By AHMAD BAHJAT AL-RAWASHDEH Submitted In

PSYCHOSOCIAL CHARACTERISTICS OF YOUTH WHO RUN AWAY FROM HOME

AHMAD BAHJAT AL-RAWASHDEH

Submitted in partial fulfillment of the requirements

For the degree of Doctor of Philosophy

Dissertation Advisor: Dr. Faye A. Gary

Frances Payne Bolton School of Nursing

CASE WESTERN RESERVE UNIVERSITY

May, 2006

DEDICATION

This dissertation is dedicated to my father, who passed away eleven years

ago. He had always wanted me to seek higher education. I also wish to dedicate this

effort to my mother, who has long been suffering the absence of me, her eldest son, along

with her grandchildren.

In addition, I give thanks to my dear wife, Intisar, who has always stood by me

with patience, endless love, support, and encouragement while caring for our six children—sons Mu’men, Mu’taz, and Mohammad, and daughters Taqwa, Ayeh, and

Sarah. I express appreciation to my entire family in Jordan, including my brothers,

sisters, and my in-laws, and finally to my beloved country itself, Jordan, with its entire

people.

TABLE OF CONTENTS

TABLE OF CONTENTS 1

LIST OF TABLES 4

LIST OF FIGURES 6

ACKNOWLEDGEMENTS 7

ABSTRACT 8

CHAPTER I: INTRODUCTION………………………………………… 10

Youth who Run Away: A Brief Profile…………………………….. 12

Statement of the Problem…………………………………………... 18

Conceptual Framework…………………………………………….. 19

Definition of Terms………………………………………………… 25

Research Questions………………………………………………… 27

CHAPTER II: RUNAWAY YOUTH: PSYCHOSOCIAL, BEHAVIORAL,

AND PHYSICAL CHARACTERISTICS……………... 29

Psychosocial and Behavioral Characteristics……………………… 31

Externalizing Behaviors…………………………………… 33

Gang-Related Behaviors…………………... 35

Alcohol and Substance Abuse…………….. 36

School Truancy and Failure………………. 37

Crime and Delinquent Behaviors………… 38

Internalizing Behaviors………………………………….. 39

Anxiety…………………………………... 40

Depression……………………………….. 41 2

Suicidal Ideation and Behaviors………….. 41

Physical Health Status of Youth who Run Away……………….. 43

Sexual Health……………………………………………. 43

Potential for Early Parenthood…………………………... 44

Reproductive Health Conditions……………………….... 45

Dermatological Conditions……………………………… 46

Neuro-Skeletal Conditions……………………………… 47

Oral Health Problems…………………………………… 47

Sleep Deprivation………………………………………. 48

Child Abuse in the Life of Runaway Youth……………………. 49

Child Sexual Abuse…………………………………….. 49

Child Physical Abuse…………………………………... 50

Child Psychological Abuse…………………………….. 51

Summary……………………………………………………….. 52

CHAPTER III: METHODS…………………………………………. 54

Setting, Sample, and Design…………………………………… 54

Sample Size Determination……………………………………. 58

Research Measures…………………………………………….. 58

Procedures for Data Analysis…………………………………. 65

Data Analysis Plan……………………………………………. 66

Protection of Human Subjects……………………………….... 68

CHAPTER IV: RESULTS…………………………………………… 71

Description of the Major Study Variables…………………….. 71 3

Results of Analysis of the Research Questions………………... 74

Summary of the Results……………………………………….. 85

CHAPTER V: DISCUSSION……………………………………….. 86

Life Events in the Past 12 Months and

Youth Runaway Behavior……………………………………... 86

History of Sexual Abuse and Youth Runaway Behavior……… 91

Externalizing/Internalizing Behaviors and

Youth Runaway Behavior..……………………………………. 95

Limitations of the Study……………………………………… 101

Significance of Findings……………………………………... 101

Recommendations for Further Research……………………... 107

Summary……………………………………………………… 109

REFERENCES……………………………………………………… 111

APPENDICES………………………………………………………. 150

Appendix A. Data Coding……………………………………. 151

Appendix B. Structured Clinical Interview…………………... 158

Appendix C. Coddington’s Life Events Scale………………... 164

Appendix D. Adolescent Multiphasic

Personality Inventory…………………………… 175

LIST OF TABLES

Table 1: Demographic Characteristics of Youth in a

Runaway Shelter……………………………………………. 55

Table 2: Variables and their Measurement………………………….... 65

Table 3a: Descriptive Statistics of Main Study Variables……………. 73

Table 3b: Frequencies of Life Events Scores

According to Age Group…………………………………… 74

Table 4: Frequencies of Demographic Characteristics of

Age and Number of Previous Runs…………………………. 75

Table 5: Descriptive Characteristics of Gender, Ethnicity,

Living Arrangements, and Reason for Placement…………... 77

Table 6: Descriptive Characteristics of Alcohol Use,

Parents’ Alcohol Use, Sibling Alcohol Use,

History of Arrests, Age at First Sex, Sex Learning,

Physical or Emotional Abuse, and Sexual Abuse…………... 78

Table 7a: Effect of Gender on Youth’s Decision to Run Away………. 79

Table 7b: Effect of Ethnicity on Youth’s Decision to Run Away…….. 79

Table 8: T-Test of Age and Runaway Behavior of Youth…………...... 80

Table 9: Relationship between Life Events in

The Past 12 Months and the Youth’s Runaway Behavior……. 81

Table 10: Relationship between Life Events in the Past 12

Months and the Youth’s Runaway

Behavior, Controlling for Ethnicity……………………………. 81 5

Table 11: Relationship between Sexual Abuse and the

Youth’s Runaway Behavior…………………………………. 82

Table 12: Relationship between Sexual Abuse and the

Youth’s Runaway Behavior, Controlling for Ethnicity……..... 82

Table 13: Logistic Regression of Externalizing Behaviors

Predicting Runaway Behavior……………………………….. 83

Table 14: Logistic Regression of Internalizing Behaviors

Predicting Runaway Behavior……………………………….. 83

Table 15: Logistic Regression of Externalizing Behaviors and

Internalizing Behaviors Predicting Runaway Behavior……... 84

Table 16: Logistic Regression of Externalizing Behaviors, Internalizing

Behaviors, and Ethnicity Predicting Runaway Behavior…… 84

Table 17: Correlations for Externalizing Behaviors and

Internalizing Behaviors……………………………………... 85

LIST OF FIGURES

Figure 1: Integrative Model for the Study of

Developmental Competencies in Vulnerable Children

(Adapted from Garcia Coll et al., 1996)……………………. 24

Figure 2: Conceptual Model of the Study…………………………….. 25

ACKNOWLEDGEMENTS

I could not have completed my dissertation without the support and guidance of my advisor and committee chairperson, Dr. Faye A. Gary, who has allowed me to use her data in my secondary analysis study. I also acknowledge my committee members, Dean

May Wykle, Dr. Diana Morris, and Dr. Natalie Colabianchi, for their valuable encouragement and guidance.

Sincere thanks go to Hashemite University in my beloved country, Jordan, for providing me my scholarship to study in the United States of America. The Frances

Payne Bolton School of Nursing Alumni Association and Sigma Theta Tau International deserve special acknowledgment for providing partial funding for my research study. I also appreciate Mr. Jason Barone for his great services, as well as all my countless colleagues and friends for their generous assistance and support.

PSYCHOSOCIAL CHARACTERISTICS OF YOUTH WHO RUN AWAY FROM HOME

Abstract

Ahmad Al-Rawashdeh

The number of youth who run away from home each year in the United States is

estimated to be about two million. They flee from their homes, where they are subject to

maltreatment, including physical, emotional, and sexual acts of abuse and violence. Many

of them are also neglected and do not have sufficient necessities to assure the support of

wholesome familial or community environments. These youth could perceive running

away as an escape from an abusive or neglectful home environment.

This secondary data analysis study consisted of a descriptive, correlational design

using The Integrative Model for the Study of Child Development in Minority Populations

in the United States (Garcia Coll et al., 1996) as a conceptual framework to guide the selection of variables. The sample was comprised of 78 youth (43 females, 35 males) who were admitted to a shelter for runaway and homeless youth. Data were collected using face-to-face interviews between the months of June, 1991 to January, 1992.

Standardized instruments were used to measure life events in the past 12 months and externalizing/internalizing behaviors.

Results showed that there was no significant association between the life events in the past 12 months and the youth’s runaway behaviors. No significant associations were found between the history of sexual abuse and their runaway behaviors. Results of the logistic regression analyses showed that both the externalizing and the internalizing

behaviors, separately, were associated with the runaway behavior, but the internalizing

behaviors were not significantly associated with the runaway behaviors when they were 9

added to the externalizing behaviors into the same equation. Furthermore, the

externalizing behaviors were significantly associated with the runaway behavior when

they were entered with the internalizing behaviors into the same equation, controlling for

the youth’s ethnicity. The correlation matrix explained this finding by showing the high

correlation between the externalizing and the internalizing behaviors revealing that youth

with high scores on the externalizing behaviors are the same youth with high scores on the internalizing behaviors. In addition, ethnicity was a significant predictor of the runaway behaviors.

These findings raise the question about the need to understand the personality characteristics and behaviors of these youth. In addition, nurses and health care professionals should be concerned about these issues since these behaviors have a deleterious influence on the youth, their families, the community, and the nation.

CHAPTER I

INTRODUCTION

The number of youth who run away from home each year in the United States is

estimated to be about two million (Sullivan & Knutson, 2000a). They flee from their homes, where they are subject to maltreatment, including physical, emotional, and sexual

acts of abuse and violence (Kaufman & Widom, 1999; Browne & Falshaw, 1998; Yoder,

Whitbeck, & Hoyt, 2001). Many of them are also neglected and do not have sufficient

necessities to assure the support of wholesome familial or community environments

(Higgins & McCabe, 2001). These youth could perceive running away as an escape from

an abusive or neglectful home environment. There are documented reasons why youth

run away from their homes (Haley et al., 2004; Nadon, Koverola, & Schludermann, 1998;

Safyer et al., 2004; Kaufman & Widom, 1999; Yoder, Whitbeck, & Hoyt, 2001). While

these realities might exist, the consequences of running away could be just as negative or

even devastating. Running away from home could place youth at an increased risk for

delinquency (Kingree, Braithwaite, & Woodring, 2001), health risks (Halcon & Lifson,

2004; Unger et al., 1998), psychological trauma (Huba et al., 2000; Votta & Manion,

2004), and numerous other negative outcomes (Lifson & Halcon, 2001; Kipke et al.,

1997). Hagan and McCarthy (1997), for example, found that runaway and homeless

youth, living in the two Canadian cities of Toronto and Vancouver, turned to delinquent

and criminal behaviors to survive on the streets. Such behaviors often place them at high

risk for interfacing with the juvenile justice system, and adult jails and prisons (Browne

& Falshaw, 1998). Others could be referred to long-term placement in foster care 11 facilities (Fasulo, Cross, Mosley, & Leavey, 2002), where their futures could also be compromised (Browne, 2002).

Life events, such as violence and abuse in the home, play an important role in youth’s psychological and social development (Windle, 1992; DuBois et al., 1994).

These life events are factors that can lead to the creation of a plethora of mental and emotional disorders, and compromise the youth’s overall development. Among the numerous types of deleterious outcomes that could develop among these youth are depressive symptoms (Waaktaar et al., 2004), self-destructive tendencies (Hasan &

Power, 2004), delinquent acts (Hoffmann & Su, 1997), and substance use and abuse

(Sandler et al., 1994). Furthermore, negative life events are associated with emotional difficulties and academic failure. For example, life events such as the separation or divorce of parents, a change in school or residence, and parental unemployment (Alva &

Reyes, 1999) could create havoc in the lives of youth. Other life events related to not having adequate resources to purchase goods and services can also have a negative impact on youth (Zimmerman et al., 2000). That is to say, when families cannot provide wholesome recreation and safe home and neighborhood environments, youth could be at risk for experiencing and/or participating in aggressive interpersonal acts against others

(Halliday-Boykins & Graham, 2001; Lackey, 2003; Herrenkohl et al., 2000). It is a substantiated fact that being poor can produce a constant state of stress, which could interrupt the youth’s development and compromise their well-being (Rank, 2001;

Petterson & Albers, 2001; Attree, 2004).

Furthermore, in some homes, children experience continuous neglect and abuse in a variety of forms. Child sexual abuse (Walrath et al., 2003), family conflict and violence 12 in the home (Lackey, 2003), academic failure (Brewster & Bowen, 2004), and peer problems at school and in the community (Aluede & Ikechukwu, 2003) are some of the life events that negatively affect these vulnerable youth. Emotional neglect is common among some families, though it is more difficult to identify and label (Browne &

Falshaw, 1998; Hamarman, Pope, & Czaja, 2002; Trocme et al., 2003). Hence, interventions are not readily forthcoming for this type of abuse. In fact, emotional abuse and neglect, also known as psychological maltreatment, is a detrimental form of child maltreatment; it is frequently undetected and seldom tackled within the healthcare system

(Glaser, 2002), and in the service of helping youth.

Children, subjected to emotional abuse and neglect, suffer from a combination of difficulties. In a study of 94 abused or neglected children from 56 families, the following mental health related difficulties were documented: low self-esteem; age-inappropriate responsibility; antisocial/delinquent behaviors; school nonattendance/lateness; aggressiveness; somatic manifestations like soiling and wetting (may also be behavioral), abdominal pain; sexualized behaviors, and so forth (Glaser, Prior, & Lynch, 2001).

Furthermore, Spertus et al. (2003) found that emotional abuse and neglect among youth was associated with increased anxiety, depression, posttraumatic stress, and physical symptoms with little physiological etiology (Spertus et al., 2003).

Youth Who Run Away: A Brief Profile

Life Events among Runaway Youth

A combination of life events sometimes results in youth’s decisions to leave home. They run away, face the consequences of the potential for more abuse and neglect, and encounter other extreme life experiences (Tyler & Cauce, 2002). In an attempt to 13

escape violence and abuse in the home, youth could actually experience more of the same

from perpetrators “on the streets” who exploit them for a variety of reasons. That is to

say, youth run away from their homes to free themselves from violence and abuse and to retreat from these considerable life events. As a result, policy makers and health professionals have had a tendency to label them as “endangered, street children, throwaway, and abandoned youth” (Browne & Falshaw, 1998). Unfortunately, they are likely to experience more extreme forms of violence and abuse while “on the run.” On the other hand, the consequences of remaining in their homes could also be devastating.

Hence, the youth are confronted with making a choice between two psychologically powerful outcomes: run to the streets or remain at home. Either choice could have negative consequences (Tyler, Hoyt, & Whitbeck, 2000; Kendall-Tackett, 2002; Tyler &

Cauce, 2002; Slesnick & Meade, 2001).

Straus (1994) revealed that about one-half of the youth who run away get introduced to prostitution, stealing, drug dealing and other crimes after being on the streets for about a month. Some researchers have described these noxious acts as survival tactics (Pederson & Hegna, 2003). On the other hand, large numbers of these youth could also become victims while living on the streets. Recall that the beginnings of these exploits could have actually begun in their homes, but become exaggerated on the streets.

Browne (1993) found that one in six physically abused children go on to assault others during their teenage years. Pears and Capaldi (2001) have suggested that youth are at risk for being abusive as adult intimate partners and parents of young children. The potential for the permutation of interpersonal violence has its beginnings in these types of experiences during the developmental years (Herrenkohl et al., 2000). Its consequences 14

have long term effects, and they could negatively impact the next generation of children

and families (Herrenkohl et al., 2000).

National statistics suggest that approximately 2% of the U.S. population (that is 2

million youth) under the age of 18 run away from home every year (Federal Interagency

Forum on Child and Family Statistics, 1998). These data indicate that in the American

society there are important links between running away and the characteristics of youth’s

homes that contribute to their decisions to leave and seek refuge away from their abode.

Some, but not all, of these circumstances include physical abuse, sexual abuse, physical

and sexual abuse, substance abuse, family violence, parental rejection, poor parental

monitoring, drug abuse in the home, and poor academic performance (Whitbeck, Hoyt, &

Ackley, 1997; Booth & Zhang, 1996; Warren, Gary, & Moorhead, 1997).

Sullivan and Knutson (1998, 2000a), in two separate studies, found that

maltreatment increased the risk of runaway behaviors. In their first study, comprised of

youth in a hospital-based milieu, Sullivan and Knutson (1998) reported that maltreated

children were more likely to run away from home than their non-abused peers were. They also found that running away from home could increase the probability of a conduct

disorder diagnosis. That is to say, these youth are prone to engage in delinquent type

behaviors and experience “brushes” with law enforcement (Sullivan & Knutson, 1998).

The youth have encounters with the legal system because of a variety of reasons. They steal food and other essentials for survival (Yeo, 1998). Others steal as a method of

attaining additional resources, or as a form of “recreation and thrill seeking” (Unger et

al., 1998). Yet, other youth are lured into these deleterious behaviors as survival tactics or

because of peer seduction enforced by their friends on the streets (Baron, 2003; Yoder, 15

Whitbeck, & Hoyt, 2003). Additionally, physical abuse was reported to be the most

frequent type of maltreatment; sexual abuse, however, was also significantly related to the youth’s decisions to run away from home (Sullivan & Knutson, 1998).

In their second study, Sullivan and Knutson (2000a) published a disturbing fact:

the percentage, or the overall rate, of runaway behaviors among youth in the U.S. was

thought to be quite high when compared to the rate in the United Kingdom (Wade, 2003).

They reiterated that approximately 2 million youth, who are 18 years of age or younger,

run away from home each year. Furthermore, other researchers posit that this trend will

continue because of the instability that is being experienced within American families

(Hoyt, Ryan, & Cauce, 1999), the availability of mind altering substances in families and

communities (Slesnick & Meade, 2001), and the limited opportunities for treatment for

substance abuse and behavioral disorders (Lifson & Halcon, 2001; Sullivan & Knutson,

2000b). Other contributing factors associated with runaway behaviors encompassed

family stress factors, including parental disability or illness; mental or emotional illness

in the parent or parents; domestic violence and abuse in the family; and social isolation of

the family (Sullivan & Knutson, 2000b). This study corroborated the findings of other

researchers such as Barwick and Siegel (1996), who also reported that youth who run

away from home are more likely to have poor school attendance and compromised

academic outcomes. Their health status also raises several concerns that have short and

long-term implications.

Health and Behavioral Problems among Female Youth

Youth who run away experience related deleterious life events in numerous areas

of their lives, including undesirable health outcomes (Van Leeuwen et al., 2004; Ennett et 16 al., 1999; Yoder, Hoyt, & Whitbeck, 1998). Causes and consequences of runaway behaviors seem to differ by gender. If the youth are female, they are more likely to leave home, fleeing sexual and physical abuse. On the streets, female youth are exposed to unprotected sexual activity, and confront high risks for pregnancy and a variety of diseases (Tyler, Hoyt, & Whitbeck, 2000; Shields, 2004; Haley et al., 2004), typically referencing those conditions that negatively affect the reproductive organs. They are likely to contract sexually-transmitted diseases, including HIV/AIDS (Song et al., 1999),

Hepatitis B infection (Alderman et al., 1998), Hepatitis C infection (Stein & Nyamathi,

2004), Chlamydia disease (Wendy et al., 1997), and Neisseria gonorrhea (Haley et al.,

2002). Moreover, recall that prostitution is common (Nadon, Koverola, & Schludermann,

1998; Tyler & Cauce, 2002). These young females are also at risk for school failure, truancy, and many types of exploits, including becoming the source of sexual pleasures for older men who barter for sexual favors in exchange for food, shelter, transportation, and other necessities (Halcon & Lifson, 2004).

Health and Behavioral Problems among Male Youth

On the other hand, if the youth are male, they have a high probability of being

“kicked out” of the home because of their noxious and aggressive behaviors (MacLean,

Embry, & Cauce, 1999). Their health problems can also have a devastating impact on their future lives. The male youth are often confronted with aggressive acts that lead to trauma, and more aggression. Importantly, they could be involved with acts that threaten the integrity of their bodies. These youth are more likely to present at emergency rooms and trauma centers for treatment for gunshot wounds, cuts, and other forms of physical violence that result in threats to their bodies (Klein et al., 2000; Braga, 2003; Kipke et 17 al., 1997). Recall that a variety of characteristics help to describe these youth’s life experiences that might serve as antecedents to the health conditions that they are likely to face on the streets. Again, violence against one or both parents, before and after leaving home, substance use and abuse, and extended periods away from home help to set the stage for poor behavioral and health outcomes among these youth. Their involvement in gang-related activities could be perceived as antecedents to oppositional and defiant attitudes and behaviors, which are factors that ferment pathways to a life of crime and punishment (Toro, Urberg, & Heinze, 2004; Whitbeck, Hoyt, &Yoder, 1999). While on the streets, in shelters, or in juvenile confinement facilities, the male youth is likely to have repeated “brushes” with the law (Slesnick & Prestopnik, 2004), struggles with attaining shelter and food, and even less success with attaining health care (Klein et al.,

2000; Geber, 1997; Dachner & Tarasuk, 2002). Regardless, life on the streets, in shelters, or in juvenile confinement facilities, is seldom wholesome and growth facilitating. These vulnerable youth face school failure, peer rejection, unstable environments, and a blighted future (McKnight, Huebner, & Suldo, 2002; Murberg & Bru, 2004), with too little intervention (Kaufman & Widom, 1999) that assists with improving their well-being and reducing potential for mortality and morbidity (Gary, Moorhead, & Warren, 1996;

Ribeiro & Trench Ciampone, 2001). Male youth are more likely to be perceived as perpetrators, and they may not be considered as “worthy” of preventive health services

(Mufune, 2000; Ribeiro & Trench Ciampone, 2001).

Given these detrimental outcomes that could influence children and families over several generations, it is imperative that health professionals and policy makers continue to unravel the reasons for the youth’s decisions to run away from their homes. Programs 18 that are culturally competent and relevant, designed to prevent violence and abuse perpetuated against youth, and strengthen families and communities, should be systematically explored and supported at the local, state, and national levels (Evans et al.,

2005). Importantly, intervention programs based on best practices are exclusively needed for these youth and their families (Evans et al., 2005).

Statement of the Problem

There is a plethora of information about runaway youth. The findings from these studies range from describing these youth as victims (Hoyt, Ryan, & Cauce, 1999), while others characterize them as villains or criminals (Spillane-Grieco, 2000). Few studies, however, have provided data and insights in the internal states of these youth, which describe the psychosocial characteristics and behavioral patterns that they might manifest. Even less is known about how these youth cope with the trauma that they experience when in abusive homes and then on the streets where more abuse is likely to occur. Still, even less is known about the types of treatment modalities, based on their psychosocial characteristics and other essential information, which would best serve to interrupt the internal upheaval that many of them experience (Chun & Springer, 2005;

Kidd, 2003). Perhaps, if more data were available and well researched, nurses and other health care providers would be better able to design culturally specific and profile-driven programs that would interrupt the cycle of violence and provide opportunities for these youth to experience a greater level of well-being (Lindsey et al., 2000; Tenner,

Trevithick, Wagner, & Burch, 1998). This study is based on the broad assumption that youth who are at risk for running away from home are a vulnerable population, with embedded psychosocial characteristics and behavioral manifestations that differentiate 19

them from similar youth that have not run away. An investigation that focuses on the

internal states of the youth will contribute to the scientific literature by providing

additional guidance about the best therapeutic approaches to provide relevant prevention

and management strategies for these youth and their families. The need for exploring and understanding the personality characteristics to better address assessment and possible intervention efforts for these vulnerable youth is missing, or at best, limited in the science and service domains (Kidd, 2003; Lindsey et al., 2000; Chun & Springer, 2005).

Conceptual Framework

The Integrative Model for the Study of Child Development in Minority

Populations in the United States (Garcia Coll et al., 1996) guided this study. It was

adapted and modified to fit the sample in this research, the vulnerable youth. Researchers

from different disciplines collaborated to produce this model. The Integrative Model

introduces considerations of both social position and social stratification constructs at the

core rather than at the periphery of a theoretical formulation of children’s and youth’s

development (Garcia Coll et al., 1996). This model is anchored within social stratification

theory (Barber, 1957; Tumin, 1967).

Traditionally, socio-cultural factors have been excluded from the exploration of

different phenomena that help to shape and influence the lives of children. In addition,

the focus on environmental influences on human learning and development was limited

primarily to immediate situational events (Garcia Coll et al., 1996). This model suggests

that there could be an enduring impact on the child’s or youth’s life that is linked to previous environmental influences, such as family values and persuasion, neighborhood cultures, academic pressures, and genetic predispositions (Garcia Coll et al., 1996). On 20

the other hand, culture has been incorporated more specifically by a discussion of the

importance of the cultural code in families, which serves as a regulator of family

processes and learning. Hence, culture directly influences all the developmental epochs,

and affects the youth’s lives for years to come (Sameroff, Lewis & Miller, 2000).

Although the Integrative Model of Child Development was basically formulated for the study of human growth and development in minority populations, including

African-Americans and Hispanics (with mainland Puerto Ricans), it is highly relevant for other youth who might be confronted with non-facilitating environments and hostile life experiences. The linkages among all vulnerable children and youth are explicated in this model (Garcia Coll et al., 1996). That is, the model can be adapted to fit the purpose of this study because some constructs in the Integrative Model are also relevant to the developmental processes in other populations such as vulnerable Caucasian males and females, as well as African-American and Hispanic children and youth (Garcia Coll et al.,

1996). Figure 1 also depicts the variables of interest and the relationships of the

Integrative Model for the Study of Developmental Competencies in Vulnerable Children and Youth. This schematic format shows the eight major constructs hypothesized to influence significant developmental processes among vulnerable children and youth, including ethnic minorities and Caucasians. The study herein does not explore all of the

relationships in the Integrative Model, but rather focuses on the child characteristics,

including psychological states and runaway behaviors (see Figure 1). This variable is

shaded in Figure 1 (page 24).

In the Integrative Model, social position factors are these “attributes of individuals

that societies use to stratify or place individuals in the social hierarchy, and that pertain to 21

‘children and youth of color’ (Garcia Coll et al., 1996, p.1895) and disadvantaged

Caucasian children and youth (Driscoll & Moore, 1999; Moller, 2002; LaVeist &

McDonald, 2002). Some of these factors are race, social class, ethnicity, and gender.

These social position factors can interact in ways to magnify or diminish the importance of the factors that follow (Bronfenbrenner & Crouter, 1983). Racism, prejudice, discrimination, and oppression mediate the effect of social position on the developmental outcomes and the immediate environments in which children and youth are reared and socialized. Environments of segregation, isolation, and demise are potential outcomes from these factors. Low socio-economic status among Caucasian children has similar effects on their overall well-being. They are restricted in their capacity to participate in many social activities, are without the goods and services that their more advantaged counterparts experience (Frey, 1997; Driscoll & Moore, 1999), and at times they feel isolated and alienated from the mainstream culture (Moller, 2002; Anastasio, Rose, &

Chapman, 1999). Low socio-economic status, low self- esteem, and racial and social segregation are multifaceted, combining residential, economic, and social and psychological dimensions. They directly influence the various inhibiting and promoting environments that children and youth of color experience (Garcia Coll et al., 1996).

Similarly, they negatively influence the milieu within which poor and marginalized

Caucasians must also endure (Wenner, 2003; Evans et al., 2005). The outcomes are similar and predictable: school failure, poor health, involvement with the juvenile justice system; depression, anxiety, and a blighted future (Heck & Parker, 2002; Bradshaw,

2002; Ackerman et al., 2004; Evans et al., 2005). 22

Inhibiting and promoting environments directly affect the adaptive cultures that children, youth, and their families experience. Both these inhibiting/promoting environments and the adaptive culture directly influence the nature of specific individual family processes, and they interact with the individual’s biological, constitutional, and psychological characteristics. Youth’s overall growth and development is a direct function of the contributions of adaptive culture, family processes, and the youth’s own characteristics operating through the interactions among these systems of influence

(Garcia Coll et al., 1996; Schoppe, Mangelsdorf, & Frosch, 2001; Roer-Strier, 2001).

According to the Integrative Model of Garcia Coll et al. (1996), “children are exposed to similar settings across cultures, ethnic groups, and socio-economic backgrounds (i.e., schools, neighborhoods, and health care settings)” (p. 1901). For emphasis, this model can be applied to not only ethnic minority children, but also to children from other ethnic and racial groups. In this study, it is applied to Caucasian and

African American youth who have run away from home and found respite in a shelter for homeless children. Garcia Coll and colleagues (1996) have posited that child characteristics play a key role in how environments and adaptive cultures influence behaviors; child characteristics also influence family functioning and the emergence of developmental competencies among children and youth (Garcia Coll et al., 1996).

Conceptual Model for the Proposed Study

Specific aspects of the proposed model have been explored in this research.

Hence, the Integrative Model for the Study of Developmental Competencies in Minority

Children was adapted to incorporate another vulnerable population, runaway children and youth. The variables that have been selected for examination are considered universal: 23

child characteristics variable, which is depicted as #6 in the Integrative Model. The universality of these characteristics suggests an overlap in life experiences and events among children and youth in the United States (Winkielman & Schwarz, 2001) and perhaps the world (James & James, 2001).

Specifically, the conceptual model that was used for this study is shown in Figure

2 (page 25). It is proposed here in this study that various personality characteristics describe these youth who run away from home and that they have different externalizing/internalizing behaviors that predict their risk of running away from home. It is also proposed that life events experienced by youth in the past 12 months and the history of being sexually abused are associated with these youth’s runaway behaviors.

Internal States

The internal states of these youth are addressed across multiple questionnaires.

The Adolescent Multiphasic Personality Inventory-AMPI (Duthie, 1985) is the empirical

indicator of the youth’s inner states. It is used to determine their personality

characteristics, and includes 13 scales including Infrequency, Lie, Correction,

Hypochondriasis, Depression, Hysteria, Psychopathic Deviate, Masculinity-Femininity,

Paranoia, Psychasthenia, Schizophrenia, Hypomania, and Social Introversion. Two

constructs will be utilized: Internalizing and externalizing. Examples of the internalizing

behaviors of these runaway youth include anxiety, depression, and suicidal ideation and

behaviors. On the other hand, these runaway youth’s externalizing behaviors include

gang-related behaviors, alcohol and substance abuse, school truancy and failure, and

crime and delinquent behaviors (Duthie, 1985; Chamberlain & Moore, 1998; Bagley &

LaChance, 2000). 24

Another instrument that was used in this study is the Structured Clinical Face-to-

Face Interview (Warren, Gary, & Moorhead, 1994), which was designed to collect data about the youth’s demographic characteristics, their runaway behaviors, family structure and roles, and other important variables. The occurrence of sexual abuse was ascertained from this instrument.

#2 Racism #6 Prejudice Discrimination Child Characteristics Oppression Personality Characteristics Psychological States Runaway Behaviors

#1 Social Position Variables #8 Race/Ethnicity #4 #5 Developmental Social Class Promoting/Inhibiting Adaptive Culture Competencies Gender Environments Traditions &Cultural Cognitive Schools Legacies Social Neighborhoods Economic &Political Emotional Health Care Histories Linguistic Migration Biculturalism &Acculturation Coping with Current Contextual Racism Demands

#3 Segregation Residential Economic #7 Social &Psychological Family Structure &Roles Socio-economic Status

Figure 1. Integrative model for the study of developmental competencies in vulnerable children (Adapted from Garcia Coll et al., 1996, p. 1896). 25

Additionally, the Coddington’s (Coddington, 1972) Life Events Scale (LES for

Children and Adolescents) was used to assess for life events related to childhood. This

instrument was used to obtain information on 50 life events experienced by youth during

the 12 months preceding data collection in the original study.

These three measures were examined to answer the research questions and

elucidate the association of the youth’s internal states with their decisions to run away

from home. Figure 2 follows and depicts the conceptual model used for the current study.

Life Events (Coddington’s LES)

Runaway Behavior Sexual Abuse -Runaway/non-runaway (Structured Clinical (Structured Clinical Interview) Interview)

Personality Characteristics (AMPI)

Figure 2. Conceptual model of the study.

Definition of Terms

Child sexual abuse. Theoretically, child sexual abuse is defined as any sexual

contact, coerced or otherwise, between an adult and a child less than 18 years of age. This

may include intercourse, oral contact, fondling, and exhibitionism (Haugaard, 2000). The

empirical definition of sexual abuse is the youth’s responses on the Structured Clinical 26

Face-to-Face Interview (Warren, Gary, & Moorhead, 1994). Specifically, the responses

include yes (being sexually-abused) or no (non-sexually abused).

Running away. The theoretical definition of running away is the absence from home or place of legal residence before the age of eighteen, at least overnight, without the permission of parents or legal guardians (Schaffner, 1999). The empirical definition of running away is the youth’s response on the Structured Clinical Face-to-Face

Interview (Warren, Gary, & Moorhead, 1994). The responses are either yes (runaway) or no (non-runaway).

Life events. The theoretical definition of life events is that they represent a complex measure of positive or negative experiences that cause significant emotional distress and require individuals to change established life patterns (Bourne, 2000). The empirical definition of life events is the youth’s responses on the Coddington’s Life

Events Scale (Coddington, 1972).

Aggression. This variable is included in the internalizing/externalizing behaviors.

The theoretical definition of aggression is the behavior that causes (or could cause) physical or emotional harm to others (American Psychiatric Association, 1994). The empirical definition of aggression is the youth’s responses on the Adolescent Multiphasic

Personality Inventory-AMPI (Duthie, 1985).

Summary of the Conceptual Model

In summary, the exploration of child characteristics that are associated with runaway behaviors should increase nurses’ and other health professionals’ knowledge and skills in providing culturally specific prevention and treatment interventions for this vulnerable group of youth. The child characteristics as explicated in this model are 27 universal--psychological states and runaway behaviors. The particular characteristics that this study will explore are the psychological states (personality characteristics) as measured by the AMPI. The study findings will also benefit the research that explicates the other child characteristics (e.g., health status, physical characteristics, and behavioral outcomes). Thus, the findings related to this study have the potential to increase knowledge about the personality characteristics (externalizing and internalizing behaviors) of youth who make decisions to run away from home. Life events and sexual abuse in the home are conceptualized as important variables that are associated with these youth’s decisions to leave their homes.

Purpose of the Present Study

The purpose of this study is to describe the personality characteristics of youth that attended Jennyplace and determine the association of the youth’s personality characteristics, life events in the past 12 months, and history of sexual abuse with their decisions to run away from home. The sample consisted of 78 youth, 11 to 17 years old, who were admitted to a shelter for runaway and homeless youth.

Research Questions

Research Question 1

What is the association between life events in the past 12 months and youth runaway behaviors?

Research Question 2

What is the association between being sexually abused/non-sexually abused and youth runaway behaviors?

Research Question 3

What is the association between externalizing and internalizing behaviors and youth runaway behaviors?

CHAPTER II

RUNAWAY YOUTH: PSYCHOSOCIAL, BEHAVIORAL, AND PHYSICAL

CHARACTERISTICS

Hagan and McCarthy (1997) have documented how street life can influence youth’s decisions to participate in delinquent behaviors and activities. They reported that hunger causes these youth to steal food. Problems of hunger and the lack of shelter lead to serious theft that exposes the youth to law enforcement officers and the criminal justice system. Problems related to the lack of shelter and unemployment also help to produce prostitution (Hagan & McCarthy, 1997), which overexposes these youth to sexually transmitted diseases such as HIV/AIDS. Other researchers found a relationship between running away among youth and deviant survival behaviors, such as shoplifting and stealing. More serious acts, including violence as a mechanism of “self protection”

(Whitbeck & Simons, 1993; Braga, 2003) have also been reported. Researchers (Yoder,

Whitbeck, & Hoyt, 2003; Terrell, 1997; Staller, 2003; Kidd, 2003) have suggested that life on the streets exposes youth to the potential for interacting with peers and older adults who participate in deviant acts. These vulnerable youth frequently become participants in delinquent behaviors. Two outcomes are likely: first, they might be perceived as aggressive individuals, and they could actually commit crimes, some of which are heinous. On the other hand, they could also become victims because they, though not intending to commit crimes, are lured or seduced into a “street culture” where deviant acts and crime are daily occurrences. The researchers hypothesized that runaway youth are at an increased risk for delinquency, victimization, school failure, health and 30

mental health problems, and blighted futures (Whitbeck & Simons, 1993; Murberg &

Bru, 2004).

Among 2, 019 runaway youth who were studied in eight southeastern shelters in

the United States (Kurtz et al. 1991), 28 percent were found to be abused (physically,

sexually, and emotionally) before they decided to leave home or were “thrown out” of

their family units. Feitel et al. (1992) revealed that of the homeless youth in New York

City’s Covenant House, 50 percent had been badly beaten; 52 percent of the females and

21 percent of the males had been sexually molested. In another study, Welsh et al. (1995)

reported that 80 percent of the youth who sought refuge at a shelter in Canada had been

physically abused, and 38 percent had had a sexual experience with a family member.

Significantly, among those youth who had been sexually abused, they reported that the

most frequent perpetrator was the stepfather (Maker, Kemmelmeier, & Peterson, 2001).

This finding is corroborated by other research results (Warren, Gary, & Moorhead, 1994;

Gary, Moorhead, & Warren, 1996; Joa & Edelson, 2004; Shaw et al., 2001).

Findings from Kaufman and Widom (1999) suggest that victims of child abuse and neglect were more likely to run away from home when compared with their nonabused counterparts. These researchers repeated their analyses by using specific types of childhood victimization such as physical abuse, sexual abuse, and neglect; they found that the risk for running away increased significantly when neglect and abuse occurred in the home. Kaufman and Widom (1999) also reported a significant relationship between running away and juvenile arrests. Their results indicated that running away increases the risk for delinquency; such findings are shared by other researchers as well (Yoder,

Whitbeck, & Hoyt, 2003; Slesnick & Meade, 2001). Hence, these vulnerable youth are 31

sometimes perceived as victims, and at other times, they are called villains (Kipke et al.,

1997; Tyler &Cauce, 2002; Baron, 2003).

Given the multiple risks to which these youth are exposed, health care providers

and researchers have become interested in their overall health status and the social

determinants that propel them away from their homes and onto the streets (Safyer et al.,

2004). Regarding physical health problems, researchers suggest that these youth are more

likely to have skin diseases (Cumella, Grattan, & Vostanis, 1998; Solsona et al., 2001),

dental pathologies (Raoult, Foucault, & Brouqui, 2001), sexually transmitted diseases

(Ennett et al., 1999), back pain and injuries (Langnase & Muller, 2001), and foot diseases

and malformations (Connolly et al., 2004). They are also more likely to experience

interrupted sleep (Conroy &Heer, 2003; Third, 2000) and continuous sleep deprivation

(Salize et al., 2002).

For emphasis, these youth are also at a greater risk for somatic manifestations

because of frequently engaging in risky sexual and drug use behaviors (DeMatteo et al.,

1999). They also participate in aggressive behaviors related to survival (Terrell, 1997;

Tyler et al., 2004) and are instructed by psychologically unhealthy role models who teach

and coach youth while they are on the run (Roy et al., 2002; Paradise & Cauce, 2002).

Poor nutritional habits are common occurrences (Langnase & Muller, 2001); infectious

diseases (Raoult, Foucault, & Brouqui, 2001) and other somatic co-morbidities are

factors that help to define the maladies that they confront each day (Salize et al., 2002).

Psychosocial and Behavioral Characteristics

Kingree, Braithwaite, and Woodring (2001) reported that youth detainees who had run away from home showed more psychosocial and behavioral problems than those 32

youth who did not have a history of running away. These youth were more likely to show evidence of depression, suicidal ideation, traumatic experiences, alcohol use, and unprotected sexual episodes than their counterparts who did not report running away.

Furthermore, MacLean and colleagues (1999) suggest that homeless youth come

from disturbing family backgrounds; experience high rates of psychological

symptomatology, and are frequently victimized. They also found that boys are more

likely to be “kicked out” of the home and girls are more likely to run away from home.

Typically, the male’s deviant behaviors lead to parental decisions to “kick out” the young

guys. Females, on the other hand, are more likely to experience sexual abuse within the

family that “forces” them onto the streets. Even though they flee one traumatic situation,

they are likely to run into numerous others (Slesnick & Meade, 2001; Rotheram-Borus et

al., 2003; Van Leeuwen et al., 2004). Despite the pathways that the youth take to the

streets, the consequences could be deleterious (Baron, 2003; Tyler et al., 2003).

The experiences of the youth can be conceptualized into two broadband factors of

behavioral problems: externalizing and internalizing. Externalizing behaviors include

gang-related behaviors, alcohol and substance abuse, school truancy and failure, crime

and delinquent behaviors, and other behaviors like attention-deficit problems, acting-out

behaviors, rule-breaking, and oppositional defiant behaviors (Becker & McCloskey,

2002; Baron, 2003). Internalizing behaviors include the inner states, such as anxiety, depression, suicidal ideation and attempts, and other behaviors, such as withdrawal and

somatic complaints (Unger et al., 1998; Tyler et al., 2003). Numerous psychometric

measures have been developed to identify and document both of these factors. Some, but

not all, of these measures include Child and Adolescent Psychiatric Assessment (CAPA) 33

(Angold et al., 1995); Diagnostic Interview for Children and Adolescents (DICA) (Reich

et al., 1995); Child and Adolescent Functional Assessment Scale (CAFAS) (Hodges &

Gust, 1995); Multidimensional Anxiety Scale for Children (MASC) (March et al., 1997);

Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1984); and Dissociative

Experiences Scale (DES): Version for Adolescents (A-DES) (Carlson et al., 1993). The

AMPI is based on the Minnesota Multiphasic Personality Inventory (MMPI), which is

designed for adults. The MMPI is the antecedent to the AMPI.

The Minnesota Multiphasic Personality Inventory (MMPI) is the gold standard in

assessment for a wide variety of mental health and behavioral conditions. The test can be

used to help appraise major symptoms of social and personal maladjustment

characteristics. It is frequently used to identify suitable candidates for high-risk public

safety positions, and support classification, treatment, and management decisions in the criminal justice and correctional settings. It can also provide the empirical foundation for a clinician’s expert testimony in the judicial system, and it is employed to evaluate and plan for treatment for individuals in substance abuse and mental health programs.

Importantly, it is used to help determine appropriate short and long term intervention approaches and strategies, and so forth (Pearson Assessments, 2005; Holifield, Nelson, &

Hart, 2002; Newsom et al., 2003).

Externalizing Behaviors

Running away exposes youth to high rates of victimization on the streets (Hoyt et al., 1999) because these runaway youth frequently engage in delinquent activities (Hagan

& McCarthy, 1997). A study done by Baron (1997) on homeless and runaway youth found that either a friend or an acquaintance had sexually victimized more than half of 34 the youth in this study. This means that the same persons with whom they have established relationships victimize many of these youth. Importantly, strangers are typically not the aggressors. It can be said that runaway and homeless youth are particularly vulnerable to sexual victimization for the following reasons:

1) They are highly visible, unsupervised, and spend long hours on the streets.

2) The youth are in close proximity to potential and active offenders who engage in

high-risk behaviors.

3) The victimized youth, as a rule, do not report crimes and acts of aggression

perpetuated against them to the police or other law enforcement officers because

they have probably also been perpetrators in other delinquent and criminal acts.

African American and Latino youth, for example, may not report crimes and acts

of aggression because of their fear of intimidation by law enforcement personnel

(Myers & Thompson, 2000; Crouch et al., 2000).

4) Offenders and perpetrators think that the victims will not report these acts of

aggression to law enforcement officers, which serves to increase the runaways’

and homeless youth’s vulnerability status.

5) The youth’s presentation of self that suggests seduction, coyness, inexperience

and vulnerability, along with their subtle but powerful communications related to

the risks for sexual exploitation, strategically position them for increased peril and

for sexual victimization (Tyler et al., 2004).

Gang-Related Behaviors

Yoder, Whitbeck, and Hoyt (2003) studied 602 homeless and runaway youth in

four Midwestern states; the majority of them (60.1%) were White (non-Hispanic). These

researchers found that 93 (15.4%) of the subjects were gang members who responded

positively (yes) to four questions: Have you ever participated in any gang activity? Have

you ever been asked to join a gang? Have you ever been through a gang initiation? Do

you belong to a gang now? Another finding of the same study revealed that 194 (32.2%) of the sample were involved in gangs. These subjects answered yes to at least one of the first three questions but answered no to the fourth question. All of the 287 youth gang members in this study reported a plethora of family and legal problems, had been suspended from school, ran away at a younger age, and used more alcohol and drugs,

than the youth who were not associated with gangs. The study also reported that these

same youth were over exposed to deviant peers, and had attempted suicide more frequently than their non-gang counterparts. In addition, the gang members reported less

parental monitoring, more severe parental abuse, increased street victimization, and more

deviant subsistence strategies than did the non-gang associated youth. In recent years, gang composition has changed. While the Midwest might still have racially and ethnically homogenous gangs, the West and East Coast gangs are becoming more diverse. The dynamics that drive the expanded diversity among gang members are related to territorial issues, power and empowerment, and collaboration around certain goals and sometimes rituals (Evans et al., 1999; Dishion, Nelson, & Yasui, 2005). This new phenomenon is not well-understood. 36

Similarly, Unger et al. (1998), in a study that included youth between the ages of

12 and 15 years, found that over one third (34%) of their subjects were affiliated with

“gang members.” This high prevalence of gang affiliation indicates that youth who run away from home in their teen years are at particularly high risk for joining gangs. These street youth resort to gangs with the expectation that they will receive social support, friendship, and physical protection. Some gangs provide a type of support system and identify confirmation that the youth’s families have failed to help the youth develop.

However, in reality, the youth are not protected-- and their sense of safety is, at best, a delusion. That is to say, these youth are lured into gangs, which have the appearance of being a safety net, but they may be stepping into a culture of intensive high risk behaviors and criminal activities (Yoder, Whitbeck, & Hoyt, 2003).

Alcohol and Substance Abuse

Street youth are a widely perceived “problem population” at risk for drug and alcohol use and abuse. Baron (1999) found a significant relationship between homeless youth and drug and alcohol use. He also reported that parental drug and alcohol use is important in understanding street youth’s alcohol and drug use. The results of this study revealed that the majority (90%) of the youth had a history of alcohol use. About 55% of the youth reported having used marijuana regularly.

Additionally, Van Leeuwen and colleagues (2004) conducted a survey on 186 homeless and runaway youth. They reported significant associations for marijuana, cocaine, and hallucinogen use in the youth’s living environments. Youth who were not living with their families (i.e. homeless or runaway) reported significantly more use of marijuana, cocaine, and hallucinogens. Another study was conducted by Slesnick and 37

Meade (2001); it involved 144 runaway youth in their examination of family therapy

outcomes with substance-abusing runaway youth. It was found that alcohol and drug

problem consequences were positively associated with longevity in out-of-home

placements.

School Truancy and Failure

Homeless and runaway youth tend to perform more poorly in school, repeat

grades more often, and experience excessive school failures than do other youth who do not report these similar exposures (Bruder, 1997). Unger et al. (1998) documented that the highest grade completed by homeless and runaway youth was associated with age.

The mean number of years of education completed was 5.0 for the 12-year-olds, 6.9 for the 13-year-olds, 8.1 for the 14-year-olds, and 8.6 for the 15-year-olds. These data suggest that if youth run away from home and become homeless at an early age, they will probably, simultaneously, become school drop-outs. Hence, two devastating events will occur at the same time (Biggar, 2001).

Academic failings engender damaging costs at several levels: the individual, the family, the community, and the nation (Biggar, 2001; Kaplan, Liu, & Kaplan, 1997;

Mccluskey, Bynum, & Patchin, 2004; Sylva & Evans, 1999). The economic and social costs associated with not educating youth who will live in a highly technical global economy could reach alarming levels in the American society (Figueira-mcdonough,

1983; Bryant et al., 2000). Researchers and policy-makers such as Stronge (1993), Bickel and Spatig (1999), and Bickel and McDonough (1997) have recommended that all responsible private and public agents and agencies must ensure that homeless and runaway youth will have the opportunity to receive the education to which they are 38

entitled. Furthermore, from a developmental perspective, educational approaches should address the youth’s desires to learn, create, and contribute to society in a productive

manner. In American society, a quality education is an equalizer, for without it, the

American value system will not be easily sustained (Biggar, 2001; Johnson &

Golomskiis, 1999; Jo, 2003).

Crime and Delinquent Behaviors

Running away is an antecedent for other problems in the society. Street youth, at

very early ages, can become involved with gangs, illegal operations like drug trafficking,

and other criminal acts (Matchinda, 1999). Researchers such as McCreery (2001) have

suggested that most street children (64.3%) come from low income homes and that

maltreatment constitutes a decisive determinant of the youth’s decision to run away from

home (Matchinda, 1999). She also suggested that other family background factors such as

parents’ level of education, family size, and home stability also contribute to their

decisions to leave home (Matchinda, 1999).

Running away, or being thrown out of the home, along with having significant

others who manifest delinquent behaviors, increase the youth’s risk for violence on the

streets (Baron & Hartnagel, 1998), delinquency (Kaufman & Widom, 1999), and other

criminal acts (Basso et al., 2004). Researchers found that being the victim of family

abuse or serious assault, having few financial resources, spending more time on the

streets, and associating with friends with criminal intent and behaviors are antecedents to

opportunities for more violence (Baron & Hartnagel, 1998; Baron, 2003; Berman, 2000).

Baron and Hartnagel (1998) also reported that the experiences of victimization in the

home and on the streets, along with the stresses of poverty, are factors that must be 39

unraveled in an effort to understand serious violent behaviors that occur among runaway

and homeless youth.

Kaufman and Widom (1999) examined the interrelationship among childhood

victimization, running away, and delinquency among 1,196 subjects. They found that

victims of child abuse and neglect were more likely to run away from home. The

correlation between running away and delinquent behavior showed a significant

relationship between running away and having been arrested. Thus, it can be inferred that

youth arrested while living on the streets or having the label of a “runaway” are more likely to have a juvenile arrest record when compared to those youth who are not

runaway youth and do not have arrest records.

In a recent study, Anooshian (2005) has written that homeless and runaway youth

are more likely to integrate violence and aggression in their own social relationships and

their repertoire of conflict-resolution skills. This researcher also reported that the violence

associated with homelessness and being on the run makes it convenient for youth to adopt

aggressive strategies when attempting to cope with multiple stressors.

Internalizing Behaviors

Runaway youth experience stress in various areas of their lives such as in their

interpersonal relationships with their parents and guardians, peers at school, authority

figures in communities, staff at shelters where they seek respite, and others. A plethora of

stressors, juxtaposed with underdeveloped coping mechanisms, help to set up

opportunities for internalized behaviors to develop and be maintained. Among this

population of vulnerable runaway youth (Menke, 2000), the internal states include

anxiety, depression, and suicidal ideation and behavior (Leslie et al., 2002; Whitbeck et 40 al., 2000; Yoder et al., 1998). Importantly, these youth are at risk for not having the opportunity to develop healthy coping mechanisms that can be used to protect them against inner states such as anxiety, and depression that can lead to hopelessness, despair, and suicidal behaviors (Yoder, Hoyt, & Whitbeck, 1998; Leslie et al., 2002).

Anxiety

Youth, who run away, are more likely to be negatively influenced by anxiety because they undergo greater anxiety-producing situations in most areas of their lives than youth who do not run away from home (Chun & Springer, 2005). Anxiety and stress affect the mental health of runaway youth and predispose them to more anxiety and stressful situations (Tyler et al., 2003). High levels of anxiety, depression, and suicidal ideation have been positively correlated with stress among runaway youth (Menke, 2000;

Huang & Menke, 2001). These internal states frequently dominate the lives of youth who run away from home.

Chun and Springer (2005) studied a sample of 53 participants from a shelter for runaway youth in Austin, Texas. The sample had a mean age of 16.5 years. Findings of this study revealed that White, non-Hispanic youth reported higher levels of stress due to anxiety than did non-White youth. The non-White youth, however, reported experiencing higher levels of stress from problems related to school, friends, and disrespect. The overall findings of this study documented that youth who run away are more likely to experience high levels of anxiety. They also suggested that living “homeless” and “on the streets” is a powerful stressor that produces high levels of anxiety and compromises well- being. Furthermore, these youth identified specific stressors that created anxiety in their lives: fear of the future; worry about day-to-day activities in their lives; their health 41

status; and death, as related to friends and family topped the list. They also mentioned

anxieties about their parents’ health status (Chun & Springer, 2005). Anxiety can be

pervasive, and a trigger for other psychiatric symptoms such as depression. Hence,

among these youth, anxiety and depression are often co-occurring (Slesnick & Meade,

2001; McCuller et al., 2001; Whitbeck, Hoyt, & Bao, 2000).

Depression

It has been established that youth with histories of maltreatment and physical

and/or sexual abuse tend to run away from home (Tyler & Cauce, 2002). These runaway

youth are at particular risk for depressive symptoms. They also view themselves as

unpopular and as having poor interpersonal relationships. The work of Whitbeck, Hoyt,

and Bao (2000) has shown that runaway youth experience high rates of family

disorganization, ineffective parenting, and physical and/or sexual abuse. Furthermore,

children who have grown up in hostile and abusive families are most likely to run away

from their homes to escape from these negative life experiences, but they are also more likely to have symptoms of depression (Whitbeck, Hoyt, & Bao, 2000). Street life experiences have strong effects on depression and co-occurring symptoms among homeless and runaway youth. Street victimization is a most powerful predictor of

depressive symptoms and co-occurring behavioral and emotional disorders among this population of vulnerable youth (Whitbeck, Hoyt, & Bao, 2000).

Suicidal Ideation and Behavior

Yoder, Hoyt, and Whitbeck (1998) studied risk factors associated with suicidal ideation and suicide attempts among homeless and runaway youth. They found that sexual abuse by a family member, knowing a friend who attempted suicide, drug abuse, 42

and the presence of internalizing factors (sense of isolation and depression) were strong

predictors of suicidal ideation/attempts among homeless and runaway youth. These

researchers suggested that there is a relationship between variables such as sexual abuse

and victimization, knowing a friend who attempted suicide, drug use and abuse, and

suicidal ideation and behavior. Abused youth who have experienced a significant amount

of emotionally upsetting circumstances are at risk for thinking that suicide might be the

option of choice when they are confronted with suicidal acts by friends, family members,

and significant others. Illicit drugs are often used to relieve the distressing internalized

states such as stress and anxiety, depression, emotional isolation, and loneliness. They are also used to cope with loss, and to escape feelings of pain and despair (Whitbeck et al.,

2004; Chun & Springer, 2005).

In recent years, suicidal behaviors have gained attention as a universal

concomitant of depression and despair that may have biological roots (Beautrais, 2001;

Conwell, Duberstein, & Caine, 2002). For example, Irurita et al. (1998) and Chirita et al.

(2000) have suggested that suicidal tendencies cluster in families. The regulation of

neurotransmitters such as serotonin and dopamine has been associated with suicide (van

Heeringen et al., 2000). On the other hand, environmental and contextual factors should

also be added to any discussion that is designed to better understand suicide in youth.

Together, the powerful influences of biology and environment overlap to tip the scale

toward or away from suicidal thoughts and behaviors (Sequeira et al., 2004; Harrington,

2001; Moscicki, 2001). Suicidal behaviors were present in 25% of the 151 females and

14% of the 197 males in a study that was conducted by Leslie et al. (2002), in that these

runaway youth had attempted suicide at least once in the past two years. Among females, 43

the researchers reported younger ages, low self –esteem, emotional distress, influences from suicidal friends, and a plethora of negative life events that converged to increase lethality among these youth. Male youth, on the other hand, were influenced by being labeled as “gay”, experiencing emotional distress, being involved in multiple conduct- behavioral problems, and avoidant reasons for drug use. The interpersonal influence of suicidal friends also predicted suicidality (Leslie et al., 2002). Low self-esteem, isolation, poor peer support, school failure and truancy, and substance use and abuse are early warning signs. These early signs and symptoms should be used to alert family members, teachers, and other health professionals to the struggles that these youth might be experiencing. This approach could lead to prevention programs implemented in schools and communities where the youth and their families could receive the help that they deserve (Yoder, Hoyt, & Whitbeck, 1998; Leslie et al., 2002; Conwell, Duberstein, &

Caine, 2002; Chirita et al., 2000; Sequeira et al., 2004).

Physical Health Status of Youth who Run Away

Sexual Health

Shields and colleagues (2004) found that female street youth were over-exposed to diseases such as Chlamydia, which will probably not be identified and treated in a timely manner. The consequences of untreated Chlamydia include pelvic inflammatory disease, ectopic pregnancy, infertility, and human immunity virus (HIV). In another study by Lifson et al. (2001), gonorrhea was reported to be one of the known sexually- transmitted diseases (STDs) among female youth who run away from home and live on the streets (Lifson et al., 2001). No discussion about sexual health is complete without considering syphilis because of its long-term effects on major organ systems in the body. 44

Syphilis, if not detected and treated, can cause blindness, deafness, sterility, incontinence,

altered cognitive functions, and untimely deaths (Vermund et al., 2001; Loughran, 2000;

Massa et al., 2003). It is of importance in studies such as this one because the incidence and prevalence of syphilis is increasing among American youth (Vermund et al., 2001;

Lifson et al., 2001; Lynn & Lightman, 2004; Center for Disease Control and Prevention,

2003).

HIV/AIDS is an additional sexually-transmitted disease that can cause serious complications among this population of youth. DeMatteo and colleagues (1999) have written that females and males participate in bartering: sexual favors are exchanged for food, housing, health care, and transportation. The youth, without marketable skills, limited education, and inadequate “street savvy” gamble with their health. Frequently, the use of condoms and negotiating for safer sexual practices with “street vendors” is not a viable option (Haignere et al., 2000; Ennett et al., 1999).

Moreover, Weinreb et al. (1998) documented that homelessness and poor sexual health status for females and males are highly correlated. Significantly, they suggest that the youth’s overall health status is at risk before the youth makes the decision to leave home. The conditions within the home, including exposure to specific physical and sexual abuses, help to create an undesirable health status. Later, other factors such as continuous exposure to stress, anxiety, and adverse environmental adversities, will negatively affect their health status.

Potential for Early Parenthood

Researchers, including Haley et al. (2004), reported that being homeless impairs one’s ability or capacity to practice effective birth control. They found that pregnancy 45 was a common reality among adolescent street youth in Canada. Among 225 participants,

41.8% had been pregnant. These female youth were more likely to have been “kicked out” of their homes than to have “run away”. They tended to be younger at the time they became homeless (mean age was 13.9 years). On the other hand, early motherhood overexposes the infant to inadequate mothering (parenting), which predisposes the young vulnerable child to high mortality and morbidity. Statistics regarding infant mortality and morbidity among young, especially African-American and Latino, mothers continue to be alarmingly high (Center for Disease Control and Prevention, 2005; Fiscella, 2004; Shi et al., 2004).

Males become fathers without the necessary resources and commitment to these newly formed “families”. Poverty, poor growth and development, and emotional disturbances are potential experiences waiting to engulf the newborn child (Herrenkohl et al., 1998; Steinberg, Kruckman, & Steinberg, 2000). Regarding the fathers, findings from

Mirowsky and Ross (2002) suggest that having a first birth early in life increases feelings and signs of depression. Young fathers, ill equipped for the responsibilities of parenthood, cannot interrupt the process that leads to high infant mortality and morbidity among the children that they produce (Miller, 1997; Coleman & Dennison, 1998). Their sense of failure, and internal states of isolation and sometimes despair, are likely to remain and perhaps intensify (Mirowsky & Ross, 2002).

Reproductive Health Conditions

Ensign (2001) described the reproductive problems that homeless and runaway female youth face. She mentioned examples related to the difficulties in handling menstruation and fertility control. Essential items such as sanitary napkins or tampons are 46

unaffordable. The difficulties related to changing and washing underwear during

menstruation was a Herculean challenge, and one that could seldom occur. Moreover,

when decisions involved choices between personal hygiene products and food, the latter

was selected. In Canada, among homeless female youth, while living on the streets, the

annual risks of sexual assault were approximately 20 per cent (Hwang, 2001). These

homeless female youth reported that they had been raped in the previous year. Such

actions expose the female youth to a variety of consequences such as the sexually-

transmitted diseases and pregnancy and other devastating internal emotional states

including depression, anxiety, and suicidal ideation (Hwang, 2001).

Dermatological Conditions

Homeless children are predisposed to skin problems and edema resulting from

malnourishment, poor circulation, ill-fitting shoes, cuts and soiled clothing. Common

skin problems observed among homeless and sheltered youth included atopic dermatitis,

impetigo, scabies, and seborrheic dermatitis. Pediculosis infestations were also common among the youth (DiMarco, 2000; Sasaki, Kobayashi, & Agui, 2002; Rolain et al., 2002).

The lack of adequate places for bathing, personal hygiene, washing clothes, shampooing hair, and storing items, create a scenario that makes it practically impossible for youth to care for their skin in the most basic manner (Raoult, Foucault, & Brouqui, 2001).

Furthermore, DiMarco (2000) documented the presence of various skin conditions: body and head lice, scabies, rash, chicken pox, fungal infections, and burns were common occurrences. Chronic skin conditions help to assure that the youth will experience poor health outcomes (DiMarco, 2000; Sasaki, Kobayashi, & Agui, 2002; Rolain et al., 2002).

Neuro-Skeletal Conditions

Injuries from trauma are among the top three or four conditions treated by those providing health care to homeless and runaway youth (Wright et al., 1998). Homeless and runaway children are at a high risk for neuro-skeletal problems because they are often victims of violent crime, such as rape, assault and robbery. Lacerations and wounds are the most common of the traumas, followed by sprains, bruises and fractures (Wright et al., 1998). Runaway youth may also develop peripheral vascular disease. This is the result of constant forced walking; they seldom have the opportunity to rest in a comfortable position. Conditions such as edema, thrombosis, cellulites, and ulceration are potential outcomes. Poor physical and mental hygiene and exposure to harsh elements in the environment further increase the possibility of infections. In extreme cases, these conditions can result in gangrene and amputations (Wright et al., 1998).

Hwang (2001) has written that homeless and runaway children in Canada suffer from injuries and burns. She reported that 14 per cent of the youth in her sample had been burned sufficiently to produce a scar, and 8 per cent had been hospitalized because of injury. She suggested that these youth are at-risk for neuro-skeletal disorders that could have a long-term effect on their lives.

Oral Health Problems

DiMarco (2000), a nurse practitioner, reported that a common health concern observed in many runaway and homeless youth was dental caries. Researchers have begun to emphasize the deleterious influence that poor dental health has on children; it is the most common pathway to infections and gastric related disorders among this population (Buttriss, 2002). Nevertheless, many homeless and runaway youth have never 48

been examined and treated by a dentist. Large numbers of these youth are in need of

dental surgery and medical follow-up. The possibilities of them ever receiving dental

assistance is minimal because of the lack of access to care, cost related factors, and

deficits in health literacy (Nabors et al., 2004; Hatton et al., 2001). Additionally, Beetstra

et al. (2002) found that malnutrition, poor oral hygiene, tobacco use and trauma, wreak

havoc on the oral and general health of homeless and runaway youth. Among the most

common problems seen in this population are profound dental decay requiring extractions

or root canals, periodontal (gum) disease, and missing teeth (DiMarco, 2000).

Sleep Deprivation

For most people, sleeping is difficult in the noisy atmosphere of shelters or on the

streets. Sleep disorders cause irritability, apathy, and behavioral impairment (Roberts,

Roberts, & Chen, 2001; Strine & Chapman, 2005). Among homeless and runaway youth

(National Coalition for the Homeless, 2001), sleep deprivation is one of the earliest deficits that the youth confront (National Coalition for the Homeless, 2001; Cooley-

Quille & Lorion, 1999). In addition, because the streets are unsafe, the youth are typically anxious and report that they must quickly learn to sleep with “one eye open,” and be ready to protect themselves from human perpetrators at an instance (Baron & Hartnagel,

1998; Craig & Hodson, 2000). It has been estimated that almost 40 per cent of homeless and runaway children are assaulted every year (Hwang, 2001). This is one reason why these youth are typically anxious, sleep deprived, fearful, and depressed (Hwang, 2001).

It has been documented that life in shelters and many insecure accommodations, like the streets, is noisy, chaotic, anxiety-producing, and often violent. Residents are usually required to leave the premises each morning; many walk aimlessly about the 49

streets during the daylight hours. Over time, sleep deprivation can produce apathy and /or

behavioral impairment. The youth are likely to experience emotional difficulty, school

failure, and a loss of hope (National Coalition for the Homeless, 2001).

Child Abuse in the Life of Runaway Youth

There are many potentially devastating impacts associated with child abuse (Kurtz

et al., 1991; Seiglie, 2004; Stevenson, 1999). The following disorders and conditions are the frequently reported long-term psychological sequels that result from child abuse: these devastating outcomes include depression (Springer, Sheridan, Kuo, & Carnes,

2003; Ullman & Brecklin, 2003); substance abuse (Denov, 2004; Beutel, 1999); anxiety

(Feerick & Snow, 2005); and dissociative identity disorder (American Psychiatric

Association, 1994; McEwen, 2003). Still, other deleterious consequences such as aggressive and violent behavior (McGuigan & Pratt, 2001; Hartley, 2002); nonviolent

criminal behavior (Nolan et al., 2002; Komen, 2003; Salter et al., 2003); emotional

problems (Thompson & Wyatt, 1999; Alexander et al., 2000); and academic difficulties

(Cerny & Inouye, 2001; Powell, 2003) have also been documented.

The following section provides details about three types of child abuse: child

sexual abuse; child physical abuse; and psychological abuse. Each of them will be

discussed in the following pages.

Child Sexual Abuse

Child sexual abuse is typically defined as any sexual contact, coerced or

otherwise, between an adult and a child less than 18 years of age. This may include

intercourse, oral contact, fondling, and exhibitionism (Haugaard, 2000). Browne and

Finkelhor’s (1986) review article is still considered the seminal work on the impact of 50

child sexual abuse. These authors reported that child sexual abuse results in long-term

psychological consequences. For emphasis, they documented the following symptoms as

the most frequently reported long-term psychological costs that result from child sexual

abuse: depression; suicidality; substance abuse; sexual dysfunction; anxiety;

posttraumatic stress disorder; dissociation; dissociative identity disorder; and borderline

personality disorder (Browne & Finkelhor, 1986).

In summary, child sexual abuse victims conclusively show evidence of greater

sexual dysfunction, depression, and other internal states. Other commonly reported

effects include suicidality, substance abuse, anxiety, PTSD, dissociation, multiple

personality disorder, and borderline personality disorder. Furthermore, the relationship

between age of onset of sexual abuse and impact is inconclusive. There is some evidence

that longer duration and greater frequency of abuse is associated with a larger impact.

Evidence suggests that abuse perpetrated by a close family member (especially father or step-father for females) leads to more severe long-term disturbance (Heger et al., 2002;

Tyler & Cauce, 2002). Furthermore, there is confirmation that abuse involving sexual penetration also leads to more harsh and disturbing consequences (Browne & Finkelhor,

1986; Whealin et al., 2002; Kogan, 2005).

Child Physical Abuse

Knutson (1995) states that physical abuse is “typically defined as an act of commission by a child caretaker, but the definition may specify an act, an act and a consequence, or merely a consequence” (p. 404). Often, the presence of any injury to the child is included in the definition (Knutson, 1995; Malinosky-Rummell & Hansen, 1993). 51

Malinosky-Rummell and Hansen’s (1993) report is considered the only

comprehensive review of long-term effects of child physical abuse. They divided the consequences into seven domains, which include aggressive and violent behaviors; nonviolent criminal behaviors; emotional problems; substance abuse; self-injurious and suicidal behaviors; interpersonal problems; and academic and vocational difficulties

(Malinosky-Rummell & Hansen, 1993). Findings such as these could be used to develop early intervention programs designed to forestall and prevent the far reaching consequences of child physical abuse. Importantly, these data could also be used to help prevent child abuse.

It can be concluded that being physically abused appears to negatively affect development in all aspects: cognitive, physical, social and emotional. These youth may manifest violent or delinquent behavior, neurological abnormalities, and cognitive impairment. They are candidates for psychiatric services that could extend over a lifetime

(Reinemann et al., 2003; Treuer, Koperdak, Rozsa, & Furedi, 2005; Meyerson, Long,

Miranda, & Marx, 2002).

Child Psychological Abuse

Psychological maltreatment or abuse appears to be more prevalent and potentially more destructive than other forms of child abuse and neglect (Higgins & McCabe, 2001).

The National Center on Child Abuse and Neglect (2003) states that this is the most frequently occurring type of abuse, involving approximately 1.7 million children.

The most widely accepted definition of psychological abuse was proposed at the

1983 International Conference on Psychological Abuse of Children and Youth:

“psychological maltreatment of children and youth consists of acts of omission and 52

commission which are judged by community standards and professional expertise to be

psychologically damaging. Such acts are committed by individuals, singly or collectively,

who by their characteristics (e.g., age, status, knowledge, organizational form) are in a

position of differential power that renders a child vulnerable. Such acts damage

immediately or ultimately the behavioral, cognitive, affective, or physical functioning of

the child.” Examples of psychological maltreatment include acts of rejecting, terrorizing,

isolating, exploiting, and mis-socializing (Engels, Moisan, & Harris, 1994, p. 595;

Glaser, 2002).

Like other forms of child abuse, the effects of psychological abuse, so called

maltreatment, can be devastating. The most clear-cut, isolated effect of psychological

abuse alone seems to be a decreased self-esteem (Romano & De Luca, 2001; Haj-Yahia,

2001). Furthermore, in combination with other forms of abuse, it seems to exacerbate the

severity of pathology, and increase the symptoms of anxiety, dissociation, and borderline

personality disorder (Singh Narang & Contreras, 2000; de Paul & Domenech, 2000).

Summary

Running away is a significant problem in the American society. Runaway youth are a vulnerable population with histories of sexual, physical, and emotional abuse, neglect and sometimes abandonment. After running away from home, these youth experience a plethora of physical, emotional and mental health problems. This study assumes that these youth who run away from home have embedded psychosocial characteristics and behavioral manifestations that differentiate them from similar youth that have not run away. This proposed study was designed to explore these characteristics and the manifestations of these runaway youth. 53

We now turn to a discussion about the methodology of the study that will be employed to explore the delineated research questions. The following chapter provides information about the study design, the setting, the subjects, protection of human subjects, and data analyses.

Chapter III

METHODS

This study utilized data from a previous investigation that was conducted in north

central Florida. The investigator invited the youth to participate in face-to-face interviews

between the months of June, 1991 to January, 1992. All youth who participated in this

study were residents at a shelter for youth who run away, Jennyplace.

Study Design

Purpose and Design of the Original Study

The original study consisted of a descriptive, correlational design. Its purposes were to (a) describe the identifiable characteristics of a population of runaway youth; (b) document certain aspects of the youth’s current and past life events such as alcohol and drug use/abuse, and histories of physical or sexual abuses; (c) document run histories and life events; (d) examine possible ways in which health and mental health practitioners can best assist these youth and their families through times of crisis; and (e) examine the relationship between the AMPI subscales and other selected behaviors among the youth.

The Setting: Jennyplace

Jennyplace is a shelter for runaway youth, located in a rural community in north central Florida. It is designed to house 20 runaway youth, 10 boys and 10 girls. This shelter serves youth from a 50-to100-mile radius, representing rural and semi-rural communities in Florida. However, some of the Jennyplace residents are from other regions of the State and nation. Youth are admitted to the shelter through referrals and

“pick-ups” from law enforcement officers, self-referrals from the streets and while ‘on 55 the run’, the Department of Children and Families, the juvenile courts, and through parents and guardians who request assistance with their children, primarily because of their “acting out” behaviors. Jennyplace can accommodate females and males, but larger numbers of the youth in residence were female.

Sample of the Original Study

The researchers interviewed 78 youth who were housed at a shelter for runaway youth. The interviews occurred over a seven-month period. The 78 subjects represented

10 percent of the youth admitted to the shelter during this time. The sample (n=78) was

84.6 percent White and 15.4 percent African-American. The ages ranged from 11 to 17 years, with a mean age of 14.55 years. Approximately 55 percent of the youth were females and 45 percent were males (Table 1).

Table1. Demographic Characteristics of Youth in a Runaway Shelter Gender (n=78) Race (n=78) Female 43 African- 8 (55.1%) American (10.3%)

White 35 (44.8%)

Male 35 African- 4 (44.9%) American (5.1%)

White 31 (39.8%)

Procedure and Data Collection of the Original Study

Before data collection began, the researcher discussed the study with the

executive director of Jennyplace, and shared the stated purpose of the study with the board of directors and the staff. The principal investigator also provided opportunities for

the board of directors and the staff to query the researcher about the study and its

purpose. Data collection and storage, as well as issues regarding confidentiality, were

also discussed with them. In addition, the potential contributions of this study to the

scientific literature and to practical approaches for addressing this vulnerable group of

youth were expounded upon with the board of directors and the Jennyhouse staff.

Before the research process began, the principal investigator instructed the other

members of the research team using the following topics as guides: basic information

about homeless and runaway youth; confidentiality; voluntary nature of the interviews;

anonymity of data and subsequent use of the data; benefits that would accrue if the youth

participate; and the protection of the youth from queries from agents and agencies

regarding their reported behaviors. Furthermore, the research team members were

instructed not to use pressure or coercive tactics to persuade the youth to respond to

questions that provoked discomfort and emotional upset. Before the actual face-to-face

meetings with youth at the shelter, the members of the research team were given the

opportunity to engage in a mock interview with another team member. In this way, each

team member had practice sessions designed to help with developing proficiency in

writing answers to open-ended questions in longhand. None of the interviews was tape-

recorded. Hence, researchers relied on the accuracy of hand-written responses, with the

youth validating the recording of each item that was written on the page. 57

Researchers were doctorally or masters-prepared psychiatric nurses or psychologists who were instructed about the psychometric properties of the Structured

Clinical Interview Instrument, the Adolescent Multiphasic Personality Inventory, and the

Coddington’s Life Events Scale. Before the youth were approached, the researchers had attained in-depth knowledge about all of the instruments that were to be used in the study.

Youth at Jennyhouse were invited to participate in the study if they were (a) willing to take part in the study; (b) able to read and write at the fifth grade level and; (c) not under court order or some other judicial restrictions. During the course of the study, the researchers introduced themselves to the youth, and asked for their permission to discuss the purpose of the study with them. If the youth agreed to discuss the study with the researchers, the youth would be invited to a private quiet place where there were chairs and a table, in an area that was away from the pedestrian traffic in Jennyhouse.

During the interview, there was no pressure or coercion placed on the youth to respond to any item that they felt was too sensitive for them or that produces a visible discomfort.

Thus, the youth were not required to reply to questions that they perceived as intrusive or upsetting. This approach resulted in many responses that were left partially or fully unanswered. The youth were informed that each interview would take approximately one-and-one-half hours.

Design and Sample of Current Study

This study is a secondary analysis of data from the original study. The sample consisted of 78 youth who were recruited for the purpose of the original study. The sample was comprised of 43 females and 35 males between the ages of 11 to 17 years.

The mean age of the sample was 14.55 years. 58

Sample Size Determination

Based on a formulation of 80% power, an effect size of 0.35 (R²= 0.25), at least

10 predictors, and a significance level of 0.05 for a two-tailed test, a sample of 65

subjects was deemed sufficient to address the research questions. The GPOWER

Computer Software was used to calculate the required sample size (Erdfelder, Faul,

&Buchner, 1996).

Research Measures

Several data collection instruments were used in this study. Each is discussed in

the next section.

Structured Clinical Interview Instrument

The Structured Clinical Interview Instrument has 13 sections that describe certain aspects of the youth’s current and past situations, such as alcohol and drug use/abuse, history of physical or sexual abuse, recall of school attendance, legal entanglements, and so forth, along with demographic items. Most of the items included in the questionnaire were open-ended questions that required in-depth responses. The researcher and a graduate research assistant, independent of one another to ensure interrater reliability and accuracy, then coded each quantitative and/or qualitative response. The test-retest reliability of the instrument was 0.82 (Gary, Moorhead, & Warren, 1996). Variables that were used from the Structured Clinical Instrument for the current study were: age, gender, ethnicity, living arrangements, reason for placement in the shelter, number of previous runs, alcohol use, parents’ alcohol use, sibling alcohol use, history of arrests, age at first sex, sex learning, physical or emotional abuse, and sexual abuse. 59

Age was asked as the number of years then it was entered into the SPSS software.

Gender was measured by the following item: “Sex: 1-female 2-male” then it was coded

as 1 female, 2 male. Ethnicity was asked in the following format: “Ethnicity: 1-

White/European American 2-African-American” then it was coded as 0 White, 1 African-

American. Living arrangements question was: “Living (current living arrangement): 1-

parents, 2-other family, 3-shelter, and 4-other.” Coding for this variable was as follows:

“1 parents, 2 other family, 3 shelter, 4 other.” Reasons for placement in the shelter were asked in the following way: “Placement (reasons for placement): 1-runaway, 2-beyond control, 3-truancy, 4-throwaway/homeless, 5-dependency, 6-other”; then it was coded as:

“1 runaway, 2 beyond control, 3 truancy, 4 throwaway/homeless, 5 dependency, 6 other.”

Number of previous runs was asked directly as “number of previous runs.” Youth whose answers were zero were coded as “1 non-runaway,” while those subjects who reported a number greater than zero were coded as “0 runaways.” Number of previous runs ranged from zero to 20. This variable was used for the purpose of statistical analysis of youth runaway behavior in this study.

Alcohol use was measured by the following item: “Do you use alcohol? 1-yes, 2- no”; then it was coded as: “1 yes, 2 no.” Parents’ alcohol use was asked as: “Parents’ use of alcohol: 1-yes, 2-no”; then it was coded in the following manner: “1 yes, 2 no.”

Sibling alcohol use was measured by the following item: “Do any siblings drink alcohol?

1-yes, 2-no.” Coding of this variable was as follows: “1 yes, 2 no.”

History of arrests question was: “Have you been arrested?” History of arrests coding was: “1 yes, 2 no.” Age at first sex was measured by the following item: “Do you remember how old you were when you first had sex?” Then it was coded in the following 60

format: “1 yes, 2 no, 88 not applicable.” Sex learning was asked in the following format:

“How did you first learn about sex?” Coding for this variable was as follows: “1 parents,

2 boyfriend/girlfriend, 3 school counselor, 4 health education, 5 other.” Physical or

emotional abuse question was: “Do you feel you have been abused?” This variable then

was coded as: “1 yes, 2 no.” For sexual abuse, the following question was asked: “Have

you ever been sexually abused?” Coding for this item was as follows: “1 yes, 2 no.”

(Appendix A; Appendix B).

Adolescent Multiphasic Personality Inventory

The Adolescent Multiphasic Personality Inventory (Duthie, 1985) is a brief test of

psychopathology designed specifically for an adolescent population (ages 12-19 years

old). The 133-item AMPI has 3 validity scales and 10 clinical scales. The 3 validity

scales of the AMPI are: Lie (LIE), Infrequency (FAK), and Correction (KOR). The 10

clinical scales are: Hypochondriasis (HYP) (Scale 1), Depression (DEP) (Scale 2),

Hysteria (HYS) (Scale 3), Psychopathic Deviate (PPD) (Scale 4), Femininity (FEM)

(Scale 5), Paranoia (PAR) (Scale 6), Psychasthenia (PAS) (Scale 7), Schizophrenia (SCZ)

(Scale 8), Hypomania (MAN) (Scale 9), and Social Introversion (SIN) (Scale 0). The

AMPI was tested and re-tested with adolescents, and reliability and validity studies were

carried out with adolescent populations (Duthie, 1985; Vincent & Duthie, 1987).

The psychometric properties of the AMPI correlate highly with the Minnesota

Multiphasic Personality Inventory (MMPI), the Diagnostic Inventory of Personality and

Symptoms, and the Symptom Checklist-90-Revised (SCL-90-R) (Duthie, 1985). The

AMPI is considered a useful measure of personality and psychopathology in an

adolescent population (Minarik et al., 1997). 61

The AMPI is one of the instruments that were used in this proposed study. This

inventory explores the personality characteristics and the externalizing/internalizing

behaviors of the vulnerable youth, who were residing in a shelter for runaway youth in

the current study. Major advantages of this instrument include the comprehensive and

accurate nature of clinically relevant descriptors and the relative ease of administration

and scoring (Duthie, 1985).

It should be noted that the AMPI does not directly measure aggression. However,

the interview guide does have questions that refer to externalizing and internalizing

aggression (Duthie, 1985). The externalizing behaviors as measured by the AMPI are the

Lie (LIE) Scale, the Correction (KOR) Scale, the Hypochondriasis (HYP) Scale, the

Hysteria (HYS) Scale, the Paranoia (PAR) Scale, the Hypomania (MAN) Scale, and the

Social Introversion (SIN) Scale. Externalizing behaviors include actions such as high

activity, short attention span/distractibility, and high reactivity (Young Mun, Fitzgerald,

Von Eye, Puttler, & Zucker, 2001), threatening behavior, and rule-breaking actions

(McFarlane, Groff, O’Brien, & Watson, 2003). It also involves a variety of destructive

behaviors such as fighting, bullying, using profane language, and the use of substances

(Paley, O’Connor, Kogan, & Findlay, 2005; Rubin, Burgess, Dwyer, & Hastings, 2003).

On the other hand, the AMPI measures the internalizing behaviors through the

Infrequency (FAK) Scale, the Depression (DEP) Scale, the Psychopathic Deviate (PPD)

Scale, the Femininity (FEM) Scale, the Psychasthenia (PAS) Scale, and the

Schizophrenia (SCZ) Scale (Duthie, 1985). It should be noted that the Infrequency (FAK)

Scale measures the youth’s patterns of truth telling as related to these queries (Duthie,

1985). These internalizing behaviors include negative emotions such as depression, 62 anxiety, loneliness, withdrawal, frustration, and suicidal ideation and risk (Fine, Izard,

Mostow, Trentacosta, & Ackerman, 2003; Young Mun, Fitzgerald, Von Eye, Puttler, &

Zucker, 2001; Oldehinkel, Hartman, De Winter, Veenstra, & Ormel, 2004; McFarlane,

Groff, O’Brien, & Watson, 2003).

How to score the AMPI

The initial step in scoring the AMPI is to obtain the raw score values for the desired scale. The second step in scoring is to obtain the T-score values, separately for boys and girls, corresponding to raw scores for each of these scales. A final step is to obtain scores for the factor-based groupings of the AMPI Structural Summary. The procedure for obtaining raw scores is as follows: Initially, the clinician should examine the answer sheet and identify omitted and double-marked items. The examiner could draw a red line through the True and False circles for these items which can be easily viewed through the answer keys to avoid including them in the scoring. The examiner then counts the number of omitted and double-marked responses and transfers this numerical value to the space indicated for the Raw Score at the bottom left corner of the

AMPI Profile for Basic Scales sheet (Duthie, 1985).

Several points are worth attending to in the course of hand-scoring the AMPI.

First, the examiner should note that there is a separate scoring template for each scale.

The examiner would minimize errors by ensuring that the templates are organized in the correct order and proceeding sequentially across each set of scales. In hand-scoring the basic scales, it should be noted that there are two templates for scale 5 (Masculinity-

Femininity), one for males and one for females, and only one of them would be used based on the sex of the adolescent examinee (Duthie, 1985). 63

Computerized scoring procedures

Computer scoring yields either a Basic Scale Profile Report or an Extended Score

Report. The Basic Scale Profile Report provides a single-page profile of the validity and

clinical scales and lists the raw and T scores for each scale. This report also gives some

additional information, such as the Response Rate for each scale, and the Percent True

and Percent False response rates, which are auxiliary indices to detect whether the

adolescent has responded with a style that disregards item content (Duthie, 1985). In

addition to the Basic Scales Profile, the Extended Score Report offers a separate Content

Scale Profile followed by a Supplementary Score Report, which lists the raw and T

scores for the supplementary scales. It also provides a printout of the item responses

paralleling the answer sheet (Duthie, 1985). This research is based on the scores and profiles that were generated by the computerized scoring system that was provided by the developers of the AMPI.

Scores of the externalizing and the internalizing behaviors were calculated by the

following format. For the externalizing behaviors, the individual scores of Lie,

Correction, Hypochondriasis, Hysteria, Paranoia, Hypomania, and Social Introversion

were summed-up then the total score of these seven subscales was entered into the SPSS

software as one composite score. Six subscales of Infrequency, Depression, Psychopathic

Deviate, Femininity, Psychasthenia, and Schizophrenia were totaled to get one composite

score of the internalizing behaviors and then it was entered into the SPSS software

(Appendix A; Appendix D).

Coddington’s Life Events Scale

The Coddington’s Life Events Scale (LES for Children and Adolescents)

(Coddington, 1972) is used to assess for life events related to childhood. Each life event has a weighted severity rating, which is a numerically scaled estimate of the degree of readjustment that is required to cope with or accommodate to the event (Coddington,

1972).

According to Coddington (1972), adolescent girls in junior or senior high school incur a total mean score of approximately 218, based on life events recorded in a 1-year time period. The approximate upper limit scores for 75% of an adolescent population

(both boys and girls) during a 1-year period are as follows: 110 for youths between the ages of 8 and 10, 135 for those between the ages of 11 and 13, 170 for those between the ages of 14 and 16, and 200 for those between the ages of 17 and 19 (Coddington, 1972).

The same measure was used with all the subjects regardless of their age, but the interpretation of the results changes depending on age group. Given that classification into the high group is dependent on age, another variable that considered age was created.

For example, the upper limit for the age group between 8 and 10 years is 110. So, if a youth had a score higher than 110, then he/she would be considered as ‘having high life events score.’ These subjects were coded as 2 (high) in the SPSS software. Other subjects who scored less than the upper limit for their age group (i.e. less than 110 for the ages of

8 to 10; less than 135 for the ages of 11 to 13; less than 170 for the ages of 14 to 16; and less than 200 for the ages of 17 to 19 years) were coded as 1 (normal) in the SPSS software (Appendix A; Appendix C).

The variables and measures are depicted in Table 2, which follows. 65

Table 2. Variables and their Measurement Variables Instruments

Personality characteristics:

Externalizing and Internalizing Behaviors -AMPI

Runaway Behavior -Structured Clinical Interview

Sexual Abuse - Structured Clinical Interview

Life Events (12 Months) -Coddington’s LES

Procedures for Analyzing Data for the Current Study

Coding and Data Entry

This current study required that all data be reviewed, and entered into the computer. The researcher entered the data, and coded some of the variables. The AMPI profiles were analyzed using the electronic version of the program that was purchased for data analysis. This program provides a profile for each of the youth, which includes the three validity scales and the 10 clinical scales. The scores from each of the scales were entered into the SPSS 11.00 for Windows statistical analysis program (2001). Data from the Structured Clinical Interview Instrument and the Coddington’s Life Events Scale were hand-coded and entered into the SPSS 11.00 for Windows statistical program

(2001).

Data Analysis Plan

The Statistical Program of SPSS 11.00 for Windows (2001) was used for data analyses. Statistical analysis began with preparatory activities such as the treatment of missing data, identification of outliers, and other activities such as data cleaning tasks.

The distributions of all obtained measures were plotted graphically for visual inspection regarding deviation from normality. Visual examination of scatter plots, histograms, and other graphical summaries were used to identify possible associations of interest and provide quick but accurate information about the data. A p-value of less than

0.05 was considered statistically significant.

Descriptive statistics were used to determine frequency distributions, percentage distributions, means and standard deviations, and inclusive ranges as evidenced by the data. Analysis of frequency (chi- square), correlation analyses, logistic regression analysis, and 2-group t-test analysis were used to address the research questions (Burns &

Grove, 1997; Tabachnick & Fidell, 2001; Osborne & Elaine, 2002). Before running the analyses for research question one, research question two, and research question three, and to explore if the researcher might needed to control for certain variables, Chi-Square analyses were calculated for both ethnicity and gender, and a two-group t-test was run for age with the outcome variable of runaway behavior.

Research Question One

What is the association between life events in the past 12 months and the youth’s runaway behavior?

Two-group t-test was used in analysis for the purpose of answering this research 67

Question. The predictor variable (life events in the past 12 months), and the outcome

variable (the runaway behavior) were entered alone into the system in the first equation.

Next, both the predictor variable and the outcome variable were entered along with the

control variable (the ethnicity) into the same equation using logistic regression.

Research Question Two

What is the association between being sexually abused/non-sexually abused and the youth’s runaway behaviors?

To answer this research question, Chi-Square analysis was conducted to examine

the relationship between the independent variable (sexual abuse) and the dependent

variable (the runaway behavior). Secondly, the relationship between the independent

variable (sexual abuse) and the dependent variable (the runaway behavior) was examined

while controlling for the youth’s ethnicity using logistic regression.

Research Question Three

What is the association between externalizing and internalizing behaviors and the youth’s runaway behavior?

Four separate logistic regressions were conducted to examine this research question. In the first equation, the independent variable (externalizing behaviors) was entered with the dependent variable (runaway behavior). Second, the other independent variable (internalizing behaviors) was entered with the dependent variable (runaway behavior). After that, the two independent variables (externalizing and internalizing behaviors) were entered together into the logistic regression equation. Lastly, both the independent variables (externalizing and internalizing behaviors) were entered into the 68

fourth logistic regression equation with the dependent variable (runaway behavior) along

with the control variable (ethnicity).

Protection of Human Subjects

The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research identified three ethical principles that are relevant to the

conduct of research involving human subjects (Burns & Grove, 1997). These principles

consist of respect for the person, beneficence, and justice. The principles were evident in

all aspects of this study (The National Commission for the Protection of Human Subjects

of Biomedical and Behavioral Research, 1979).

The Committee for the Protection of Human Subjects at the University of Florida

approved this study. After the study was approved, the principal investigator presented

the study to the Board of Directors of Jennyhouse for their review and endorsement. The

researchers then proceeded to discuss the study with the Jennyhouse staff. Each staff

person was given ample time to ask questions, and to discuss how this research could

help youth in the future.

During the data collection period, the researchers visited the shelter three days

each week, and youth who were at the shelter were invited to participate in the study if

they met the pre-determined criteria. The researchers approached the youth in a

professional manner, introduced themselves, and asked the youth if they could have a

conversation about the study. The researcher proceeded by asking the youth for a few

minutes of their time. If the youth agreed, the researcher and the youth would proceed to

a private and quiet room at the shelter where the purpose of the study would be explained

in detail. The Informed Consent was read to the youth as they followed along as the 69 researcher read aloud the contents of the document. The researcher would then ask the youth to query them about the study. They did. All questions and concerns were satisfactorily answered before the researcher asked the youth to sign the Informed

Consent Form, indicating that they understood the purpose of the study. After the document was signed, the youth received a copy of the signed Informed Consent Form, and the researchers retained a copy of the document for their files. The youth were then asked to prepare for the interview that might have occurred at that time. Some interviews were scheduled for later in the day or for another time during the week. Regardless of the time of the interview, the youth were again informed that the face-to-face interview would last for about one-and-one-half hours. The youth were also informed that they did not have to respond to any questions that they did not feel comfortable with answering, and that the researchers would in no way pressure them to respond. At the end of the face-to-face interviews, the researchers thanked the youth, and walked with them into the dayroom where others were engaged in activities.

All interviews were confidential and the contents of the interview were not shared with anyone except the research team members. There was one exception: The youth were explicitly informed that if they reported abusive situations in their lives, within the context of the home, the school, or the community, then this information would be shared with the staff for appropriate action. However, since all of the youth who were admitted to Jennyhouse had been interviewed and assessed by Jennyhouse staff, concerns about physical, sexual, and emotional abuse had been addressed. Nevertheless, the researchers were sensitive to this issue and kept open all lines of communication with the Jennyhouse staff. 70

In most instances, the youth at the shelter were under the custody of the

Department of Children and Family Services. Legal and social services professionals

would consider the youth’s best interest when determining their future disposition. That

is to say, some youth may have been placed in foster homes, or group homes, or some

other therapeutic environment. Still, other youth might have been referred back to their families with some type of intervention plan implemented to help the youth find other methods of communicating their displeasure with familial life. The Department of

Children and Families approved this research. Parental consents were not obtained.

CHAPTER IV

RESULTS

The purpose of this study was to describe the personality characteristics of youth that attended Jennyplace and determine the association of the youth’s personality characteristics, life events in the past 12 months, and history of sexual abuse with their decisions to run away from home. The sample consisted of 78 youth, 11 to 17 years old, who were admitted to a shelter for runaway and homeless youth. Some of these youth

(n=29) were placed in the shelter for reasons other than being a runaway. These reasons include beyond control, truancy, throwaway/homeless, and dependency. Specifically, the study was created using a descriptive, correlational design to: (1) describe the demographic characteristics of the youth in the study sample in terms of age, gender, ethnicity, living arrangements, reason for placement in the shelter, number of previous runs, alcohol use, parents’ alcohol use, sibling alcohol use, history of arrests, age at first sex, sex learning, physical or emotional abuse, and sexual abuse; (2) determine the association between life events in the past 12 months and the youth’s runaway behavior;

(3) determine the association between being sexually abused/non-sexually abused and the youth’s runaway behavior; and (4) determine the association between externalizing and internalizing behaviors and the youth’s runaway behavior. This chapter provides a summary of the results.

Description of the Major Study Variables

Table 3a and Table 3b present the frequencies for life events in the past 12 months, history of sexual abuse, personality characteristics as measured by the 72

externalizing and the internalizing behaviors, and the runaway behavior. These results are shown here for descriptive purposes.

Table 3a shows that the life events variable ranged from 2 to 200, with a mean of

123.68 and a standard deviation of 45.81. According to Coddington (1972), the approximate upper limit scores for 75% of an adolescent population (both boys and girls) during a 1-year period are as follows: 110 for youths between the ages of 8 and 10; 135 for those between the ages of 11 and 13; 170 for those between the ages of 14 and 16; and 200 for those between the ages of 17 and 19 (Coddington, 1972). The same measure was used with all the youth regardless of their age, but the interpretation of the results changes depending on age group. Provided that classification into the high group is dependent on age, another variable that took age into consideration was created. For example, the upper limit for the age group between 8 and 10 years is 110. So, if a youth had a score higher than 110, then he/she would be considered as ‘having a high life

events score.’ These youth were coded as 2 (high) in the SPSS software. Other youth who

scored less than the upper limit for their age group (i.e. less than 110 for the ages of 8 to

10; less than 135 for the ages of 11 to 13; less than 170 for the ages of 14 to 16; and less

than 200 for the ages of 17 to 19 years) were coded as 1 (normal) in the SPSS software

(Table 3b). This frequencies table of the life events in the past 12 months (Table 3b)

shows that some of the youth in the sample (n=14) scored over the upper limit according

to their age group.

For the sexual abuse variable, 73 of the youth were valid cases (answered either

‘yes’ or ‘no’ to this question) and five cases were missing (6.4%). Among the 73 youth

who answered the question of being sexually-abused/non-sexually abused, 25.6% (n=20) 73

gave a positive answer (0*); the remaining 53 youth (67.9%) indicated that they had never been sexually abused (1*) (Table 3a).

The externalizing behaviors composite score ranged between 283 (minimum composite score) and 541 (maximum composite score), with a mean of 374.48. The internalizing behaviors minimum score was 240 and the maximum score was 420. The mean of the internalizing behaviors score was 315.65. Seven cases out of the 78 cases were missing (9.0%); these seven cases were the same for both the externalizing and the internalizing behaviors.

Depending on the number of previous runs, youth who reported zero as the number of previous runs were coded as non-runaways (1**), and youth who reported a number larger than zero were coded as runaways (0**). Forty-nine youth (62.8%) were runaways and the remaining 29 (37.2%) were non-runaways (Table 3a).

Table 3a. Descriptive Statistics of Main Study Variables Variable n Mean SD Range Life events in the 70 123.7 45.8 2-200 past 12 months Sexual abuse 73 .73 .5 0-1* Yes 20 (27.4) No 53 (72.6) Externalizing behaviors 71 374.5 43.8 283-541 Internalizing behaviors 71 315.7 39.5 240-420 Runaway behavior 78 .37 .5 0-1** Yes 49 (62.8%) No 29 (37.2%)

* 0 indicates sexually-abused 1 indicates non-sexually-abused ** 0 indicates runaway

1 indicates non-runaway 74

Table 3b. Frequencies of Life Events Scores According to Age Group

n %

Normal* 56 71.8

High** 14 17.9

Missing 8 10.3

Total 78 100

* Normal=1 (score less than the upper limit according to age group)

**High=2 (score higher than the upper limit according to age group)

Results of Analysis of the Research Questions

Demographic Characteristics of the Sample

Frequencies were used to describe the demographic characteristics of the youth in the study sample in terms of age, gender, ethnicity, living arrangements, reason for placement, number of previous runs, alcohol use, parents’ alcohol use, sibling alcohol use, history of arrests, age at first sex, sex learning, physical or emotional abuse, and sexual abuse. The minimum age in the sample was 11 years and the maximum age was

17 years, with a mean age of 14.55 years. The majority of the youth were aged 13, 14, 15, and 16 years with 15 youth in each of these age groups (total of 60 youth). One youth was aged 11 years, seven were aged 12 years, and the rest (n=10) were the oldest in the sample (17 years). Number of previous runs ranged from zero to a maximum of 20 times;

29 youth reported that they have never run away from home in the past. Eleven youth stated that they had run away from home once before. The mean for the number of previous runs was 3.88 times and the standard deviation was 5.04 (Table 4).

Table 4. Frequencies of Demographic Characteristics of Age and Number of Previous Runs Variable n % Mean SD Minimum Maximum Range Age (years) 78 100 14.55 1.58 11 17 6 11 1 1.3 12 7 9.0 13 15 19.2 14 15 19.2 15 15 19.2 16 15 19.2 17 10 12.8 Number of 78 100 3.88 5.04 0 20 20 previous runs (times) 0 20 25.6 1 11 14.1 2 7 9.0 3 5 6.4 4 7 9.0 5 2 2.6 6 3 3.8 7 3 3.8 8 2 2.6 9 1 1.3 10 1 1.3 14 1 1.3 15 3 3.8 17 1 1.3 20 2 2.6 Missing 9 11.5

Forty-three youth (55.1%) were females and 35 (44.9%) were males. Of the 78

youth in the study sample, 66 youth (84.6%) were White, and only 12 (15.4%) were

African-American (Table 5).

Forty-one percent (n=32) of the youth were living in the shelter; 35.9% (n=28)

were living with their parents. The remaining youth were living either with other family

(n=11, 14.1%), or in other places not specified in the answer (n=3, 3.8%). Four youth

(5.1%) did not answer this question. Those who were placed in the shelter because of 76

their status as runaways were 26 (33.3%); beyond control youth were 7 (9.0%);

throwaway or homeless youth were 5 (6.4%); and only one youth was placed in the

shelter for school truancy (1.3%). Youth who were placed in the shelter for dependency

reasons were 15 (19.2%); and 18 youth (23.1%) were placed in the Jennyplace shelter for

other reasons that they were not asked by the interviewer to specify. Six youth were missing (7.7%) (Table 5). These data were obtained from the Structured Clinical

Interview when youth were asked a question in the following format: “Reason for

Placement: Runaway______Beyond Control______Truancy______

Throwaway/Homeless______Dependency______Other______.”

One-third of the youth (n=26, 33.3%) indicated that they had been arrested before

as compared to 48 youth (61.5%) who reported that they have never been arrested. Four

youth did not answer this question (5.1%). Almost half of the youth in the sample

(48.7%) reported a history of alcohol use compared to 44.9% who had never used alcohol

(n=35). Five youth (6.4%) were missing. Two-thirds of the parents were alcohol users

(n=52), and less than one-third (n=21, 26.9%) were not using alcohol, with five missing

cases (6.4%). The majority of the youth’s siblings were non-alcohol users (n=48, 61.5%)

compared to only 29.5% (n=23) of being alcohol users. Two youth did not answer this

question (2.6%) and five cases were missing (6.4%) (Table 6).

The question of “do you remember how old you were when you first had sex?”

was left unanswered by 21.8% (n=17) of the youth. Thirty youth (38.5%) remembered

their age when they first had sex. Twenty-six youth (33.3%) said ‘no’ for this question

while 6.4% (n=5) of the cases were missing. Nearly half of the youth (n=36; 46.2%) had

learned about sex from sources other than their parents (n=14; 17.9%); 77 boyfriend/girlfriend (n=17; 21.8%), school counselor (n=3; 4%), and health education

(n=3; 3.8%). Five youth were missing (6.4%) (Table 6).

Table 5. Descriptive Characteristics of Gender, Ethnicity, Living Arrangements, and Reason for Placement Variable n % Gender 78 100 Female 43 55.1 Male 35 44.9 Ethnicity 78 100 White 66 84.6 African-American 12 15.4 Living arrangements 74 94.9 Parents 28 35.9 Other family 11 14.1 Shelter 32 41.0 Other 3 3.8 Missing 4 5.1 Reason for placement 72 92.3 Runaway 26 33.3 Beyond control 7 9.0 Truancy 1 1.3 Throwaway/homeless 5 6.4 Dependency 15 19.2 Other 18 23.1 Missing 6 7.7

When the youth were asked about feeling physically or emotionally abused, five youth did not respond (6.4%). More than 50% of the youth reported that they had been physically or emotionally abused (n=41; 52.6%) while 32 youth (41.0%) reported that they do not feel they have been physically or emotionally abused. One-fourth of the youth (25.6%; n=20) stated that they were sexually abused. However, 67.9% (n=53) indicated that they had never been sexually abused and five youth did not respond to this question (6.4%) (Table 6). 78

Table 6. Descriptive Characteristics of Alcohol Use, Parents’ Alcohol Use, Sibling Alcohol Use, History of Arrests, Age at First Sex, Sex Learning, Physical or Emotional Abuse, and Sexual Abuse Variable n % Alcohol use 73 93.6 Yes 38 48.7 No 35 44.9 Missing 5 6.4 Parents’ alcohol use 73 93.6 Yes 52 66.7 No 21 26.9 Missing 5 6.4 Sibling alcohol use 71 91.0 Yes 23 29.5 No 48 61.5 Missing 5 6.4 Not applicable 2 2.6 History of arrests 74 94.9 Yes 26 33.3 No 48 61.5 Missing 4 5.1 Age at first sex 56 71.8 Yes 30 38.5 No 26 33.3 Missing 17 21.8 Not applicable 5 6.4 Sex learning 73 93.6 Parents 14 17.9 Boyfriend/girlfriend 17 21.8 School counselor 3 3.8 Health education 3 3.8 Other 36 46.2 Missing 5 6.4 Physical or emotional abuse 73 93.6 Yes 41 52.6 No 32 41.0 Missing 5 6.4 Sexual abuse 73 93.6 Yes 20 25.6 No 53 67.9 Missing 5 6.4

Before running the analyses for research question one, research question two, and

research question three, and to explore if the researcher might needed to control for certain variables, Chi-Square analyses were calculated for both ethnicity and gender

(Table 7a; Table 7b), and a two-group t-test was run for the variable of age (Table 8) with

the outcome variable of runaway behavior. The results revealed that the only significant demographic variable was ethnicity (p<.05). The significance values for the other two demographic variables, which were gender and age, were p=.99 and p=.81, respectively.

As a result, ethnicity was taken into consideration as a control variable. Tables 7a, 7b, and 8 show these results.

Table 7a. Effect of Gender on Youth’s Decision to Run Away

Runaway Behavior Females Males χ2 p

(n=43) (n=35)

Yes 27 22 .82 .99

No 16 13

Table 7b. Effect of Ethnicity on Youth’s Decision to Run Away

Runaway Behavior White Africa-American χ2 p

(n=66) (n=12)

Yes 46 3 37.4* .003*

No 20 9

* p<.05

Table 8. T-Test of Age and Runaway Behavior of Youth Runaway Non-runaway t p M SD M SD Age 14.8 1.6 14.2 1.6 .06 .81

Research Question One

What is the association between life events in the past 12 months and the youth’s runaway behavior?

An independent, two-tailed t-test was analyzed for the purpose of answering this research question. The predictor variable (life events in the past 12 months), and the

outcome variable (the runaway behavior) were entered alone into the system in the first

equation. The results showed that life events were not significantly associated with

youth’s runaway behavior (F=.15; p=.70) (Table 9). Next, both the predictor variable and the outcome variable were entered along with the control variable (ethnicity) into the same equation using logistic regression. The life events, when they were regressed on runaway behavior while controlling for ethnicity, remained non-significantly associated with the runaway behavior (p=.41) while ethnicity was positively associated with the runaway behavior (p<.05) (Table 10).

Table9. Relationship between Life Events in The Past 12 Months and the Youth’s

Runaway Behavior

Runaway Non-runaway t p

M SD M SD

Life events in the 126.9 44.4 116.2 49.3 .15 .70

past 12 months

Table 10. Relationship between Life Events in the Past 12 Months and the

Youth’s Runaway Behavior, Controlling for Ethnicity

Predictor β SE Odds ratio p

Life events in -.01 .01 .99 .41

the past 12 months

Ethnicity 2.04 .76 7.7 .007*

* p<.05

Research Question Two

What is the association between being sexually abused/non-sexually abused and the youth’s runaway behavior?

To answer this research question, Chi-Square analysis was conducted to examine

the relationship between the independent variable (sexual abuse) and the dependent

variable (runaway behavior). Table 11 presents the non-significant results of this analysis

(p=.43). Secondly, the relationship between the independent variable (sexual abuse) and

the dependent variable (runaway behavior) was examined while controlling for the 82

demographic variable of ethnicity using logistic regression. The results were the same in

that the relationship between sexual abuse and runaway behavior was non-significant

(p=.26) while there was a significant positive relationship between ethnicity and youth

runaway behavior (p<.05) (Table 12).

Table 11. Relationship between Sexual Abuse and the Youth’s Runaway

Behavior

Sexual Abuse Runaway Non-runaway χ2 p

(n=49) (n=24)

Yes 12 8 14.9 .43

No 37 16

Table 12. Relationship between Sexual Abuse and the Youth’s Runaway

Behavior, Controlling for Ethnicity

Predictor β SE Odds ratio p

Sexual abuse -.66 .59 1.94 .26

Ethnicity 2.15 .75 .12 .004*

* p<.05

Research Question Three

What is the association between externalizing and internalizing behaviors and the youth’s runaway behavior?

externalizing behaviors were a significant predictor of the runaway behavior (p<.05). The

odds ratio showed that for each unit increase in the externalizing behaviors, there is an

increased probability of 2% that the youth will run away (Table 13).

Table 13. Logistic Regression of Externalizing Behaviors Predicting Runaway Behavior Predictor β SE Odds ratio p

Externalizing behaviors .2 .008 1.02 .007*

* p<.05

Second, internalizing behaviors were entered with the dependent variable,

runaway behavior. The results showed that internalizing behaviors were a significant

predictor of the runaway behavior (p<.05). The odds ratio showed that for each unit

increase in the internalizing behaviors, there is an increased probability of 1% that the

youth will run away (Table 14).

Table 14. Logistic Regression of Internalizing Behaviors Predicting Runaway

Behavior

Predictor β SE Odds ratio p

Internalizing behaviors .01 .007 1.015 .03*

* p<.05

After that, externalizing and internalizing behaviors were entered together into the

logistic regression equation. Externalizing behaviors were still a significant predictor of the runaway behavior (p<.05). However, internalizing behaviors were no longer a significant predictor of the runaway behavior (p=.47). The odds ratio showed that for each unit increase in the externalizing behaviors, there is an increased probability of 2% that the youth will run away (Table 15). 84

Table 15. Logistic Regression of Externalizing Behaviors and Internalizing Behaviors Predicting Runaway Behavior Predictor β SE Odds ratio p

Externalizing behaviors .02 .01 1.02 .029*

Internalizing behaviors .006 .008 1.006 .47

* p<.05

Lastly, externalizing and internalizing behaviors were entered into the fourth logistic regression equation with the dependent variable, runaway behavior, and the control variable, ethnicity. The results showed that externalizing behaviors remained a significant predictor of the runaway behavior (p<.05), and internalizing behaviors remained a non-significant predictor of the runaway behavior (p=.73) when controlling for ethnicity. The odds ratio showed that for each unit increase in the externalizing behaviors, there is an increased probability of 2% that the youth will run away when controlling for ethnicity. The results of this analysis also showed a significant positive association between ethnicity and youth runaway behavior (p<.05) (Table 16).

Table 16. Logistic Regression of Externalizing Behaviors, Internalizing

Behaviors, and Ethnicity Predicting Runaway Behavior

Predictor β SE Odds ratio p

Externalizing behaviors .02 .01 1.02 .04*

Internalizing behaviors .003 .009 1.003 .73

Ethnicity 1.8 .79 .165 .02*

* p<.05 85

Finally and to explain this finding, Pearson’s product moment correlation coefficient was calculated between the two independent variables of externalizing and

internalizing behaviors. The results explained that these two variables are highly

correlated (r=.74; p<.05) (Table 17). Hence, it can be said that youth who have high

externalizing behaviors scores also have high internalizing behaviors scores.

Table 17. Correlations for Externalizing Behaviors and Internalizing Behaviors

Externalizing behaviors p

Internalizing behaviors .74* .000*

* p<.05

Summary of the Results

Results of this study showed that there was no significant association between the

life events in the past 12 months and the youth’s runaway behavior. No significant

associations were found between the history of sexual abuse and the runaway behavior.

Results of the logistic regression analyses showed that both the externalizing and

the internalizing behaviors, separately, were associated with the runaway behavior, but

the internalizing behaviors were not significantly associated with the runaway behavior

when they were added to the externalizing behaviors into the same equation.

Furthermore, the externalizing behaviors were significantly associated with the runaway

behavior when they were entered with the internalizing behaviors into the same equation

while controlling for ethnicity. The correlation matrix explained this by showing the high

correlation between the externalizing and the internalizing behaviors revealing that youth

with high scores on the externalizing behaviors are the same youth with high scores on

the internalizing behaviors. 86

CHAPTER V

DISCUSSION

The purpose of this study was to describe the personality characteristics of youth between the ages of 11 and 17 years who were residing in a shelter for individuals who

had run away from home and others who had experienced a variety of crises and traumas

in their lives. The study focused on the youth with a recorded history of runaway

behaviors to determine the association of the youth’s personality characteristics, life

events in the past 12 months, and history of sexual abuse with their decisions to run away

from home. This chapter provides an explanation of the study findings as discussed

through each of the research questions. It will also provide perspectives about the

significance of these findings as related to research, nursing practice, and public policy.

The chapter concludes with addressing the limitations of the study, as well as recommendations for future studies based on the findings of this research.

Life Events in the Past 12 Months and Youth Runaway Behavior

What is the association between life events in the past 12 months and youth

runaway behavior?

In this study, no significant associations were found between the life events in the

past 12 months and youth runaway behavior. These findings regarding life events in the

past 12 months were inconsistent with previous studies. For example, Yoder (1999) and

Yoder et al. (1998) reported a significant relationship between life events and running

away from home among youth aged 15-19 years. However, Yoder et al. (1998) studied

life events in the lives of youth in the past six months while life events in the current

study were examined in the past 12 months. Furthermore, Walrath et al. (2003) and Clatts 87 et al. (2005) reported that life challenges (referred to as negative life events) increase the probability that youth will run away from their homes.

In their study about the characteristics of troubled youth in a shelter, Gary,

Moorhead, and Warren (1996) documented the important impact of negative events in the lives of runaway youth. They reported that running away behaviors could perhaps be an option used by the youth to cope with maltreatment and neglect that they experienced in their families. These researchers also found that many runaway youth have witnessed domestic violence, physical and sexual abuse at the hands of their parents or guardians, parental drug and alcohol abuse, and parental neglect. Furthermore, they suggested that dysfunctional family members might have helped to drive some youth out of their homes and onto the streets or into shelters. Other youth could have been abandoned because their family’s resources were inadequate to support and care for them. In summary, Gary,

Moorhead, and Warren (1996) reported that youth leave their homes or places of legal residence because of serious social, familial, economic, and/or personal crises (Gary,

Moorhead, & Warren, 1996).

In an earlier study, Warren, Gary, and Moorhead (1994) suggested that conflict within the home environment helped to create harsh circumstances for the youth, who sometimes sought refuge elsewhere. Other studies supported similar finding as did the results from studies by Hamilton and Browne (1998), Walrath et al. (2003), and Berdahl et al. (2005). The ages among the youth in these investigations ranged from 5 to 17.5 years, and the samples consisted of 199 males and 644 females.

Additionally, Matchinda (1999) studied the relationship between home rearing patterns and runaway behaviors among a group of 13 to 18 year old males (n=210) and 88

females (n=690). She found a significant relationship (X²=68.0; p=.001) between harsh and undesirable home rearing patterns and inadequate income to support the family members. In these instances, the youth’s decisions to abandon the home environment in favor of life on the streets were evident. Matchinda (1999) concluded that youth reared in authoritarian homes are more likely to become street youth; youth who live in poverty tend to be at a higher risk for “street life” and a blighted future (Evans et al., 2005).

Kaufman and Widom (1999) posit that childhood victimization (abuse, neglect, family violence, and continuous familial conflict) increases the risk that a youth will run away from home. Moreover, Berdahl, Hoyt, and Whitbeck (2005) have written that a significant portion of the youth in their study, who were homeless and runaways, had received mental health services before they decided to run away from home the first time.

Importantly, they suggested that parental rejection had a positive effect on the likelihood of a youth receiving mental health services from a professional. Also, family instability was strongly associated with the need for professionals to implement pre-run interventions into the long term approaches for the youth and parents in their research

(Berdahl, Hoyt, & Whitbeck, 2005).

In the current study, the findings regarding the lack of associations between life events in the past 12 months and the youth’s runaway behaviors could be based on

several explanations. First, the families and youth might be living in harsh interpersonal

circumstances. For families with limited socioeconomic resources and numerous stressors

in their lives, many variables converge upon them. The Integrative Model suggests that

social position factors, including socioeconomic class, ethnicity, and gender are 89

significant factors that influence the quality of life that youth and their families

experience (Garcia Coll et al., 1996).

Garcia Coll et al. (1996) also suggest that family structure and roles, family values and beliefs, and the nature of the environment within which the youth reside are also significant factors in their overall development and in determining the positive and

deficit profiles of the youth (Evans et al., 2005). The lack of economic resources, along

with being African American or a member of another ethnic minority group, could help

to “set the stage” for upheaval to occur within the lives of the youth (Chamberlain &

Moore, 1998; Slesnick & Prestopnik, 2004). One life event after the other is more likely

to occur; youth and family members adjust, though many times in a maladaptive manner

(Mearns, 2000; Ruschena et al., 2005; Azar et al., 2005). Too frequently, the outcomes

associated with having to navigate harsh familial and environmental conditions are

detrimental for the youth (Wolfe & Yuan, 2001).

Second, the majority (66.7%) of the youth in the current study stated that alcohol

and substance use was prevalent in their family dynamics. The mind-altering substances

are used for many reasons, including lessening anxiety, lifting depression, and for

“coping” (Beautris, 2002). Ineffective parental coping is associated with high rates of

physical abuse during adolescence. It has been hypothesized that conflicts between

parents and youth are more likely to occur during this developmental epoch (Sedlak &

Broadhurst, 1996; Wolfe & Yuan, 2001).

Many times, youth who are estranged from their families seek solace and comfort

in relationships outside of the family structure. When disruption occurs in these

relationships, the youth can experience emotional devastation (Fenning et al., 2005; Cole 90 et al., 2006). That is to say, relationships with boyfriends/girlfriends take on a highly significant meaning, where the youth perceives this person to be one of the most important individuals in his/her life. If the relationship is turbulent or ends in “breakups,” the youth might experience depression, anxiety, and other behavioral manifestations

(Hester, Pearson, & Harwin, 2000). Academic performance and school peer relations are not personally satisfying. Other life events such as parental loss of job, moving to a new house, mother starting a new job, etc., did not rank as high as they perhaps would if other events and circumstances in their lives were not so dominant. Perhaps these findings underscore the youth’s sense of familial detachment and disengagement, which prohibits the development and maintenance of a facilitating environment within the home for the youth (Evans et al., 2005).

Of importance in this study are findings that the youth considered the use of alcohol and substance abuse in the family and “breakups” with boyfriends/girlfriends to be the most important negative life events that they faced in the past 12 months. These findings are also important when examined from the perspective of the environmental context of the youth’s lived experiences. Consider the importance of the environment on the youth’s development, regardless of whether it is negative or positive: family, school, youth sports and supervised after-school activities, community involvement, and religious affiliations are the social contexts within which youth interact. These positive and negative experiences help to shape the youth’s perceptions about his/her current and future realities (Evans et al., 2005). Unfortunately, if the experiences are negative, as in the instances of youth who run away from home, the outcomes could be detrimental.

Evans et al. (2005) suggest that the negative outcomes might include, for example, 91

devastating effects such as more violence and abuse, mental disorders (depression,

posttraumatic stress disorders, and anxiety) and other deleterious conditions (Fitzpatrick,

1997). Importantly, Harris (1995) has hypothesized that parents are not the major and predominant influence on youth at the adolescent state of growth and development; instead, the socialization and communication that occur between and among the youth and their peers outside of the familial environment are the most potent influence.

Third, the Coddington’s Life Events Scale, which produced one composite score, was computed and reported in this study. Perhaps, if each of the items was examined separately or more in-depth examination into the importance of each of the events was explored, the findings might have been different. In addition, it might be informative to carefully review Coddington’s Life Events Scale and determine if it is sensitive enough to capture the lived experiences of youth who are confronted with surviving in harsh familial environments. Given the experiences of children and youth who live in unstable and sometimes unsafe familial and community milieus, perhaps different measures are needed to document these life events (McKnight, Huebner, & Suldo, 2002). In-depth thought needs to be given to an instrument that is sensitive enough to capture the youth’s interactions with family, school, peers, and other community-based activities (Evans et al., 2005; Wodarski & Wodarski, 1998).

History of Sexual Abuse and Youth Runaway Behavior

What is the association between being sexually abused/non-sexually abused and youth runaway behavior?

No significant associations were found between being sexually abused and the youth’s runaway behavior. These results are not consistent with those of Yoder, 92

Whitbeck, and Hoyt (2001), Tyler and Cauce (2002), Kaufman and Widom (1999), and

Rotheram-Borus et al. (1996). Yoder, Whitbeck, and Hoyt (2001) found that youth who

experienced sexual abuse were more likely to run away from their homes. Similarly,

Tyler and Cauce (2002) reported that being sexually abused increases the possibility that

a youth will run away from home. Moreover, Kaufman and Widom (1999) assessed the relationship between child victimization and running away using a prospective cohort

design with over 1,000 respondents who were physically or sexually abused, or neglected

and matched with a control group of youth with similar social class backgrounds. The

participants in this study were between the ages of 10 to 18 years; the study used data from a prospective cohort design in which a large group of youth , who were physically

or sexually abused or neglected approximately 20 years prior to the study, were matched

with a control group of youth, and followed into adulthood, and interviewed. Their

study supported the hypothesis that victims of sexual abuse are more likely to run away

from home when compared to their control group.

Furthermore, Rotheram-Borus et al. (1996) posited that 37% of their

racially/ethnically diverse sample of 190 runaway youth had a history of sexual abuse,

but found no significant difference for males and females. Their results indicated that

early sexual abuse was significantly associated with a number of high-risk behaviors such

as trading sex for other goods and services and participating in unprotected sexual

intercourse. Chapple, Johnson, and Whitbeck (2004) found that familial and sexual

abuses were significantly associated with youth’s decisions to run away from home.

Several other researchers (Lenssen et al., 2000; Chartier et al., 2001; Choquet et al.,

1997) reported similar findings. 93

Unfortunately, sexual abuse occurs too frequently within families and communities. However, the findings in this study did not corroborate previous reports in the literature (Lenssen et al., 2000; Chartier et al., 2001). Our results can be explained in the following manner. According to Sedlak and Broadhurst (1996) and Kaplan et al.

(1994), sexual abuse among females has a different dynamic than what is manifest in males. Among females, sexual abuse is more likely to occur at a much earlier age than males. There are also sociopolitical consequences when a youth reports that a parent, relative, or friend, has engaged in this noxious behavior with her or him. For starters, sexual abuse against a female youth in the family is difficult for her to report to the mother or other family members (Tyler & Cauce, 2002). When a female youth reports one of her family members as a sexual-abuser, the results of this reporting could have far reaching consequences. The family, including the perpetrator and the mother (his wife), might blame the youth for being seductive, or cunning, or inviting—all of which are labels that suggest that the female youth provoked and “set up” the event to occur. The implication is that she should be responsible for the outcome (Mason, Zimmerman, &

Evans, 1998; Molnar et al., 1998; Perkins & Luster, 1999), and not necessarily the perpetrator. Such outcomes are typically referred to as “blaming the victim.” This scenario happens most often between female youth and their step-fathers (Greenberg et al., 2005).

From the political/legal perspective, if formal charges are brought against the perpetrator, the female youth could be targeted as the person in the family who was responsible for bringing legal action against the male family member (father or the stepfather, or uncle) who, if found guilty, could be placed in confinement for a designated 94

period of time. In some instances, long-term prison sentences are the outcomes. In both

scenarios, the “blaming of the victim” or confinement, the family could suffer emotional,

economic, and social hardships. Family members might also be confronted with shame

and ridicule from friends and relatives (Tyler & Cauce, 2002; Bouvier et al., 1999), and

sometimes professionals. If the youth is blamed, scapegoating and other maladaptive

familial dynamics are likely to become manifest (Sedlak & Broadhurst, 1996). If, on the

other hand, incarceration is the outcome, instability within the family is one anticipated

consequence. The family might be forced to move, wages could be reduced or stopped,

families might be placed on public assistance, and public opinion could “brand” the

family as dysfunctional and “participants in shameful acts” (Greenberg et al., 2005).

The emotional and mental states of these youth may not be given enough attention

by parents, teachers, and professionals. Many of them do not receive the needed mental

health services (Evans et al., 2005; Garcia Coll et al., 1996). Instead, the youth are at risk

for a variety of internalizing and externalizing behaviors and emotional states that may or

may not be perceived as being caused by the abuse that they have had to endure (Nolan et

al., 2002; Carlson & Chamberlain, 2003).

There is also another consequence that needs to be elucidated. Some researchers

(Bryan & Stallings, 2002; Wesley, 2002) suggest that youth, especially females, who are

victims of sexual favors for their close family members may be rewarded for these sexual

exploits. This is evident when fathers, step-fathers, or uncles and others give favors to the

females in the form of extra allowance, use of the family vehicle, etc. The female youth, in turn, could learn that sexual behavior can be used as a means to meet one’s immediate needs. Regardless, there are deleterious consequences that are attached to these situations 95

as well (Kendall-Tackett, 2002). Finkelhor (1994) has hypothesized that children with

early sexual experiences, including incest, develop inappropriate repertoires of sexual behaviors and associated values, are confused about sexual self-concepts, and have unusual emotional associations to sexual activities.

Furthermore, Kendall-Tackett (2002) reported powerlessness--or what might also

be referred to as ‘disempowerment’ in that the child’s will, desires, and sense of efficacy

are continually thwarted. Powerlessness occurs when a child is repeatedly sexually or

physically exploited against her/his will and is unable to disclose the activity because of

fear of the consequences (Brand & Alexander, 2003; Rudd & Herzberger, 1999) from the

family that could follow the disclosure. Some research studies have demonstrated that

ethnic minority families and individuals without adequate economic means are less likely

to report abuse and violence in their families. One explanation is related to the distrust

that ethnic minority and poor people have for law enforcement. A second rationale is that

the criminal justice system and juvenile confinement facilities are overwhelmingly

representative of ethnic minorities and economically disadvantaged individuals (Bent-

Goodley, 2001; Carlson & Chamberlain, 2003; Lewis-O’Connor, Sharps, Humphreys,

Gary, & Campbell, 2006). These studies will perhaps help to explain the seemingly

“inaction” and indecision to run that was observed among the youth in this study who

were sexually abused.

Externalizing/Internalizing Behaviors and Youth Runaway Behavior

What is the association between externalizing and internalizing behaviors and

youth runaway behavior? 96

Both variables, externalizing and internalizing behaviors, were significantly associated with the youth’s runaway behaviors when they were entered separately into two different logistic regression equations. However, when these variables were entered into the same logistic regression equation, the variable of the internalizing behaviors dropped out and was no longer significantly associated with the youth’s runaway behaviors. However, the externalizing behaviors variable remained significantly associated with the youth’s runaway behaviors.

Results regarding the externalizing behaviors of youth in this study are consistent with those of Whitbeck and Hoyt (1999), who reported that conduct behavior problems were associated with runaway behavior. Recall that lying, paranoia, hysteria, hypomania

(scales), and so forth, are the items that consist of externalizing behaviors in the AMPI and in the current study.

Yoder, Hoyt, and Whitbeck (1998) posit that homeless and runaway adolescents might experience violence--and participate in violent acts. Violence may be a learned response to harsh parenting during their formative years and into the adolescent stage of development. Yoder, Hoyt, and Whitbeck (1998) emphasized that violence is a learned response and that early experiences in abusive and fearful homes might predispose youth to aggressive behaviors in their youth and adult lives (Dong et al., 2004; Felitti et al.,

1998; Garcia Coll et al., 1996; Evans et al., 2005). Moreover, youth who have experienced a significant amount of stress and emotional problems may begin to see running away as a viable option to free themselves from the burdens of familial tensions and chronic turbulent emotional states (Yoder, Hoyt, & Whitbeck, 1998; Keily et al.,

2000; Gjone & Stevenson, 1997; Oldehinkel et al., 2004). In other words, children who 97

externalize their inner states are more likely to manifest behavioral or psychomotor

options, some of which may or may not be in compliance with societal expectations

(Grych, Jouriles, Swank, McDonald, & Norwood, 1999). They are also at high risk for

being diagnosed with other psychiatric conditions, such as conduct disorder and

oppositional defiant disorder (DSM-IV-TR, 1998).

Another study completed by Youssef, Attia, and Kamel (1998) hypothesized that

youth who were troublesome to their parents, doing poorly in school, disobedient, liars,

destructive, and disrespectful to their parents and other adults were at higher risk for

running away; they leave their homes to escape maltreatment and avoid getting into more trouble at home and in the community. Youth with externalizing behaviors could be at a greater risk for becoming delinquent (Rodney et al., 2003; McGee & Baker, 2002; Bryan

& Stallings, 2002). Many of these youth are placed in confinement facilities with legal charges (McGee & Baker, 2002), but few of them receive the professional help that they deserve (Evans et al., 2005; Dong et al., 2004).

On the contrary, the results regarding the internalizing behaviors--such as infrequency, depression, femininity, psychasthenia, and schizophrenia--are in contrast with those of Bagley and LaChance (2000). These researchers reported that children with

histories of sexual abuse manifest behavioral or emotional problems following the

traumatic experience. These symptoms include heightened fears, post-traumatic stress

disorders, conduct problems, poor self-esteem, somatic disorders, eating and body image

disorders, and depression. Bagley and LaChance (2000) also reported substance abuse

and self-inflicted injuries as common occurrences. One consequence for these youth,

according to their study, is the decision to leave home. Another study, conducted by 98

Yoder, Hoyt, and Whitbeck (1999), also contradicted the results of this current study.

These authors found internalization (depression and self-esteem) as strong predictors of

running away behaviors among youth aged 12-21 years. The majority of the youth in

their study were female (58%), and White (non-Hispanic) (67%) much like the youth in the current study.

One explanation for the inconsistency of the findings of this study when compared to the cited research that suggest that there is an association between internalizing behaviors and youth runaway behaviors could be associated with differences in definitions. Internalizing behaviors in the present study were defined as the total score on subscales of Infrequency, Depression, Psychopathic Deviate, Femininity,

Psychasthenia, and Schizophrenia. In other studies, the definitions were self-esteem,

anxiety, and depression (Bagley & LaChance, 2000; Yoder, Hoyt, & Whitbeck, 1999). In

addition, some researchers have suggested that there are no existing studies that are

available to help determine the accuracy and efficacy of screening tools for the

identification of at-risk children who are exposed to family interpersonal violence. This is

a fertile ground for nurse researchers. Even less is known about ethnic minority youth

and youth who live in the United States but have backgrounds in other cultures and

countries (United States Preventive Services Task Force, 2004). However, at the present time, nurse researchers and others speculate that screening for violence and maltreatment

in families is just as urgently needed as screening for breast cancer, cardiac disease, or

diabetes (Lewis-O’Connor, Sharps, Humphreys, Gary, & Campbell, 2005; Gary,

Humphreys, & Campbell, 2005). It is also important to remember that definitions of 99

abuse and laws governing the various types of abuse and neglect vary across states

(Margolin et al., 2005).

Another suggested explanation for the lack of association between internalizing

behaviors and running away is the fact that the majority of the youth who participated in

the study were White females. Their despair and distress can be expressed somewhat

differently than that of males. Among females, internalizing behaviors suggest that the females could be “suffering in silence” and not able to express their distress except through maladaptive behaviors that may or may not elicit the help that they deserve

(Wesley, 2002).

Even though the sample was small (n=12), the study revealed that the ethnic minority participants, African Americans, responded differently to the reported life events and abuse: They tended to run away from home and enter the culture of the streets.

From a long term perspective, these youth are at greater risk than their non-runaway peers for being diagnosed with conduct disorders, including Oppositional Defiant

Disorder. Their externalizing behaviors—lying, paranoia, hypomania, and numerous others—are likely to increase their vulnerability to being perceived as “misfits” in

society, with little possibilities for making contributions to their families and

communities (DSM-IV-TR, 1998; Sullivan & Knutson, 1998; Yeo, 1998; Unger et al.,

1998; Biggar, 2001; Mccluskey, Bynum, & Patchin, 2004; Basso et al., 2004). Our

analysis also demonstrated that they are at high risk for internalizing behaviors--

depression, anxiety, schizophrenia, femininity-- and other maladaptive characteristics.

Manifesting externalizing and internalizing behaviors place them in double

jeopardy. Given their likelihood of living in poverty, and the potential for experiencing 100

more numerous negative life events, these youth could be confronted with life’s perils that are beyond their capacity to successfully navigate (Wesley, 2002; Weinreb et al.,

1998; Wade, 2003; U.S. Conference of Mayors, 2004; Tyler, Hoyt, & Whitbeck, 2000;

Tumin, 1967; Petterson & Albers, 2001). Without intensive and appropriate interventions, preferred outcomes are miniscule (Washington & Washington, 2001;

Moehling, 2002; Gutman & McLoyd, 2000).

Finally, Friedrich and Boriskin (1976) and Gary, Campbell, and Humphreys

(2004) have written that the youth’s role in their own exploitation is neither well

researched nor easily explained. However, it is important to introduce the phenomena in this discussion. Certain types of children and youth may be more at risk for abuse than

others. Children with intellectual or physical limitations and children with certain

physical or emotional characteristics are a few examples (Balogh et al, 2001). They could

play a passive role in the abuse dynamic. There are three conditions that have been

identified as placing the child/youth in a vulnerable state of abuse and maltreatment: (1)

the child/youth must have certain physical, emotional, or psychological needs (i.e.,

mental retardation, a health condition that requires special attention from the adult—

diabetes, for an example; (2) a series of crises or states of extreme disequilibrium with the

parents or caregivers having to confront more day-to-day demands that create unusual

stress levels, and (3) a high potential for the parent or caregiver to display pathological

aggression toward the child or the youth. Having outlined these three conditions for child

abuse and neglect, it should be emphasized that abuse and maltreatment must also be

carefully examined within the context of cultural beliefs and practices. This topic is

beyond the scope of the current study, but it is a highly relevant framework for future 101 scientific explorations (Gary, Campbell, & Humphreys, 2004; Azar, 1991; National

Institute of Justice, 2002).

Limitations of the Study

There are several limitations of this study. First, this study was a secondary analysis of data from a larger study with different aims. Another limitation of this study that deserves to be addressed is the homogeneity of the sample. The majority of the youth in the sample of this study were Caucasian females. It is difficult to generalize the findings of this current study to other populations such as minority males and females, and Caucasian males as well. Finally, it should be pointed out that the original study was conducted about 15 years ago, and that the results of this study reflect the youth’s growth and development issues during that decade.

Significance of Findings

Implications for Nursing Science

The present study investigated the association between externalizing and internalizing behaviors, variables known to play a key role in affecting the present and future lives of the youth. This study will help to extend our knowledge regarding the influence of externalizing behaviors and ‘acting out’ as related to the decision of the youth to run away from their homes and their families. These empirical data are important for evidence-based practice and program planning.

In addition, findings of the present study revealed that life events in the past 12 months, history of sexual abuse, and internalizing behaviors were not associated with youth runaway behavior. Such findings should not suggest that these variables are not as important as the externalizing behaviors. To the contrary, the results suggest that there is 102

a need for in-depth study to be conducted in future research that examines specific types of life events, alcohol and substance abuse, sexual abuse, internalizing behaviors, and the

quality of relationships between these youth and their families. Youth’s peer relationships

and their school performance should also be explored within the context of their

decisions to run away and live on the streets. Prinz and Feerick (2003) have provided guidelines for researchers who examine violence in interpersonal relationships. These guidelines can be extended to youth who run away from home. They recommend that researchers use tools that are reliable and valid, and that are relevant for the different racial and ethnic minority groups in this nation. Better definitions of violence and abuse are needed; culture-specific and age-appropriate interventions will also be required.

Innovative and creative research designs and analyses should help to unravel some of the unknown dynamics that are associated with the decisions that drive youth to the streets.

All of these domains are considered essential elements when advancing the science in this area.

Implications for Nursing Practice

The results of this study will provide nurses and health care professionals with information about how to better plan and implement culturally-specific and age- appropriate programs for early detection, prevention, and treatment that would be helpful for these youth and their families. Despite the findings related to no associations between life events in the past 12 months and the lack of association between the history of sexual abuse and runaway behaviors, nurses and other health professionals should be on the alert for these devastating events and intervene as is appropriate (McGuigan & Pratt, 2001;

Itzhaky & York, 2001; Sheppard, 2003). 103

Internalizing behaviors could be conceptualized as the youth being “disturbed”

but not “disturbing.” On the other hand, externalizing behaviors might be thought of as

disturbing, which implies that adults at home and the youth’s peers are more likely to

take action and set limits or help “push the youth out of the home and into the streets”

(Gary, Campbell, & Humphreys, 2004).

It should be emphasized that specific assessment strategies for the identification

of at-risk and vulnerable youth should be fine-tuned and made available at health clinics and community agencies where youth are served. Engaging families, teachers, siblings, peers, and other responsible individuals could also help to reduce abuse and lessen the frequencies and severities of the noxious life events that youth experience (Vincent &

Daniel, 2004; Glaser, 2000; Steinhausen & Metzke, 2001; Mowbray et al., 2004).

Findings from this study revealed a positive association between externalizing behaviors and runaway behavior. These results raise the question about the need to understand the personality characteristics of these youth. Perhaps their running away suggests that they reject the abuse and maltreatment that have been perpetrated against

them. Leaving home can be associated with psychological health and/or maladaptive

behaviors. Acting out could be interpreted as a refusal to accept violence in one’s home.

Nurses and health care professionals are strategically positioned to address these concerns through their work at clinics, schools, faith-based institutions, and other settings. Even though healthcare systems have made remarkable progress in addressing the needs of youth who run away from home, there is still an overwhelming need to develop and test protocols and interventions that will concentrate on the health and 104 emotional needs of youth who experience violence and abuse in their homes (Lewis-

O’Connor et al, 2006; Campbell & Parker, 1999).

Implications for Public Policy

Causes of running away among youth fall into three inter-related categories: family problems, economic problems, and residential and community instability. Many youth leave home after years of physical and sexual abuse, strained relationships, substance addiction of a family member, and parental neglect (Tyler & Cauce, 2002). On the streets, these runaway youth face many challenges. Many runaway youth find that exchanging sex for food, clothing, and shelter is their only chance of survival on the streets. In turn, they are at a greater risk of contracting AIDS or HIV-related illnesses

(Yoder, Whitbeck, & Hoyt, 2001). Runaway youth often suffer from severe anxiety and depression, poor health and nutrition, and low self-esteem. Furthermore, they face severe challenges in obtaining an education and supporting themselves emotionally and financially (Kingree, Braithwaite, & Woodring, 2001; Chung & Springer, 2005). Poverty is an undesirable, though likely outcome (Harris & Marmer, 1996; Eamon, 2002).

Public policy should promulgate and support programs that focus on the prevention of runaway behaviors among youth. Other initiatives should benefit runaway youth through providing safe places for them, where they can get their basic needs met without fear, anxiety, and threats of retribution (Phoenix, 2003; Ensign, 2004; Aviles &

Helfrich, 2004). Such programs should focus on helping these youth regain stability, preferably in their own families. If this option is not available, then other alternatives that would help with stability and assure their safety ought to be considered. Educational outreach programs, transitional living initiatives, and health care systems that are 105

designed to be responsive to their needs are logical next steps. In the long term, runaway

youth would benefit from many of the same measures that are needed to eradicate

poverty, eliminate and reduce health disparities, and improve the well-being of youth and their families across this nation. The child welfare structure, in conjunction with the legal, public school, and health care systems, should develop a “wrap around” programmatic approach that will assure that these vulnerable youth receive a variety of required services to help assure their well-being (Center for Law & Social Policy, 2003; Dachner

& Tarasuk, 2002; Sullivan, 2006).

Runaway youth frequently have feelings of worthlessness, loneliness, and hopelessness. Situations that produce these feelings include the lack of familial, emotional, and material resources. National policy initiative that concentrates on the problems, societal prejudice/oppression toward the youth and their families, and the social context on the streets are cogent topics for beginning this discourse.

Sullivan and Knutson (2000b) and Sullivan (2006) have clearly outlined a host of stressful life events to which maltreated or abused youth are exposed; all of these events require immediate attention from policy makers and analysts at all levels of decision making. They include: voluntary foster care; inadequate parenting; inadequate housing; financial problems; marital problems; pregnancy/birth of newborn; parent who is ill or disabled; mental or emotional problems experienced by the parent; parental alcohol and drug problems; social isolation; family involved with the legal system; step-parent/child conflict; fetal alcohol syndrome; and AIDS in a family member.

Therefore, public policy should concentrate on programs that provide preventive services that would help to “nip in the bud” the antecedents to youth’s runaway behaviors 106

(Sullivan, 2006; Evans et al., 2005; Garcia Coll et al., 1996; IDEA, 2003; Omaha World-

Herald, 2004; Rossman & Rosenberg, 1998).

From a similar framework, policy implications can be conceptualized through five major categories. First, there is a need to protect these youth in their homes and to stabilize their families and communities. This will mean providing greater resources to agencies, such as youth services, the public and private schools systems, health clinics, and other agents and agencies that serve at-risk and vulnerable youth. Mental health services should be immediately available to the youth and their families. Second, training and education programs for these runaway youth need to be developed and designed to improve their sense of self-worth, self-esteem, and academic and skills sets for future productive contributions to society. Third, there is a pressing need for the development of affordable housing readily available to vulnerable youth who would be supervised and nurtured in a safe and facilitating setting with caring and competent adults. Fourth, given the mental and physical health problems of runaway youth, better access to health care and mental health preventive and treatment modalities are desperately needed.

Finally, steps should be taken to combat the pervasive social stigma faced by

these youth. Rather than dismissing them and criminalizing their behaviors, there is a need for citizens to recognize their own degree of responsibility in social policy and in maintaining the social order (U.S. Conference of Mayors, 2004; U.S. Department of

Health and Human Services, 1997; Kidd, 2003). Hence, public awareness campaigns that would inform the American public about the plight of these youth is one of the responsible actions that members of the general public could initiate and sustain (Garcia

Coll et al., 1996; Sullivan, 2006; Kidd, 2003; U.S. Conference of Mayors, 2004). 107

Recommendations for Further Research

This study was informative in that it was the first initiative to address internal

states of individuals in a shelter for runaway and homeless youth. Results of this study

were that several independent variables were not significantly associated with the

outcome variable, youth runaway behaviors. These results were not consistent with previous studies. The results provide new information on the relationship between life

events in the past 12 months, sexual abuse, externalizing and internalizing behaviors, and

youth runaway behavior.

The current study did not find significant associations between the youth’s

runaway behavior and most of the predictor variables (life events in the past 12 months,

sexual abuse, and internalizing behaviors). However, it is well documented that life

events, history of sexual abuse, and internalizing behaviors (e.g. depression, anxiety)

influence whether or not a youth decides to run away from home. How these variables

interact is not yet fully known. The complex components of all key elements that help to

influence the youth’s decisions to run away from home need to be more carefully

explored.

Future studies should include additional variables or different definitions that may

better explain the relationship between the youth’s runaway behaviors and life events in

the past 12 months, sexual abuse, and internalizing behaviors. Examples of additional

variables to include in future studies are the direct relationship between being sexually-

abused and the decision to run away from home. A more focused study could help to understand the role that sexual abuse plays in the youth’s decisions to leave home and enter the culture of “mean streets.” Future studies could also utilize internalizing and 108 externalizing behaviors and examine them in combination with and separate from each other through sub-scores and subscales that are generated by the AMPI. That is, each of the internalizing (Infrequency, Depression, Psychopathic Deviate, Femininity,

Psychasthenia, and Schizophrenia) and externalizing (Lie, Correction, Hypochondriasis,

Hysteria, Paranoia, Hypomania, and Social Introversion) subscales could also be analyzed from the perspective of their association and predictive value associated with the youth’s decisions to run away from home.

Additionally, research should be conducted that determines the extent to which the youth manifest psychiatric disorders or are at risk for developing such disorders. The long-term consequences of violence and abuse in the home, being neglected or abandoned, and living on the streets should also be systematically explored and documented. From these data, prevention and intervention programs ought to be developed and implemented for these youth and their families. Longitudinal studies would help nurse researchers, clinicians, and public policy experts with assessments, treatment, and evidence-based programs for these vulnerable youth and their families as well.

Moreover, research should be undertaken that explicates the decision-making process that results in the placement of White females in protective environments such as a shelter like Jennyhouse, while African-American males and females and Caucasian males are relegated to other less desirable settings. Researchers suggest that these youth are placed in juvenile detention facilities where they are more likely to be labeled as

“trouble makers, deviants, and delinquents” (Leiber & Fox, 2005). Their future could be negatively influenced through these decisions. 109

It is recommended that a nationwide study be conducted that will include more

minority youth, including African-Americans, Hispanics, American Indians, Alaska

Natives, and Pacific Islanders in the sample (Kingree, Braithwaite, & Woodring, 2001).

With adequate ethnic minority representation, researchers, clinicians, and policy experts

could examine the same (and additional) variables which might help to clarify this complex web of overlapping and ruinous phenomena, youth who run away from their

homes (Yoder, Whitbeck, & Hoyt, 2001; Shields et al., 2004; Kaufman & Widom, 1999;

Safyer et al., 2004).

Summary

The purpose of this study was to describe the personality characteristics of youth

who were admitted to Jennyplace and determine the association of the youth’s personality

characteristics, life events in the past 12 months, and history of sexual abuse with their

decisions to run away from home. This study was one of the first systematic inquiries to

concentrate on the internal states of runaway and homeless youth who were residing in a

shelter in rural central Florida.

No significant associations between life events in the past 12 months, sexual

abuse, internalizing behaviors, and youth runaway behavior were found. However, a

significant association was found between externalizing behaviors and youth runaway

behaviors.

The findings of this study raise the question about the need to understand the

personality characteristics and behaviors of these youth. In addition, nurses and health

care professionals should be concerned about these issues, since the antecedent and 110 subsequent behaviors have deleterious outcomes on the youth, their families, the community, and the nation.

111

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150

Appendices

Appendix A. Data Coding

Appendix B. Structured Clinical Interview

Appendix C. Coddington’s Life Events Scale

Appendix D. Adolescent Multiphasic Personality Inventory

151

Appendix A

Data Coding

152

Variable Information

Missing Variable Position Label Values age 1 age 99 sex 2 gender 99 ethnicity 3 ethnicity 99 custody 4 custody 99 living living 5 99 arrangement placemen 6 placement reason 99 runlengt length of run 7 999 (days) prevrun 8 # previous runs 999 closefri 9 close friends 99 grade 10 school grade 999 suspensi 11 # suspensions 999 susreasn reason 12 99, 88 suspension arrests 13 arrests 99, 88 alcuse 14 alcohol use 99 agealcoh 15 age at 1st alcohol 99, 88 alcfrequ 16 alcohol frequency 99, 88 paralcoh parents' alcohol 17 99 use parfrequ parents' 18 99, 88 frequency sibalcoh 19 sibling alcohol 99, 88 ill12 illness in 12 20 99 months legal12 problems in 12 21 99 months preg12 pregnancy in12 22 99, 88 months 153 brekup12 breakup in 12 23 99 months cowpar12 conflict w parents 24 99 12 months cobpar12 conflict b parents 25 99, 88 12 months joblos12 job loss 12 26 99 months refsourc 27 referral source 99 sibnumbe 28 # siblings 99 menillhx mental 29 99 illness/family menrethx mental 30 99 retardation/family age1sex 31 age 1st sex 999, 888 sexlearn 32 sex learn 99 sexactiv 33 sex active 99 aidsknow 34 AIDS know 99 birthcon 35 use birth control 99 condouse 36 use condom 99 stdknow 37 know STDs 99 gonoknow 38 know gonorrhea 99 syphknow 39 know syphilis 99 famabuse 40 family abuse 99 selfabus 41 you feel abused 99 sexabuse 42 sexual abuse 99 agesexab 43 age sexual abuse 999, 888 le12 life events 12 44 999 months liescale 45 LIE 999 fscale 46 FREQUENCY 999 kscale 47 CORRECTION 999 amphyp HYPOCHONDRI 48 999 ASIS 154 ampdep 49 DEPRESSION 999 amphys 50 HYSTERIA 999 ampppd PSYCHOPATHIC 51 999 DEVIATE ampfem 52 FEMININITY 999 amppar 53 PARANOIA 999 amppas PSYCHASTHENI 54 999 A ampscz SCHIZOPHRENI 55 999 A ampman 56 MANIA 999 ampsin SOCIAL 57 999 INTROVERSION runaway RUNAWAY 58 BEHAVIOR Externalizing EXTERNALIZING 59 BEHAVIORS

Internalizing INTERNALIZING 60 BEHAVIORS

LIFEEVENTS LIFE EVENTS 61 RECODED

Variables in the working file

155

Variable Values

Value Label sex 1 female 2 male ethnicity 0 white 1 african-american custody 1 parents 2 legal guardian 3 hrs-fc 4 hrs-er 5 other living 1 parents 2 other family 3 shelter 4 other placemen 1 runaway 2 beyond control 3 truancy 4 throwaway/homeless 5 dependency 6 other closefri 1 yes 2 no susreasn 1 fighting/physical aggression 2 arguing/verbal aggression 3 stealing 4 loitering 5 tardiness 6 other arrests 1 yes 2 no alcuse 1 yes 2 no alcfrequ 1 once a year 2 once a month 3 once every couple of weeks 4 every week 5 every other week 6 every day 7 other frequency 88(a) don't drink paralcoh 1 yes 2 no parfrequ 1 once a year 2 once a month 3 once every couple of weeks 156

4 every week 5 every other week 6 every day 7 other frequency 88(a) don't drink sibalcoh 1 yes 2 no ill12 1 yes 2 no legal12 1 yes 2 no preg12 1 yes 2 no 88(a) not applicable brekup12 1 yes 2 no cowpar12 1 yes 2 no cobpar12 1 yes 2 no 88(a) not applicable joblos12 1 yes 2 no refsourc 1 law enforcement 2 child (self-referral) 3 parent(s)/guardians 4 relatives 5 dhrs 6 other social service agency 7 school system 8 juvenile division of court 9 other menillhx 1 yes 2 no menrethx 1 yes 2 no age1sex 1 yes 2 no 88 not applicable sexlearn 1 parents 2 boyfriend/girlfriend 3 school counselor 4 health education 5 other sexactiv 1 yes 2 no aidsknow 1 yes 157

2 no birthcon 1 yes 2 no condouse 1 yes 2 no stdknow 1 yes 2 no gonoknow 1 yes 2 no syphknow 1 yes 2 no famabuse 1 yes 2 no selfabus 1 yes 2 no sexabuse 0 yes 1 no runaway 0 runaway 1 non-runaway LIFEEVENTS 1 normal 2 high

a Missing value

158

Appendix B

Structured Clinical Interview

164

Appendix C

Coddington’s Life Events Scale

175

Appendix D

Adolescent Multiphasic Personality Inventory