Runaway Youth: Caring for the Nation's Largest Segment of Missing Children Thresia B

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Runaway Youth: Caring for the Nation’s Largest Segment of Missing Children Thresia B. Gambon, MD, MPH, MBA, FAAP,a Janna R. Gewirtz O’Brien, MD, FAAP,b COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COUNCIL ON COMMUNITY PEDIATRICS

The largest segment of missing children in the United States includes abstract runaways, children who run away from home, and thrownaways, children who are told to leave or stay away from home by a household adult. Although aCitrus Health Network, Miami, Florida; and bDepartment of Pediatrics, estimates vary, as many as 1 in 20 youth run away from home annually. These University of Minnesota, Minneapolis, Minnesota unaccompanied youth have unique health needs, including high rates of Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external trauma, mental illness, substance use, pregnancy, and sexually transmitted reviewers. However, clinical reports from the American Academy of infections. While away, youth who run away are at high risk for additional Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. trauma, victimization, and violence. Runaway and thrownaway youth have high Drs Gambon and Gewirtz O’Brien drafted, reviewed, and revised the unmet health care needs and limited access to care. Several populations are manuscript, approved the final manuscript as submitted, and agree to at particular high risk for runaway episodes, including victims of abuse and be accountable for all aspects of the work. neglect; lesbian, gay, bisexual, transgender, and questioning youth; and youth The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking in protective custody. Pediatricians and other health care professionals have into account individual circumstances, may be appropriate. a critical role to play in supporting runaway youth, addressing their unique All clinical reports from the American Academy of Pediatrics health needs, fostering positive relationships within their families and with automatically expire 5 years after publication unless reaffirmed, other supportive adults, and connecting them with available community revised, or retired at or before that time. resources. This report provides clinical guidance for pediatricians and other This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed health care professionals regarding (1) the identification of adolescents who conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process are at risk for running away or being thrown away and (2) the management of approved by the Board of Directors. The American Academy of the unique medical, mental health, and social needs of these youth. In Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. partnership with national, state, and local resources, pediatricians can DOI: significantly reduce risk and improve long-term outcomes for runaway youth. https://doi.org/10.1542/peds.2019-3752 Address correspondence to Thresia B. Gambon. E-mail: tbgambon@ me.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

The largest segment of missing children in the United States includes FINANCIAL DISCLOSURE: The authors have indicated they have no runaways, children who run away from home, and thrownaways, children ﬁnancial relationships relevant to this article to disclose. who are told to leave or stay away from home by a household adult.1,2 This report aims to provide clinical guidance for pediatricians regarding (1) the To cite: Gambon TB, Gewirtz O’Brien JR, AAP COMMITTEE identiﬁcation of adolescents who are at risk for running away or being ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COUNCIL ON COMMUNITY PEDIATRICS. Runaway Youth: thrown away and (2) the management of the unique medical, mental Caring for the Nation’s Largest Segment of Missing health, and social needs of these youth. Children. Pediatrics. 2020;145(2):e20193752

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 2, February 2020:e20193752 FROM THE AMERICAN ACADEMY OF PEDIATRICS There has been a considerable a runaway episode occurs when state and by study population. As amount of research conducted in the a child leaves home without noted previously, NISMART-3 area of runaway and thrownaway permission and stays away overnight estimated a prevalence of running youth since the 2004 publication of for at least 1 night (for children away of 5.3 per 1000 children.2 In the previous clinical report “The younger than 15 years) or 2 nights another study, published in 2006 on Pediatrician’s Role in the Prevention (for children 15 years or older). A the basis of data from the 1996 wave of Missing Children.”3 This clinical thrownaway episode occurs when of the National Longitudinal Study of report expands on the previous a child is asked or told to leave the Adolescent Health, authors reported report’s discussion of youth who run home by a household adult or is that 6.4% of youth (nearly 850 000) away in the United States. Although prevented from returning home by had run away in the 12 months estimates of the prevalence of a household adult for at least 1 night before the 1996 survey.6 By using the running away vary depending on when no adequate alternative care is data from the National Longitudinal definitions, methodology, and arranged.2 Survey of Youth (1997 cohort), it was population, the 2013 National found that nearly 1 in 5 youth ran Runaway and thrownaway episodes Incidence Studies of Missing, away before age 18. A school-based are grouped together because youth Abducted, Runaway, and survey of Minnesota youth in grades often fall into both categories. Thrownaway Children (NISMART-3), 8 through 11 revealed that between Information varies depending on released by the US Office of Juvenile 4% and 7% of students had run away who is interviewed regarding the Justice and Delinquency Prevention in at least once in the previous year.7,8 circumstances; youth do not always 2017, estimated that 413 000 view the circumstances the same way Each report of a missing child made children ran away or were thrown as the guardians and/or parents to law enforcement is required by away in 2013, at a rate of 5.3 per 1000 do.20 Twenty-two percent of youth federal law to be entered into the children, comparable to previous described the episode as Federal Bureau of Investigation NISMART cycles.2,4 Other studies a combination of running away and National Crime Information Center have estimated that between 5% being thrown out.20 In this report, the (National Center for Missing and and 8% of adolescents run away 21 – term “runaway” is used to refer to Exploited Children [NCMEC]). Some every year.5 8 It is important that both categories, although the term of the reports may be regarding the pediatricians understand this “thrownaway” is occasionally used to same child because a report can be population so they can better serve be consistent with the data. made each time a child is missing. In these youth and families in clinical 2017, 464 000 reports were made practice and in the community setting. Runaways may not always be into this database. One role of the classified as missing children, making NCMEC, the national clearinghouse Unaccompanied adolescents who run it difficult to quantify the problem. and resource center for missing and away or who are asked to leave home Many runaways are not considered exploited children, is to help with have unique health needs. Before missing because guardians and/or finding these children. In 2017, the running away, many have learning parents know the whereabouts of the NCMEC assisted with more than disabilities, struggle with mental youth. Youth who run away may stay illness, experience school failure, or 27 000 cases, including 25 000 with friends or other family 21 engage with peer groups who 1,20 runaways (missingkids.org). 9 members. In addition, some participate in high-risk behaviors. runaways may not be reported The Runaway Safeline, (1–800- Many have experienced abuse or RUNAWAY), formerly known as the 10–13 missing because the guardians and/ neglect before running away. or parents are not looking for them. National Runaway Switchboard, is While away, these unaccompanied There is a small category of children a federally funded national resource minors are at high risk for who are permanently abandoned and that provides services to youth and victimization and violence; substance are often not included in data because their families (https://www. use; risky sexual behavior, including they may not be reported as missing.1 1800runaway.org/). The Safeline survival sex; further absenteeism allows runaway and homeless youth from school; and other or their parents to call for assistance DEMOGRAPHICS associated negative health or guidance; attain 24-hour referrals 9–11,14–19 consequences. The total number of youth who run to community resources, including away is difficult to measure for shelter, food banks, legal assistance, a number of reasons, including and social services agencies; and seek DEFINITIONS inconsistent definitions and difficulty crisis intervention counseling.20 The According to the Office of Juvenile with sampling.4 The data regarding Safeline handled more than 70 000 Justice and Delinquency Prevention, the incidence of running away vary by calls and electronic contacts in

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS 2017.22 Of those contacts, 31% of reported for NISMART-3, NISMART-2 questioning (LGBTQ) youth are contacts were about youth who were data suggest that youth of color may disproportionately represented contemplating running away, 16% be slightly overrepresented among among runaway and thrownaway were about youth who had run away, runaway youth.1,2 Research published youth. An estimated 20% to 40% of 5% were about youth asked to leave in 2006 exploring the demographic teenagers who are homeless identify home or prevented from returning profile of runaway youth in the as LGBTQ, compared with 4% to 10% home (thrownaway), and 9% United States using data from the of nonhomeless peers.25–28 In a 2015 were about youth experiencing National Longitudinal Study of study of 434 homeless youth in Texas, homelessness. Approximately three- Adolescent Health did not reveal 25% of youth identified as lesbian, fourths of the calls came from the significant differences in running gay, bisexual, transgender, or affected youth.22 Research compiled away among racial and ethnic something else.25 The unique by the National Opinion Research groups.6 However, more recent data runaway experiences and health care Center found that more than 70% of from the National Runaway Safeline needs of LGBTQ runaway youth are youth left home on the spur of the reveal that youth of color seem to be discussed in detail later in this report. moment, 36% of youth planned to overrepresented among runaway run in advance, and 23% of youth youth in crisis who are connecting who were thrown out said they with the Safeline; 23% of those youth HEALTH IMPACTS 20 expected to be thrown out. This connecting identify as black or A generation of research reveals that information was compiled from calls African American, compared with runaways are at high risk for adverse 22 to the National Runaway Switchboard 14% of the general population. health outcomes, including disease, 23 from 2000 to 2009, a comprehensive Morton et al found similar results in crime (both as victims and review of research on runaways, and 2018, revealing that black or African perpetrators), injuries, alcohol use, new research conducted on youth in American youth were more likely to illegal drug use and sales, and sexual the streets and shelters in Chicago be homeless (including runaway contact including abuse and and Los Angeles between October episodes) than their peers. Although activity.1,9,10,15–17,29 It is critical that 20 2008 and January 2010. More than data on American Indian/Alaska pediatricians are aware of the health half of the adolescents reported that Native youth who have run away are implications of runaway episodes so friends knew where they were, and limited, an estimated 1 in every 130 that they can better care for these 26% said that their parents knew American Indian/Alaska Native children. Many, but not all, runaways 24 their whereabouts. Only 13% of children go missing each year. The are homeless while away. The youth interviewed said that no one number missing is likely to be higher, American Academy of Pediatrics 20 knew where they were. but estimates of American Indian/ (AAP) policy statement “Providing Alaska Native youth are limited The NISMART-3 response rate was Care for Children and Adolescents because there is no centralized not high enough to be able to break Facing Homelessness and Housing reporting system in tribal Insecurity” details the health risks down the characteristics of the 24 communities. 30 runaway episodes.2 Data from associated with homelessness. This NISMART-2, conducted in 1999, The data regarding the gender section focuses on health risks reveal that 68% of runaways were distribution of runaway youth are associated with running away, between 15 and 17 years of age, 28% also mixed but consistently reveal although there is some overlap. were 12 to 14 years of age, and 4% that girls run away more often than While away from home, youth are at were 7 to 11 years of age.1 Runaway boys.6 Sanchez et al6 reported that high risk for poor sexual health episodes are most likely to occur female-identifying youth were more outcomes, including pregnancy, during the summer; runaways usually likely to have runaway. Data from the sexually transmitted infections, and go between 10 and 50 miles from National Runaway Safeline reveal – sexual exploitation and abuse.17,31 35 home. Twenty-three percent traveled a similar trend. Among those youth Nearly half of female street youth and more than 50 miles from home. Most connecting with the National one-third of female youth living in were gone from 24 hours to 1 week. Runaway Safeline in 2017, 69% emergency shelters report a history Seven percent of runaways were identified as female, 29% identified of pregnancy.33,36 Although not the missing for 1 to 6 months.9 as male, and 3% identified as either focus of this report, runaways may transgender or gender The data regarding the distribution of become involved in sex trafficking or nonconforming.22 runaway youth from racial and exploitation, including survival sex, ethnic minority backgrounds are More than a decade of data which is sex in exchange for food, inconsistent.1 Although racial and suggest that lesbian, gay, clothing, or housing.1,15 Readers are ethnic distributions have not been bisexual, transgender, and referred to the AAP policy “Child Sex

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 2, February 2020 3 Trafficking and Commercial Sexual including physical or sexual approach, which involves being aware Exploitation: Health Care Needs of assault.1,14,15,42 Poor mental health is of trauma and adverse childhood Victims” and other publications for believed to be associated with street experiences that can affect health. “A additional information on this critical victimization among homeless and trauma informed practice is defined topic.37,38 For youth who have been runaway youth.38 Running away as an organizational structure and victims of abuse or neglect before puts youth at risk for exposure to treatment framework that involves running away or while away from additional trauma, further limits their understanding, recognizing, and home, pediatricians are mandated social supports, and makes it difficult responding to the effects of all types reporters. In states where sex to access the necessary medical help of trauma.”45 The AAP Trauma trafficking is considered a form of for these disorders.38 Toolbox for Primary Care contains abuse, pediatricians must make resources on implementation for There is a strong association between a formal report of suspected a primary care practice to become substance use and runaway episodes, exploitation to law enforcement and trauma informed.45 although a causal link has not been to child protective services as well, if established.9,14,43 It is unclear Many factors drive adolescents to run indicated. whether the use of drugs and/or away or to be asked to leave home. Youth who run away are more likely alcohol precipitates running away or The most common reason youth give to engage in substance use.1,9 In being asked to leave home or whether for running away is fleeing a negative 9 addition to the health consequences the circumstances associated with the home environment. In a study 9 associated with substance use alone, episodes lead to increased substance conducted by Tucker et al , several substance use increases the risk of use, although longitudinal studies factors were found to be common in sexual assault and mental health suggest that the association is likely the runaway population. These 9 consequences dramatically for bidirectional. A 2013 study by factors included a perception of low 14 runaway adolescents.38 In urban Edinburgh et al of youth presenting parental support in the ninth grade, areas, these youth often join gangs or at a child advocacy center revealed school disengagement, substance use, 9 are involved in violent and/or drug- that 1 in 3 runaway youth met and depressive affect. Disruption of related criminal activity.1,39 They criteria for problem substance use, the family structure and dysfunction have a high likelihood of being whereas 1 in 10 nonrunaway youth and disorganization of homes are affected by violence while away from met criteria. NISMART-2 data known risk factors for running 9,10 home.1,11 revealed that 17% of runaway youth away. reported using “hard drugs”; 18% Runaway behavior is more common Youth who run away experience were in the company of someone in youth who have been exposed to higher rates of mental illness, known to be using drugs while away, violence, had a poor parent-child including anxiety, depression, and and 19% of runaway and 1,9,14,40 14 relationship, and/or had a history of suicidality. Edinburgh et al thrownaway youth surveyed were delinquent behavior or depressive showed that among runaway youth substance dependent.1 presenting to a child advocacy center, symptoms. Some studies have shown nearly a quarter had a history of Running away also has long-term that economic problems in the home effects on educational success. Youth may lead to more youth running a suicide attempt, compared with 19 46 13.7% of youth who had not run who run away multiple times are away. Tyler and Bersani noted away. Older data from NISMART-2 18% more likely to drop out of high that youth living in disadvantaged 44 revealed that 4% of endangered school. Youth who run away from neighborhoods were also more likely runaway and thrownaway youth had home are less likely to graduate from to run away. high school. Seventy-five percent of attempted suicide previously, but Disengagement from school is runaway or homeless youth drop out these data were not updated in a significant risk factor for a child 1 of school.19 NISMART-3. A 2004 study running away or becoming homeless. measuring the prevalence of mental Tucker et al9 reviewed an analysis of health disorders among runaway and IDENTIFYING YOUTH WHO ARE AT RISK more than 15 000 youth in crisis homeless youth in small- to midsized FOR RUNNING AWAY shelters or transitional living cities in 4 Midwestern states revealed programs and found that 47% had There is no current, validated significantly higher rates of mental irregular school attendance and 22% screening tool for runaway episodes, health disorders when compared with had dropped out or been expelled. age-matched peers.41 but practices should consider assessing for previous runaway Youth who are asked to leave home Unfortunately, runaways frequently episodes and risk factors for running may include youth who are pushed risk further trauma while away, away using a trauma-informed out of their homes for different

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS reasons, some because the family Runaway Safeline and the NCMEC more likely to have been abused cannot provide for their specific (see Resources). Pediatricians can ask previously.10 As previously noted, mental health or disability needs, adolescents where they would go if while youth are away, they are at risk some because parents cannot afford they were to run away or be forced for further victimization.14,38 to provide care, and many because of out, specifically assessing for other poor relationships between parents safe, supportive adults who might be and youth.1,19 able and willing to provide shelter LGBTQ YOUTH and support in a crisis. Pediatricians Implementation of various screens As noted previously, a decade of can refer families to local resources during health care visits can assist to research suggests that an estimated for behavioral health, family therapy, identify family stressors, school 20% to 40% of teenagers who are and support and assistance with problems, and other social homeless identify as LGBTQ, other issues. determinants of health that may compared with 4% to 10% of 25–28 increase the risk of running away. Several high-risk populations deserve nonhomeless peers. In a 2012 Screening tools such as the Well Child additional attention, including victims survey of service providers for Care, Evaluation, Community homeless youth and youth at risk for of abuse and neglect, LGBTQ youth, 50 Resources, Advocacy, Referral, and youth in protective custody. Each homelessness, Durso and Gates Education survey instrument (WE of these populations is discussed in explored reasons for homelessness CARE) and Safe Environment for further detail in the sections that among LGBTQ youth and found that Every Kid (SEEK) parent screening follow. Adolescents in these nearly half (46%) of LGBTQ youth questionnaire screen families for subgroups are at high risk for running reported running away because of problems related to education, away and may experience significant rejection relating to sexual housing, child maltreatment, health effects while away. orientation or gender identity, and domestic violence, and more. More 43% reported being forced out by information is available on the AAP parents because of sexual orientation Poverty and Child Health Web site.47 VICTIMS OF ABUSE AND NEGLECT or gender identity. Nearly one-third of For, adolescents, pediatricians should these youth (32%) attributed their Among runaway and thrownaway conduct a thorough, confidential homelessness to physical, sexual, or youth surveyed as part of NISMART- 50 psychosocial assessment, such as the verbal abuse at home. To the 2, 21% (estimated 350 400) reported HEEADSSS assessment (home authors’ knowledge, there are no being physically or sexually abused at environment, education and specific data that are focused on home in the year before the episode employment, eating, peer-related LGBTQ runaway youth; thus, the or were afraid of abuse if they activities, drugs, sexuality, suicide/ literature on LGBTQ homeless youth returned.1 Across multiple studies of depression and safety).48 Routine is used more generally in this homeless youth, rates of sexual abuse depression screening is also discussion given the significant ranged from 17% to 35% and recommended for teenagers. overlap in this population. physical abuse ranged from 40% to Pediatricians should also assess for 60%.19,26 Approximately 20% of LGBTQ youth are more likely to be protective factors, including whether street youth have, at some point, been affected by the many health risks adolescents consider themselves to removed from their homes by associated with homelessness.41,50,51 have several sources of support at authorities because of neglect or LGBTQ youth who are homeless home, at school, and in the abuse.32 Runaway youth consistently report higher rates of survival sex, community.14 report family conflict as a primary substance use, and victimization When an adolescent at high risk for reason for leaving the home.32,49 when compared with non-LGBTQ running away is identified, early Thrane et al10 studied the impact of homeless youth.41,51–53 A survey by intervention to prevent runaway family abuse on running away, Cochran et al51 comparing LGBT episodes is recommended. Use of deviance, and street victimization and homeless youth and heterosexual practice- and community-based found that adolescents who had been homeless youth revealed that LGBT resources to address any modifiable exposed to neglect and sexual abuse youth reported, on average, 7.4 more risk factors, support the psychological ran away sooner and were more acts of sexual victimization than their and behavioral health needs of the likely to be victimized on the street. heterosexual counterparts and had child and family, and ensure safety Although most runaway youth are significantly higher rates of can be helpful. Pediatricians can missing for less than 1 week and psychopathology.50 LGBTQ youth also share information regarding national remain close to home, those who go experience higher rates of depression resources for runaways and their missing for longer periods of time and suicidality.41,53,54 In a multistate families, including the National and who travel farther from home are single-day survey of homeless youth

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 2, February 2020 5 by Van Leeuwen et al,54 62% of away, whereas children with mental Children who run away from out-of- LGBTQ homeless youth reported and behavioral health problems were home care are at increased risk of a previous suicide attempt, compared more likely to run away.57 Courtney negative consequences similar to all with 29% of non-LGBTQ homeless and Zinn57 found that some mental runaway youth, such as criminal youth.54 In the same study, homeless and/or behavioral disorders, such as victimization, sexual exploitation, and LGBTQ youth had higher rates of schizophrenia and other psychoses, substance or alcohol use.55 sexually transmitted infections, were associated with lower risk of For youth in protective custody, including HIV, than heterosexual running away, but alcohol- and other 54 pediatricians should discuss stability homeless youth. substance-related disorders were of placement with the foster parent, associated with increased risk. Data case manager, and/or child, and YOUTH IN PROTECTIVE CUSTODY from the 2009 Adoption and Foster a confidential discussion with the Care Analysis and Reporting System child should take place about how the Data on runaway youth living in (AFCARS), a federally mandated data child feels about where he or she is protective custody, including foster collection system that includes case- living and any concerns. For all care, vary depending on the source of level information on (1) all children children in foster care, it is critical the data.55–57 In 2017, 4734 (1.1%) of in foster care for whom child welfare that pediatricians recommend that the 442 995 children in foster care in agencies have responsibility for their behavioral health needs be met. the United States ran away from their placement, care, and supervision and Pediatricians and other health care foster care placements, consistent (2) children adopted through child providers for youth in out-of-home with data reported by the US welfare agencies, found that autism custody can refer to the multiple Department of Health and Human spectrum disorder was associated resources available through the AAP Services in 2016. Data from 2010 with a decreased incidence of running on the Healthy Foster Care America include all runaways in foster care 55 away. Web page (https://www.aap.org/en- from birth to 18 years of age, but us/advocacy-and-policy/aap-health- because young children do not have Child welfare system–related initiatives/healthy-foster-care- the capability to run away, the characteristics, including the type of america/Pages/default.aspx). estimate of children who run away placement, permanency plan while in increases with age, with care, reason for placement, number of approximately 30% of youth 12 years placements, and the quality of care ROLE OF TECHNOLOGY AND SOCIAL MEDIA or older in out-of-home care received in placements were also placements having run away.58,59 In found to be factors associated with The rapid expansion of social media 2013, Benoit-Bryan59 reported that runaway behaviors.58 The instability has influenced the experiences of older youth in foster care were more of foster care placements is runaway youth in several ways. Early than 2.5 times more likely to run a predictor of youth running away data exploring the nature of Internet- away than youth who do not live in behavior, and multiple placements are initiated crimes suggest that online foster care. Lin58 found that most related with an increased risk of relationships may increase the risk of foster youth who run away run to running away.58 Children who ran running away.60 However, the their family of origin and/or their away experienced an average of 6 evolving social media landscape friends out of a desire to maintain placement settings.58 Stabilization of makes the effects difficult to measure, relationships with their community of foster care placement is associated and available follow-up data are origin. with fewer runaway episodes.58 limited. A study conducted from Placement type is also important; October 2001 to July 2002 of One study from 2015 reported that youth in foster homes, especially if a random sample of law enforcement youth in foster care who run away placed with a relative, are less likely agencies described the characteristics have often experienced emotional or to run away than those placed in of episodes in which juveniles became psychological problems that began residential care.57 In addition, victims of sex crimes committed by before entering foster care.55 children who are placed in the same people they met through the Experiences such as parental foster home as a sibling are less likely Internet.61 This study revealed that incarceration and personal history of to run away.57 Youth who know they victims in these crimes were substance use were associated with are unlikely to be reunified with primarily 13- to 15-year-old girls who a higher number of runaway family or relatives and/or be adopted met adult male offenders and episodes.55 are more likely to run away.55 Of developed romantic relationships While in out-of-home care, children note, youth with a history of running with them for 1 month or longer. In with developmental and cognitive away are 92% more likely to run most cases, offenders did not deceive disabilities were less likely to run away again.58 victims regarding their age or sexual

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS motives. Of 129 cases studied, 5% Although much of this work has Innovative, evidence-based involved violent offenses and 3% focused on homeless youth interventions aimed at the prevention involved brief abductions in the specifically, it has potential of runaway and thrownaway episodes setting of sexual assaults. Notably, implications for runaway youth and in the clinical and community setting 29% of the victims who attended requires further study. should also be developed and studied face-to-face meetings were reported to guide practice- and community- missing to police, with 24% being MANAGEMENT OF RUNAWAY EPISODES based intervention. runaways and 5% who had Another potential area of study is the misinformed parents regarding For children who have run away, role of the Internet and social media where they were going.61 In a 2014 pediatricians can conduct a thorough in episodes of runaway youth, study of law enforcement assessment of mental health including further exploration of safe perspectives on the role of technology concerns; substance use; previous media use and applications of social in child sexual exploitation, history of abuse, violence, or media and technology to better investigators working on child sexual victimization while away; exposure to support youth who have run away. exploitation cases report that trauma; and sexual and reproductive technology has played a significant health needs and treat accordingly. Finally, policies and programs that role in the majority of cases.62 Pediatricians should provide improve health care access for comprehensive care, including runaway youth are essential. Federal Recognizing the potential links psychological and social support, to legislation supporting the Runaway between runaway youth, sexual families who have a child or and Homeless Youth Program, exploitation, and technology, in April adolescent who has recently returned initially passed in the 1970s and 2018, the Family and Youth Services home after running away. Often, these revised as recently as 2017, Bureau added a tool titled “Online children are targeted for punishment recognizes this need and provides Recruitment of Youth Via Social for the act of running away or for the funding for services that support Media and the Internet” to its “Human associated misdeeds of substance use, runaway and homeless youth. This Trafficking and Runaway and theft, or prostitution when what is legislation includes grant funding for Homeless Youth: Practical Tools for needed is medical and psychological programs that target mental and Grantees.” This tool explores the role treatment, family realignment, or physical health among runaway youth of social media trafficking 3 placement in protective custody. and integrate health care into existing recruitment, lists red flags, and services for youth.70,71 Shelter-based recommends prevention strategies Pediatricians can support and clinics, clinics for runaway youth, for youth-serving agencies.63 maintain awareness of programs that serve runaway youth and build health care services for street youth, Innovative work has also emerged connections with these programs and free youth clinics all may serve as exploring the potential use of through the medical home. options to meet the health care needs technology to improve health and Pediatricians may also consider of this population but must provide access to services for homeless sharing information regarding readily accessible, culturally 64–68 youth. A 2016 study by Harpin national resources for runaways and competent, trauma-informed, and 69 fi 72–75 et al of homeless youth in Denver, their families listed below, including con dential care. The Runaway Colorado, revealed that 71.9% of the National Runaway Safeline and Intervention Program in Minnesota youth consistently used social media. the NCMEC (see Resources). represents an innovative nursing-led Tyler and Schmitz68 reported on intervention targeting runaway youth using texting technology for data with promising outcomes.73,76,77 OPPORTUNITIES FOR FUTURE collection and explored potential Community-based interventions that RESEARCH AND ACTION opportunities for interventions improve health care access and leveraging technology. Buccieri and Additional research on the outcomes in a cost-effective manner Molleson64 explored the use of recognition, management, and should be studied and supported. a youth-developed application for prevention of runaway episodes is Policy strategies are needed that homeless youth. In their study of law critical. Specifically, the development improve access to health insurance enforcement, Mitchell and Boyd62 of well-validated screening tools for and health care for runaway youth. discussed the potential opportunity identifying children who are at high for technology to be used to connect risk for running away or being CONCLUSIONS with difficult-to-reach populations thrown away would help that may be at risk for commercial pediatricians and other health care Runaway and thrownaway youth, the sexual exploitation, including providers better identify this high- largest category of missing children, homeless and runway youth. risk population of adolescents. require ongoing support and

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 2, February 2020 7 continued engagement with away and provide necessary mental health concerns; substance pediatricians and other health care health care to mitigate risk, such use; previous history of abuse, providers and community resources as reliable contraception and violence, or victimization while to prevent recurrence and address access to mental health care. away; exposure to trauma; and their unique health needs. If risk factors are identified, sexual and reproductive health intervene early to prevent needs and treat accordingly. Youth who have run away may run RECOMMENDATIONS FOR CLINICAL runaway episodes by using away again. Refer at-risk youth to PRACTICE practice- and community-based programs that are focused on self- resources to address any Identify youth who are at high modifiable risk factors, support empowerment, healthy sexuality, risk for running away or being the psychological and behavioral and relationships and safety thrown away. health needs of the child and planning with the goal of ○ increasing youth resilience. Conduct a thorough, confidential family, and ensure safety. social history and home Provide comprehensive care Consider counseling special environment, education and through a trauma-informed lens, populations as follows: employment, eating, peer-related including psychological and ○ activities, drugs, sexuality, suicide Victims of abuse and neglect: For social support, to families who and/or depression, and safety children with a known or suspected have a child or adolescent who (HEEADSSS) assessment for all history of abuse or neglect, confirm has recently returned home after adolescents, including that they feel safe in their current running away. surveillance for risk factors living situation. Although the prevention of known to be associated with ○ LGBTQ youth: Help support runaway episodes has not been 48 running away. Routine sexual minority children and youth well studied, prevention likely depression screening is and their families, particularly depends on the development of recommended for children 12 about the process of coming out strong, nurturing, reciprocal and up by using standardized regarding nonconforming gender relationships from early tools such as the Patient Health expression or sexual orientation. childhood. Building on existing Questionnaire for Adolescents ○ Youth in protective custody: For approaches within Bright (PHQ-A) and the primary care youth in protective custody, Futures for health supervision version of the Beck Depression discuss stability of placement with visits and validated community Inventory (BDI).78 the foster parent, case manager, programs, the AAP supports ○ Assess whether adolescents and/or child. Discuss with the efforts to promote positive consider themselves to have child how he or she feels about relationships and positive sources of support, including the whereheorsheislivingandany parenting strategies early on. pediatrician, so that they do not concerns. In states where sex trafficking is need to resort to running away. ○ Youth with mental health and/or considered a form of abuse, Ask them to identify an adult pediatricians must make fi substance use issues: Recommend they feel comfortable con ding in a formal report of suspected and recommend they go to that appropriate ongoing mental health support and services. For exploitation to law enforcement adult if they are having any and to child protective services substance use, consider using the issues. as well, if indicated. screening, brief intervention, and Consider posting and sharing information regarding national referral to treatment (SBIRT) RESOURCES resources for runaways and outlined in the AAP policy statement and clinical report.79,80 their families in waiting or • The National Runaway Safeline, examination rooms. Support and maintain awareness formerly known as the National If an adolescent is believed to be of programs that serve youth Runaway Switchboard (1–800- at high risk for running away or who have run away or are RUNAWAY; https://www. has run away before, discuss homeless, including hotlines, 1800runaway.org/), serves as a safety plan for future runaway shelters, and other resources to a hotline for children considering episodes, including a plan for provide for basic needs while running away and those who have accessing safe housing. Review youth are away (see Resources). run away. potential health and behavioral For youth who have run away, • NCMEC (www.missingkids.com): If risks associated with running conduct a thorough assessment of a child runs away, the parent or

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS guardian should contact the NCMEC Thresia B. Gambon, MD, FAAP Janna R. Gewirtz O’Brien, MD, FAAP at 1-800-THE-LOST in addition to Keith M. Lemmon, MD, FAAP Virginia Keane, MD, FAAP reporting the incident to law Jason Richard Rafferty, MD, MPH, EdM, FAAP Lawrence Sagin Wissow, MD, MPH, FAAP enforcement. Any information about LIAISONS a missing child or suspected sexual Donene Feist exploitation should be reported to LIAISONS Zheyi Teoh, MD NCMEC. Sharon Berry, PhD, ABPP, LP – Society of • Strengthening Families (www. Pediatric Psychology STAFF Edward R. Christophersen, PhD, ABPP, strengtheningfamilies.net) FAAP – Society of Pediatric Psychology Dana Bennett-Tejes, MA provides resources for building Kathleen Davis, LSW – Family Liaison Jean Davis, MPP resilience in parents and Norah L. Johnson, PhD, RN, CPNP-BC – children. National Association of Pediatric Nurse • Practitioners National Network for Youth (www. Rachel Shana Segal, MD – Section on Pediatric nn4youth.org) is a public education Trainees ABBREVIATIONS and policy advocacy organization Abigail Boden Schlesinger, MD – American dedicated to the prevention and Academy of Child and Adolescent Psychiatry AAP: American Academy of – eradication of youth homelessness. Amy Starin, PhD, LCSW National Pediatrics Association of Social Workers LGBT: lesbian, gay, bisexual, and transgender LEAD AUTHORS STAFF LGBTQ: lesbian, gay, bisexual, Thresia B. Gambon, MD, MPH, MBA, FAAP transgender, and ’ Carolyn McCarty, PhD Janna R. Gewirtz O Brien, MD, FAAP questioning NCMEC: National Center for COMMITTEE ON PSYCHOSOCIAL ASPECTS OF COUNCIL ON COMMUNITY PEDIATRICS, Missing and Exploited CHILD AND FAMILY HEALTH, 2019–2020 2019–2020 Children Arthur Lavin, MD, FAAP, Chairperson James Duffee, MD, MPH, FAAP, Chairperson NISMART-2: 1999 National George LaMonte Askew, MD, FAAP Kimberley J. Dilley, MD, MPH, FAAP Incidence Studies of Rebecca Baum, MD, FAAP Andrea E. Green, MD, FAAP Missing, Abducted, Joyce Javier, MD, MPH, MS, FAAP Evelyn Berger-Jenkins, MD, FAAP Runaway, and Tiffani Johnson, MD, FAAP Madhulika Mathur, MD, MPH, FAAP Douglas Jutte, MD, MPH, FAAP Gerri Mattson, MD, FAAP Thrownaway Arwa Nasir, MBBS, MSc, MPH, FAAP Kimberly G. Montez, MD, MPH, FAAP Children Jacqueline L. Nelson, MD, FAAP NISMART-3: 2013 National Christopher B. Peltier, MD, FAAP FORMER COMMITTEE ON PSYCHOSOCIAL Incidence Studies of ASPECTS OF CHILD AND FAMILY HEALTH Missing, Abducted, MEMBERS FORMER COUNCIL ON COMMUNITY Runaway, and PEDIATRICS MEMBERS Thrownaway Michael W. Yogman, MD, FAAP, Former Chairperson Benjamin A. Gitterman, MD, FAAP Children Nerissa S. Bauer, MD, MPH, FAAP Thresia B. Gambon, MD, MPH, MBA, FAAP

FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conﬂicts of interest to disclose.

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