Mental Health Outcomes Among Homeless, Runaway, and Stably Housed Youth.

BACKGROUND AND OBJECTIVES: Runaway youth and homeless youth are at risk for adverse mental health outcomes. These 2 populations are frequently pooled together in both research and interventions yet may have unique health needs. We sought to assess differences in mental health outcomes among these populations. METHODS: We conducted a secondary data analysis of ninth- and 11th-graders in the 2016 minnesota Student Survey (n = 68 785). We categorized youth into 4 subgroups based on housing status in the previous year: (1) unaccompanied homeless youth (0.5%), (2) runaway youth (4%), (3) youth who had both run away and been homeless (0.6%), and (4) stably housed youth (95%). We performed multivariable logistic regression to compare 4 mental health outcomes (self-injury, suicidal ideation, suicide attempts, and depressive symptoms) across groups, controlling for demographics and abuse history. RESULTS: Unstably housed youth had poorer mental health outcomes when compared with their stably housed peers (P < .05). For example, 11% of homeless youth, 20% of runaways, and 33% of youth who had experienced both had attempted suicide in the previous year compared with 2% of stably housed youth (adjusted odds ratios 2.4, 4.9, and 7.1, respectively). Other outcomes showed a similar pattern. CONCLUSIONS: Our findings suggest that runaway and homeless youth represent unique populations with high levels of mental health needs who would benefit from targeted clinical and community interventions. Pediatric clinicians represent one potential point of screening and intervention.

Featured Counter-Trafficking Program: The Minnesota Runaway Intervention Program.

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked children. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research. This article describes the Minnesota Runaway Intervention Program (RIP), a Minneapolis-St. Paul based program dedicated to supporting youth aged 12-17 who have run away and experienced sexual violence, including sexual assault and exploitation. It is a comprehensive, health care focused intervention, embedded within a hospital-based Child Advocacy Center. RIP is developed and led by nurse practitioners who provide services tailored to participants' diverse needs, including health care, case management services, and a therapeutic empowerment group.

The Links Between Sexual Abuse Severity, Running Away, and Parental Connectedness Among Youth at a Hospital-Based Child Advocacy Center.

PURPOSE: Runaway adolescents often have strained relationships with their parents. Given parental support is an important protective resource for traumatized young people, understanding differences in support within parent-adolescent relationships could aid in designing more effective interventions. We hypothesized (1) runaway adolescents seen at a Child Advocacy Center (CAC) would have poorer parental relationships than adolescents without a history of running away and (2) severity of diagnosed sexual violence would be associated with lower parental connectedness. METHODS: Data were from 2,042 adolescents aged 10-19 years and their parents evaluated for any reason at our hospital-based CAC from 2008 to 2017. Parent-adolescent relationship scales were completed by adolescents and at least one parent/guardian (usually mothers). Sexual abuse was stratified at four levels, higher levels indicating increasingly severe forms of abuse. T-tests and analyses of variance to tested relationships between supportive and controlling parental behaviors by runaway status, and, among runaways, by the severity of sexual abuse. RESULTS: Runaway adolescents comprised 58.3% of adolescents seen at the CAC; runaways reported lower parental support and higher parental controlling than patients without a history of running away. Those with the most severe forms of sexual abuse (including sexual exploitation and gang rape) reported the least supportive and most controlling relationships with parents, as did their parents. CONCLUSIONS: Findings support our clinical observations that polyvictimization of adolescents who have spent significant time as runaways may further strain parent-adolescent relationships. Future clinical research should focus on developing interventions to promote parental connectedness after a runaway episode.

A nurse practitioner-led intervention for runaway adolescents who have been sexually assaulted or sexually exploited: Effects on trauma symptoms, suicidality, and self-injury.

BACKGROUND: Adolescent victims of sexual assault and exploitation suffer significant mental health distress including PTSD, self-harm, suicidal ideation, and attempts. OBJECTIVE: This longitudinal observational study investigated the Runaway Intervention Program's influence on trauma responses at 3, 6, and 12 months for adolescents who have run away at least once and have been sexually assaulted or exploited. PARTICIPANTS: Runaways (n = 362) received nurse practitioner (NP) home and community visits, intensive case management, and optional empowerment groups. SETTING: An urban Midwestern city's hospital-based Children's Advocacy Center. METHODS: Trauma responses were measured by the UCLA PTSD-RI index, past 30 days emotional distress scale, and self-harm, suicidal ideation, and suicide attempt questions. Repeated Measures ANOVA assessed trauma response changes over time. Growth curve analyses using intervention doses determined which aspects of the intervention predicted change. RESULTS: From program entry to 3 and 6 months, mean values decreased significantly for emotional distress (-0.67, -.91) self-harm (-.30, -.55), suicidal ideation (-.45, -.57), suicide attempts (-.58, -.61), and trauma symptoms (-11.8, -16.2, all p < .001) all maintained at 12 months. In growth curve models, NP visits independently predicted declines in emotional distress (-.038), self-injury (-.020), suicidal ideation (-.025) and attempts (-.032), while empowerment groups predicted trauma symptoms (-.525) and all others except suicide attempts. CONCLUSIONS: The program, especially NP community visits and empowerment group elements, decreased trauma responses in runaway youth with a history of sexual assault. Given high rates of PTSD and emotional distress among runaways, the Runaway Intervention Program offers promise for improving mental health outcomes.

Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings.

PURPOSE: Estimate the prevalence of child sex trafficking (CST) among patients seeking care in multiple healthcare settings; evaluate a short screening tool to identify victims in a healthcare setting. METHODS: This cross-sectional observational study involved patients from 16 sites throughout the U.S.: five pediatric emergency departments, six child advocacy centers, and five teen clinics. Participants included English-speaking youth ages 11-17 years. For emergency department sites, inclusion criteria included a chief complaint of sexual violence. Data on several domains were gathered through self-report questionnaires and examiner interview. Main outcomes included prevalence of CST among eligible youth; sensitivity, specificity, positive/negative predictive values, and positive/negative likelihood ratios for a CST screening tool. RESULTS: Eight hundred and ten participants included 91 (11.52%) youth from emergency departments, 395 (48.8%) from child advocacy centers, and 324 (40.0%) from teen clinics. Overall prevalence of CST was 11.1%: 13.2% among emergency department patients, 6.3% among child advocacy center patients, and 16.4% among teen clinic patients, respectively. The screen had a sensitivity, specificity, and positive likelihood ratio of 84.44% (75.28, 91.23), 57.50% (53.80, 61.11), and 1.99% (1.76, 2.25), respectively. CONCLUSIONS: This study demonstrates a significant rate of CST among patients presenting to emergency departments (for sexual violence complaints), child advocacy centers, and teen clinics. A six-item screen showed relatively good sensitivity and moderate specificity. Negative predictive value was high. Intervention for a "positive" screen may identify victims and help prevent high-risk youth from becoming victimized. This is one of the first CST screening tools specifically developed and evaluated in the healthcare setting.

Assessing exploitation experiences of girls and boys seen at a Child Advocacy Center.

The primary aim of this study was to describe the abuse experiences of sexually exploited runaway adolescents seen at a Child Advocacy Center (N=62). We also sought to identify risk behaviors, attributes of resiliency, laboratory results for sexually transmitted infection (STI) screens, and genital injuries from colposcopic exams. We used retrospective mixed-methods with in-depth forensic interviews, together with self-report survey responses, physical exams and chart data. Forensic interviews were analyzed using interpretive description analytical methods along domains of experience and meaning of sexual exploitation events. Univariate descriptive statistics characterized trauma responses and health risks. The first sexual exploitation events for many victims occurred as part of seemingly random encounters with procurers. Older adolescent or adult women recruited some youth working for a pimp. However, half the youth did not report a trafficker involved in setting up their exchange of sex for money, substances, or other types of consideration. 78% scored positive on the UCLA PTSD tool; 57% reported DSM IV criteria for problem substance use; 71% reported cutting behaviors, 75% suicidal ideation, and 50% had attempted suicide. Contrary to common depictions, youth may be solicited relatively quickly as runaways, yet exploitation is not always linked to having a pimp. Avoidant coping does not appear effective, as most patients exhibited significant symptoms of trauma. Awareness of variations in youth's sexual exploitation experiences may help researchers and clinicians understand potential differences in sequelae, design effective treatment plans, and develop community prevention programs.

Multiple perpetrator rape among girls evaluated at a hospital-based child advocacy center: seven years of reviewed cases.

The aim of this study was to describe contextual events, abuse experiences, and disclosure processes of adolescents who presented to a hospital-based Child Advocacy Center for medical evaluation and evidentiary collection as indicated after experiencing multiple perpetrator rape during a single event (n=32) and to compare these findings to a group of single perpetrator sexual assaults (n=534). This study used a retrospective mixed-methods design with in-depth, forensic interviews and complete physical examinations of gang-raped adolescents. Patients ranged from 12 to 17 years (M=14 years). Girls who experienced multiple perpetrator rape during a single event were more likely to have run away, to have drunk alcohol in the past month, and to have participated in binge drinking in the past 2 weeks. Acute presentation of these victims were rare but 30% had hymenal transections and 38% had sexually transmitted infections (STIs). Forensic interviews revealed alcohol was a common weapon used by offenders, and its use resulted in victims experiencing difficulty in remembering and reporting details for police investigation or physical and mental health care. Most victims were raped at parties they attended with people they thought they could trust, and they felt let down by witnesses who could have helped but did not intervene. Although relatively rare, multiple perpetrator rape during a single event is a type of severe sexual assault experience and has significant risks for deleterious health outcomes. These victims require health care by trained providers to diagnose physical findings, treat STIs, screen for trauma, and support victims.

The illusions and juxtapositions of commercial sexual exploitation among youth: identifying effective street-outreach strategies.

To explore sexually exploited youths' perspectives of how street outreach workers can effectively provide outreach and connections to services, we conducted qualitative interviews with 13 female participants, ages 14 to 22, in a Midwest U.S. city. Participants reported multiple types of exploitation, most first exploited by age 13, plus substance use and recurrent homelessness. Nearly all had a pimp, and all used the internet as a venue for sexual exploitation. Participants wanted outreach workers to use "soft words" to refer to exploitation. They expressed contradictory images of their "boyfriend" pimps and their exploitation. They wanted outreach workers to "provide resources," "be nonjudgmental," "listen," and "care." Street outreach can be one way to support sexually exploited youth but should occur in multiple settings.

It's called "Going out to play": a video diary study of Hmong girls' perspectives on running away.

How do Hmong immigrant adolescent girls decide to run away, return home, leave again, or stay home? Video diaries by 11 sexually exploited runaway Hmong girls, ages 13-16, revealed four themes: "fighting restrictions," or resisting family and cultural expectations and desires to be like other American teens; "not running away, going out to play," which captured impulsive decision making; "unrestrained partying," which described runaway experiences but minimized the dangers faced; and "trying to change," or returning home because of family bonds and wanting to "be someone good." Given their limited ability to anticipate risks, interventions should focus on runaway prevention initiatives for Hmong families and teens.

Differences in Abuse and Related Risk and Protective Factors by Runaway Status for Adolescents Seen at a U.S. Child Advocacy Centre.

OBJECTIVES: This study examined the abuse prevalence and characteristics, and risk and protective factors, among both runaway and non-runaway adolescents evaluated at a Child Advocacy Center (CAC) in Minnesota, which had implemented a referral program to assess runaways for potential sexual assault or sexual exploitation. METHODS: A cross-sectional analysis of self-report and chart data for the 489 adolescent girls who were evaluated between 2008 and 2010. Chi-square and t-tests by runaway status compared abuse experiences, trauma responses, health issues, and potential protective assets associated with resilience between runaways and non-runaways. Bivariate logistic regressions explored the relationship of these risk and protective factors to self-harm, suicide attempts, and problem substance use, separately for runaways and non-runaways who had experienced sexual abuse. RESULTS: Runaways were significantly more likely than non-runaways to have experienced severe sexual abuse, to have used alcohol and drugs, and reported problem substance use behavior, higher levels of emotional distress, more sexual partners, and they were more likely to have a sexually transmitted infection (STI). Runaways had lower levels on average of social supports associated with resilience, such as connectedness to school, family or other adults. Yet higher levels of these assets were linked to lower odds of self-harm, suicide attempt and problem substance use for both groups. CONCLUSIONS AND IMPLICATIONS: CACs should encourage referrals of runaway adolescents for routine assessment of sexual assault, and incorporate screening for protective factors in addition to trauma responses in their assessments of all adolescents evaluated for possible sexual abuse, to guide interventions.

Restoring healthy developmental trajectories for sexually exploited young runaway girls: fostering protective factors and reducing risk behaviors.

PURPOSE: To examine effects of the Runaway Intervention Program (RIP), a strengths-based home visiting, case management, and group support program for sexually assaulted or exploited young runaway girls; staffed by advanced-practice nurses, RIP aims to restore healthy developmental trajectories by reestablishing protective factors, reducing trauma responses, and lowering risk behaviors that are common sequelae of sexual violence. METHODS: Quasi-experimental study of RIP girls (N = 68) ages 12 to 15 (mean, 13.75 years), assessed at baseline, 6 and 12 months for changes in family and school connectedness, other adult caring, self-esteem, emotional distress, suicidality, recent substance use, plus risky sexual behaviors. Responses at each time were also compared to nonabused and abused urban ninth-grade girls (mean age, 14.64, N = 12,775) from the 2004 Minnesota Student Survey (MSS). Analyses used paired t-tests, McNemars test, Wilcoxon sign-rank, chi-square, and Pearson's correlations. RESULTS: At entry, RIP girls were most like sexually abused MSS peers, with lower levels of protective factors and higher levels of distress and risk behaviors than nonabused MSS girls (p < .05 to p < .01). However, they saw significant improvements by 6 and 12 months, such that all measures of protective factors, positive development, distress, and risk behaviors more closely resembled nonabused MSS girls by 12 months. Of equal note, RIP girls with the greatest emotional distress, the lowest levels of connectedness, and lowest self-esteem at baseline demonstrated the greatest improvement (all p < .001). CONCLUSIONS: This appears to be a promising intervention for restoring sexually abused runaway girls to a healthy developmental trajectory.

A novel, intensive home-visiting intervention for runaway, sexually exploited girls.

PURPOSE: Few studies have examined interventions that help adolescents who run away. This study both describes a home-visiting intervention program for young, sexually assaulted runaways (10-14 years old) and provides preliminary outcomes from the first 20 female participants. DESIGN AND METHODS: Using a strengths-based approach, advanced practice nurses provided frequent home and school visits and case management, and assisted girls to access an empowerment group over a 1-year period. RESULTS: Teens' risk behaviors decreased, including truancy, runaway episodes, sexually transmitted infections, and substance use. CONCLUSIONS: Preliminary results suggest that this is an effective intervention for reducing risk behaviors and helping younger runaways reconnect to school and family. PRACTICE IMPLICATIONS: Client-centered interventions in community settings can address the complex health needs of vulnerable young runaways.

Building intervention responses for sexually exploited, runaway youth.

The health and safety of runaway, sexually exploited youth is a national concern and challenge. This article describes how nursing administrators can support outreach to vulnerable and difficult to serve populations, develop collaborations with community agencies, and promote the delivery of healthcare.

Caring for young adolescent sexual abuse victims in a hospital-based children's advocacy center.

OBJECTIVES: This study compared health care assessments, referrals, treatment, and outcomes for young adolescent sexual assault/sexual abuse victims seen at a hospital-based Child Advocacy Center (CAC), to that provided to similar victims evaluated by other community providers. A second purpose was to document how common DNA evidence is found among such cases. METHOD: A retrospective matched case-comparison design matched index CAC cases diagnosed with extra-familial sexual assault to non-CAC cases referred for prosecution in the same county, matched by age and sex of victim, age and sex of perpetrator, and type of assault (N=128 pairs). Since the case-comparison design produces paired data, analyses used paired t-tests, McNemars test, and Wilcoxon signed-rank tests. Health care outcomes included whether victims received a health exam, indicated tests, findings of trauma on genital exams and counseling referrals; legal outcomes included whether cases were prosecuted, verdicts, and length of sentences. RESULTS: CAC cases were significantly more likely to receive a physical exam, a genital exam when indicated, and referral for counseling (all p<.001). In the CAC group 26.7% vs. 4.8% had positive genital trauma findings, and only 6.3% of CAC cases failed to get indicated sexually transmitted infection (STI) tests or prophylactic treatment for STIs vs. 80% of the comparisons (p<.001). There were no differences in decisions to prosecute, convictions, or sentence lengths between the groups. DNA was documented in only 27.3% of acute cases, although evidence kits were completed. CONCLUSIONS: Young adolescent sexual abuse victims received markedly different health care in a hospital-based CAC compared to elsewhere. DNA is not commonly found in acute cases. IMPLICATIONS FOR PRACTICE: Community health care providers and law enforcement should be encouraged to refer victims to hospital-based CACs for specialized examinations and treatment.

The Hmong Youth Task Force: evaluation of a coalition to address the sexual exploitation of young runaways.

The Minnesota Wheel of Public Health Nursing Interventions identifies coalition building and community organizing as effective strategies for addressing population health issues. One program that exemplifies these strategies is the Hmong Youth Task Force, a coalition formed to address a growing issue of young Hmong girls in a Midwest state running away from home, being truant from school, and experiencing subsequent sexual exploitation. This is an evaluation of the Task Force. It draws on existing records and semi-structured interviews with Task Force members from various sectors of government, health services, and community organizations, including public health nurses. The results, evaluated in the context of best practices identified by the Wheel of Interventions, document the Task Force's development, accomplishments, challenges faced, and community changes that have resulted from the coalition's efforts to date.

Gender differences in extrafamilial sexual abuse experiences among young teens.

Extrafamilial sexual abuse experiences of young adolescents (ages 10-14), particularly young teen boys, are not well studied. This retrospective chart review study compared psychosocial correlates and victimization experiences between young adolescent girls (n = 226) and boys (n = 64) referred to a hospital child advocacy center. Several differences in risk behaviors and abuse experiences were found: Girls were more likely to have run away, to be truant from school, to report substance use, to have multiple perpetrators, and to have physical findings from the abuse. Boys were more likely to have a diagnosis of attention deficit disorder and to report anal penetration, and rarely disclosed abuse at the time of the incident. Peers were girls' most common choice for disclosing abuse, whereas boys confided most often in their mothers or other adults. These findings suggest sexually abused young adolescent girls and boys need distinct, developmentally appropriate screening and care in school and health care settings.

Sexual exploitation of very young Hmong girls.

PURPOSE: Recent increases in Hmong girls referred to a Midwest hospital-based child advocacy center prompted this comparison of abuse experiences for Hmong extra-familial sexual abuse cases versus peers. METHODS: Retrospective chart review of all girls, aged 10 to 14 years, with extra-familial sexual abuse 1998-2003 (n = 226). Fourteen percent of cases were Hmong (n = 32). Demographics, risk behaviors, abuse experiences, physical findings and legal outcomes were compared for Hmong (H) and Other (O) girls using chi-square. Multivariate logistic regressions explored differences in gynecologic findings and sexually transmitted disease (STD) results. RESULTS: Hmong girls were more likely to be runaways (90% H vs. 8% O), truant (97% H vs. 13% O), self-mutilating (38% H vs. 10% O), and suicidal (41% H vs. 21% O). Seventy-seven percent of Hmong reported gang rape, prostitution, or multiple assaults versus 16% Others; most had 5+ perpetrators (69% H vs. 2% O) and 5+ assaults (75% H vs. 24% O, both p < .001). Gynecologic findings were more prevalent among Hmong girls (63% H vs. 21% O). Controlling for penetration, number of partners/assaults, and acuity at examination, Hmong ethnicity predicted gynecologic findings (adjusted odds ration [AOR] = 6.57). Hmong girls were more likely to have a positive chlamydia screen (36% H vs. 4% O, p < .001), but only number of perpetrators was an independent predictor (AOR = 15.09). Most cases were prosecuted, but Hmong had higher prosecution rates (83% H vs. 57% O, p < .001). CONCLUSIONS: Hmong girl assault experiences were markedly more severe than peers. Health care providers need appropriate knowledge of Hmong culture to conduct forensic examinations. Abused Hmong girls need culturally sensitive, developmentally appropriate after-care that helps connect them back with families and school.