexual assault. Temple Political & Civil Rights Law sion. Australian Occupational Therapy Journal, 58, 429–436. https://doi. Review, 24, 323–342. org/10.1111/j.1440-1630.2011.00977.x Roy, L., Vallée, C., Kirsh, B. H., Marshall, C. A., Marval, R., & Low, A. (2017). Townsend, E., & Whiteford, G. (2005). A participatory occupational therapy Occupation-based practices and homelessness: A scoping review. Canadian justice framework: Population-based processes of practice. In F. Kronenberg, Journal of Occupational Therapy, 84, 98–110. S. Simo Algado, & N. Pollard (Eds.), Occupational therapy without borders: Savina, E. (2014). Does play promote self-regulation in children? Early Child Learning from the spirit of survivors (pp. 110–126). Edinburgh: Elsevier. Development and Care, 184, 1692–1705. https://doi.org/10.1080/03004430.2 Townsend, E., & Wilcock, A. (2004). Occupational justice. In C. H. Christiansen 013.875541 & E. A. Townsend (Eds.), Introduction to occupation: The art and science of Schultz-Krohn, W. (2004). The meaning of family routines in a homeless living (pp. 243–273). Upper Saddle River, NJ: Prentice Hall. shelter. American Journal of Occupational Therapy, 58, 531–542. https://doi. U.S. Department of Housing and Urban Development. (2017). The 2017 Annual org/10.5014/ajot.58.5.531 Homeless Assessment Report (AHAR) to Congress—Part 1: Point-in-time estimates Schultz-Krohn, W. (2009). There’s no place like home: Occupational therapy of homelessness. Retrieved from https://www.hudexchange.info/resources/ services for people who are homeless. In E. B. Crepeau, E. S. Cohn, & B. A. documents/2017-AHAR-Part-1.pdf B. Schell (Eds.), Willard and Spackman’s occupational therapy (11th ed., pp. VanLeit, B., Starrett, R., & Crowe, T. K. (2006). Occupational concerns of wom- 896–900). Philadelphia: Lippincott, Williams & Wilkins. en who are homeless and have children: An occupational justice critique. Schultz-Krohn, W. (2012). Pediatric occupational therapy services in emerging Occupational Therapy in Health Care, 20, 47–62. https://doi.org/10.1080/ practice arenas: What’s an OT doing out here? In S. Lane & A. Bundy (Eds.), J003v20n03_04 Kids can be kids: A childhood occupations approach. Philadelphia: F. A. Davis.

JUNE 2018 ARTICLE CODE CEA0618 CE-7 Continuing Education Article Download the CE Exam Click here to purchase and take the exam for CE credit.

4. When a mother is working three jobs to pay the rent and Final Exam has very limited time to spend with her children, this Article Code CEA0618 form of occupational injustice is referred to as: Community-Built Occupational Therapy Services for A. Occupational deprivation Those Who Are Homeless B. Occupational alienation C. Occupational apartheid June 2018 D. Occupational imbalance To receive CE credit, exam must be completed by June 30, 2020 5. Family homelessness has become an increasing problem in the United States. Homeless families generally make Learning Level: Intermediate up what percentage of the total homeless population in Target Audience: Occupational Therapists and Occupational Therapy the United States? Assistants A. 20% Content Focus: Professional Issues; Occupational Therapy Interventions B. 35% C. 60% 1. A community-built program should: D. 75% A. Focus on producing outcomes that can be measured with well-accepted external instrument(s) 6. Homeless elementary school–aged children are often at B. Require occupational therapy practitioners to possess risk for academic delays and poor educational achieve- substantial expertise in the area of practice before provid- ment. The main reason this occurs is: ing services A. Parents are unable to provide adequate study time for C. Always be aligned with the specific occupational therapy children to learn. practice guidelines directing the services to be provided B. Homeless children have a high frequency of school D. Be developed through collaborative efforts between all moves and absences. stakeholders and occupational therapy practitioners C. Teachers do not need to teach children who do not permanently reside in the school district. 2. Occupational justice is built on several factors, D. The public educational laws do not include homeless including: children as an identified group. A. Social justice, the Americans with Disabilities Act, and engagement in occupations as health promoting 7. Homeless families constitute approximately what per- B. The Americans with Disabilities Act, occupational centage of the total sheltered homeless population: therapy expertise, and social justice A. 30% C. Client-centered services, social justice, and engagement B. 50% in occupations as health promoting C. 75% D. The Occupational Therapy Practice Framework, the Americans with Disabilities Act, and social justice D. 90%

3. Occupational injustices take several forms. When an 8. Which of the following has consistently been demon- individual is unable to engage in a preferred occupation strated in the literature as a barrier to working within because illness or disease, it is referred to as: this population? A. Occupational deprivation A. Violence among the population B. Occupational alienation B. The transient nature of the population C. Occupational apartheid C. Difficulty partnering with community agencies D. Occupational imbalance D. Lack of interest among the occupational therapy community

CE-8 ARTICLE CODE CEA0618 JUNE 2018 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

9. What percentage of domestic violence survivors living at a homeless shelter report difficulty engaging in work, school, and social interactions? A. 5% B. 10% C. 25% D. 44%

10. Which of the following should practitioners not do when working with a youth experiencing homelessness? A. Acknowledge the client’s strengths and abilities B. Collaborate with the client to create goals for therapy C. Focus on developing healthy roles and routines for the transition to adulthood D. Provide interventions focused on the age-appropriate occupation of education

11. The majority of the literature available that explores interventions for co-occurring mental illness and homelessness focuses on: A. Peer-based and self-management programs B. Life skills curriculums C. Medication management D. Assistance with attending psychiatric appointments

12. Occupational therapy practitioners working with the homeless population should: A. Require clients to design their own treatment sessions independently B. Demonstrate expert knowledge in homeless culture C. Assist clients in avoiding participating in tasks that are difficult D. Allow clients to embody the role of the “expert” in being homeless

Now that you have selected your answers, you are only one step away from earning your CE credit.

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JUNE 2018 ARTICLE CODE CEA0618 CE-9