154 PEDIATRIC NURSINGMay-June 2009Vol. 35No. 3Lost in t.docx

154 PEDIATRIC NURSING/May-June 2009/Vol. 35/No. 3
Lost in the Shuff l e :
C u l t u re of Homeless
A d o l e s c e n t s
E
v e ry culture has a schema,
which can be expressed as
family stru c t u re; dietary habits;
religious practices; the devel-
opment of art, music, and drama;
ways of communicating; dress; and
health behavior. Literature on ru n a w a y
adolescents dates back to the 1920s,
but very little re s e a rch focuses on the
c u l t u re of homeless adolescents.
Homeless adolescents exist literally on
the periphery of society, often leading
to exclusion and marginalization, as
these youth gravitate toward isolated
locations, such as abandoned areas of
the city, hidden spaces in public build-
ings, and remote or inaccessible sites.
U l t i m a t e l y, they find themselves pro-
hibited from participating in society
and limited in their use of societal
powers and re s o u rces (Raleigh-
D u R o ff, 2004; Rice, Milburn ,
R o t h e r a m - B o rus, Mallett, & Rosenthal,

2005). This study explores the culture
and life experiences of homeless ado-
lescents in a major urban area.
Life on the streets has the potential
to erode the emotional and physical
w e l f a re of the abandoned child
( M i l b u rn et al., 2007; Robert s o n ,
1998). To survive, many of these ado-
lescents re s o rt to drug dealing and a
myriad of high-risk activities that re n-
der their life issues diff e rent fro m
those of the general adolescent popu-
lation (Auerswald & Eyre, 2002;
B a rry, Ensign, & Lippek 2002; Ginzler,
G a rret, Baer, & Peterson, 2007).
These youth are at increased risk for a
host of physical, psychosocial, and
psychological problems (Alexander &
Schrauben, 2006; Slesnick, Pre s t o p n i k ,
Meyers, & Glassman, 2007; Ta y l o r-
S e e h a f e r, Jacobvitz, & Steiker, 2008).
Homeless Adolescents
Homeless adolescents, also re f e rre d
to as street youth, tend to roam the
s t reets at night in search of safe shel-
ter and/or to avoid victimization.
Because of their fear of victimization,
these homeless youth try to avoid
contact and interactions with the adult
homeless population (Rew, 2008).
Fear and the need to survive may
evolve into participation in altern a t i v e

behaviors, such as selling and/or
using drugs, prostitution, and other
crimes that elicit disdain from main-
s t ream society and perpetuate isola-
tion and marginalization (Auerswald &
E y re, 2002; Peterson, Baer, We l l s ,
G i n z l e r, & Garrett, 2006).
Adolescence is a period of pro-
found biopsychosocial development.
Identity formation, the quest for
autonomy and independence, and
t r a n s f o rmations in family and peer
relationships, emerging cognitive abil-
ities, and socioeconomic factors inter-
act and affect the adolescent’s
thoughts, feelings, and behavior.
Adolescents who no longer think they
belong or feel safe at home may run to
the streets in a seemingly fru i t l e s s
attempt to find another place they can
call home (Armaline, 2005; Whitbeck,
Hoyt, Johnson, & Chen, 2007). In
e ffect, street youth no longer fit within
m a i n s t ream social networks, and
thus, tend to shy away from institu-
tions designed to help them, including
shelters and soup kitchens. For many,
this hiding out behavior stems from a
m i s t rust of the adult population, as
well as the lack of privacy and person-
al space within institutional enviro n-
ments (Armaline, 2005; Auerswald &
E y re, 2002).
Homeless youth’s transient, invisi-

ble, and/or illegal status make it diff i-
cult, if not impossible, to obtain an
accurate count (Kidd & Scrimenti,
2004; Knopf, Park, Brindis, Mulye, &
Objectives and the
CNE posttest can be
found on pages 162-163.
Continuing
Nursing
Education
Series
Estimates indicate that approximately 1.7 million youth are
homeless in the United States. Many associat-
ed risk factors have been identified for adolescent
homelessness, including family conflict, leaving foster
care, running away or being thrown away, physical or sexual
abuse, and coming out to parents as gay, les-
bian, bisexual, transgender, or questioning one’s sexual identity
(GLBTQ). The purpose of this ethnograph-
ic study was to explore the culture of homelessness for
adolescents. Nineteen homeless adolescents from
a major urban area in the northeast U.S. were observed and
interviewed over an 18-month period. The ele-
ments of the street culture of homeless adolescents were
identified by study participants’ stories. For many
study participants, the decision to live on the streets was a
logical and rational alternative to remaining in
possibly dangerous and unstable home environments. It
provided a means to their generating social capi-
tal. Nevertheless, it can be concluded that existing programs
and policies relative to adolescents who are

at risk for homelessness or already living on the streets should
be re-examined and redesigned to meet the
unique needs of vulnerable youth so they do not get lost in the
shuffle.
Joanne O’Sullivan Oliveira
Pamela J. Burke
Joanne O’Sullivan Oliveira, PhD, RN, FNP,
B C , is Dire c t o r, Nurse Scientist/Researc h e r,
S u rgical Programs, Childre n ’s Hospital,
Boston, MA.
Pamela J. Burke, PhD, RN, FNP, PNP-BC,
is Nurse Practitioner, Division of Adolescent
Medicine, Co-Director for Nurse Tr a i n i n g ,
C h i l d re n ’s Hospital, LEAH Interd i s c i p l i n a ry
Fellowship Program, and Assistant
P rofessor of Pediatrics, Harv a rd Medical
School, Boston, MA.
Statement of Disclosure: The authors
re p o rted no actual or potential conflict of
i n t e rest in relation to this continuing nursing
education art i c l e .
Note: The names of the youth cited in this
study have been changed.
PEDIATRIC NURSING/May-June 2009/Vol. 35/No. 3 155
I rwin, 2007; Raleigh-DuRoff, 2004).
A c c o rding to the Youth Services for
the Child We l f a re League, most of
these youth are not in the child wel-
f a re, juvenile justice, or mental health
systems, and there f o re, get “lost in the

s h u ffle” (Slavin, 2001). Estimates
indicate that 1.7 million youth are
homeless in the U.S. (National
Network for Youth, 2009). Accord i n g
to a re p o rt from the 2007 U.S.
C o n f e rence of Mayors, unaccompa-
nied (homeless) youth account for 1%
of the urban homeless population
(National Coalition for the Homeless,
2008). However, such a low pre v a-
lence rate is most likely an under- re p-
resentation of the actual population.
The number of homeless youth is
equally divided among males and
females, and most are between the
ages of 15 to 17 years (Molino, 2007).
Ten percent of homeless youth were
re p o rted as pregnant. It is estimated
that nationally, at least 6% to 10% of
homeless youth are gay, lesbian,
bisexual, or transgender (GLBT)
(Alexander & Schrauben, 2006;
M i l b u rn et al., 2007; Robertson &
To ro, 1998).
The term homeless youth is used
as an over- a rching term connoting the
many pathways through which youth
find their way to the streets. (Hammer,
F i n k e l h o r, & Sedlak, 2002; Raleigh-
D u R o ff, 2004). Thousands of youth
a re thrown out of their homes each
year (Milburn et al., 2007; Robert s o n
& To ro, 1998). There is no official def-
inition of a thro w a w a y / c a s t a w a y /
pushed-out youth. The parents or

legal guardians have ejected the youth
f rom their living environment, making
it clear that he or she is no longer wel-
come back home. These youth have
literally been abandoned or desert e d
( A rmaline, 2005; Hammer et al.,
2002). Some are homeless because
they have simply lost track of their
families, or their families are homeless
and unable to care for them.
Immigrant adolescents who become
homeless face additional challenges,
such as language-barriers, cultural
conflicts, and legal obstacles to seek-
ing help or readily integrating into the
c u l t u re of the street (Van Wo rm e r,
2003). System youth are individuals
who have been, at one time or anoth-
e r, in the custody of the state due to
familial conflicts, neglect, or abuse.
Some of these youth have been
repeatedly placed in foster homes
and/or group homes, but eventually
run away from this care (Smith,
2008). Brannigan and Caputo (1993)
re f e rred to youth who left the system
p re m a t u rely as absconders from care.
priate study design to meet this
s t u d y ’s aims was ethnography.
Method
The principal investigator (O’Sullivan-
Oliveira) used ethnographic data col-
lection methods (participant observ a-

tion and tape re c o rded interviews)
to study homeless adolescents.
S p r a d l e y ’s (1979) 12-Step Develop-
mental Sequence Method guided data
collection and analysis. The intent of
the observations and interviews was to
see the world through adolescents’
eyes, discover what life on the stre e t s
was actually like, and understand
what activities and relationships stru c-
t u re held in their unique street subcul-
t u re. Observ a t i o n s by the principal
investigator provided a context or
b a c k g round for the adolescents’ sto-
ries and enriched the descriptions of
their experiences (Spradley, 1980).
The principal investigator conducted
o b s e rvations in a variety of settings,
including a medical outreach van, a
homeless youth drop-in center, and
outdoors at two sites where stre e t
youth gathered – a metropolitan urban
subway center and a public park.
These observations were made in var-
ious settings over an 18-month period
in 2001 and 2002 during an average
of 10 to 20 hours per week, and at
various times of day and days of the
week. One setting, the medical van,
was an outreach program staffed by
volunteer social service pro v i d e r s ,
nurses, and physicians to provide first
aid or basic medical care and social
s u p p o rt to homeless individuals. The
medical van traveled around the city
to high-risk areas, and typically

logged visits with adults and adoles-
cents, yielding encounters with
a p p roximately 8 to 10 street youth per
night.
The principal investigator noted
homeless street youth’s interactions
with each other as well as with people
f rom the mainstream culture, such as
pedestrians, students from the sur-
rounding universities, tourists, and
other health care professionals. She
o b s e rved their physical appearance,
moneymaking endeavors such as
panhandling (also known as s ’ p a n g -
i n g – asking people for spare change),
and re c reational activities. Obser-
vation dates, duration, and detailed
descriptions of the social enviro n m e n t
w e re documented. Field notes were
written during observations, including
the dates and duration of observ a t i o n s
as well as detailed descriptions of the
e n v i ronment, atmosphere, mood, and
Homeless adolescents have few
options for services available to them
because they are on the fringe of soci-
e t y. Vulnerable, lost, alone, and often
victimized, they no longer fit society’s
definition of children. The official U.S.
g o v e rnment definition for street youth
is those who are indefinitely or inter-
mittently homeless and at high risk for
sexual abuse, sexual exploitation,
p rostitution, or drug abuse (National

Center for Missing and Exploited
C h i l d ren, 2000). Street youth are
often chronically homeless, long-term
runaways, or throwaway youth.
A c c o rding to Hagan and McCart h y
(1997), street youth sleep in locations
such as doorways, heating vents, AT M
e n c l o s u res, bus terminals, and rail-
road tunnels or platforms, and often
engage in illegal survival strategies.
These youth spend most of their time
on the streets unsupervised and may
seek shelter in abandoned buildings or
makeshift camp sites in outdoor
parks, under bridges, or on ro o f t o p s .
Some may have intermittent contact
with family, but they are usually left to
their own devices for survival (Milburn
et al., 2007).
Many associated risk factors have
been identified for adolescent home-
lessness, including family conflict,
leaving foster care, running away or
being thrown away, physical or sexual
abuse, and coming out to parents as
g a y, lesbian, bisexual, transgender, or
questioning one’s sexual identity
(GLBTQ). Much of the existing
re s e a rch on homeless adolescents has
focused on the epidemiology of home-
lessness, precipitating factors, and
perspectives of service pro v i d e r s .
H o w e v e r, what is not well understood
is the youth’s perspective of life on the
s t reets and the dynamic re l a t i o n s h i p s

that homeless youth form for surv i v a l .
P revious re s e a rch has focused intently
on the problems and deficits of home-
less adolescents, with little or no
attention to the strengths and compe-
tencies these youth possess. Researc h
is needed to explore the subculture of
homelessness as experienced by the
adolescents and described from their
own perspective.
The aims of this doctoral dissert a-
tion study were to 1) explore the
meaning of life for homeless adoles-
cents, 2) examine how these youth
s t ru c t u re their lives and how society
has helped create that stru c t u re, 3)
describe the cultural norms and more s
of street life, and 4) understand how
social, economic, and political forc e s
within mainstream culture may influ-
ence the formation of a homeless ado-
lescent subculture. The most appro-
Lost in the Shuffle: Culture of Homeless Adolescents
interactions that occurred. Reflective
j o u rnaling was also incorporated into
field notes.
Sample

Sampling for formal interviews was
not pre - d e t e rmined, but rather, it
o c c u rred after entry into the field.
Purposive sampling was used to
re c ruit adolescents, ages 16 to 21
years, who re p o rted they were home-
less and living/sleeping on the stre e t
or some other location not intended
for human habitation. In the process of
re c ruiting participants, it became
a p p a rent that not all homeless youth
lived exclusively on the street. Some
re p o rted they were “couch surf i n g ”
(staying with friends) or altern a t e d
between living in their homes of origin
during the week and living on the
s t reets on the weekends. Although
obviously at-risk, these youth were
essentially flirting with homelessness,
and thus, were excluded from this
s t u d y.
P a rents of homeless adolescents
a re generally unavailable. Furt h e r-
m o re, obtaining parental perm i s s i o n
for the adolescent to participate in
re s e a rch would potentially compro-
mise the adolescent’s need for privacy
a round sensitive areas, and in turn ,
could provoke parental reprisal –
emotional, physical, or economic.
R e s e a rchers who have studied home-
less adolescents cite precedent fro m
state statutes that allow emancipated
or mature minors to obtain health care
without parental notification if such

notification would be contrary to the
a d o l e s c e n t ’s best interest (Rew,
Ta y l o r- S e e h a f e r, & Thomas, 2000).
This study was approved by the
Institutional Review Boards (IRB) of
the university where the investigator
was a doctoral student at the time, as
well as the health care agency that
had oversight for the youth drop in
c e n t e r. Participation in the study was
v o l u n t a ry and involved minimal risk.
P a rticular attention was paid to the
need to maintain privacy. In keeping
with the study aims, and the re c o m-
mendations cited in the Office for
P rotection from Research Risks, Code
for Federal Regulations (1996) Art i c l e
46.407, as well as the Society for
Adolescent Medicine’s position paper
on adolescent health re s e a rc h
(Santelli et al., 2003), the investigator
requested and was granted an IRB
waiver of parental consent. Inform e d
consent was obtained from the ado-
lescent participants who selected a
pseudonym for their interv i e w. In
a p p reciation for their time, part i c i-
pants were given a $20 gift card.
componential analysis, 11) doing a
theme analysis, and 12) writing the
f i n d i n g s .
The domain analysis identified the
rich and thick descriptions that were

central components of the homeless
c u l t u re. In the domain of the “Pit rat,”
homeless street youth used labels that
signified the clique with which they
identified. These groupings were akin
to tribal names of a larger gro u p .
Within the larger culture of homeless
adolescents, a variety of self-identified
s u b g roups were based on qualifica-
tions these youth deemed import a n t ,
such as aesthetic style (Goth), spiritu-
al or religious belief (Wiccan), mode
of travel (hitchhiker), or re s i d e n t i a l
identification (squatter kids). Domains
found in this study included the aes-
thetic styles worn and coveted by
youth and their accompanying sym-
bols, rituals and behaviors, codes/law
and ethics, drugs, ways to earn
m o n e y, place/location – home away
f rom home, and daily routines. A
major theme within these domains
was the importance of re l a t i o n s h i p s
for survival. Iro n i c a l l y, it was because
they did not fit in so well elsewhere
that these youth felt they fit in with
each other. No matter how disparate
their backgrounds, their desperate
and immediate need for surv i v a l
bound them together. This need tran-
scended diff e rences that can cause
serious social problems in mainstre a m
s o c i e t y. Their strategy for survival was
the formation of a subculture that lived
on the margins of mainstream culture .

Taxonomic analysis was used to
examine the relationships among
t e rms within a domain. In the pro c e s s ,
relationships among certain domains
became apparent. Taxonomies were
developed as these domains were
placed under a larger umbrella of
o rganizing domains.
Componential analysis focused on
identifying the unique characteristics
of terms within a domain (Spradley,
1979). For example, within the
domain of supportive techniques for
s u rviving life on the streets, most par-
ticipants were ambivalent about their
relationships with systems, including
helping professional agencies. Instead
they related to individual outreach cli-
nicians outside the agency pro p e r. A
thematic analysis integrated the
domains and components of the sub-
c u l t u re of homeless adolescents.
C redibility or internal validity was a
s t rong point of this study because the
p a rticipants and the re s e a rcher devel-
oped relationships. According to
Lincoln and Guba (1985), three activ-
ities can increase the probability of
Nineteen street youth (15 males
and 4 females) were interviewed. The
sample included 1 Latino, 2 bi-racial
(Caucasian and African American), 1
African-American, and 15 Caucasian

p a rticipants. Caucasian youth were
m o re likely to be sleeping on the
s t reets. According to anecdotal
re p o rts from homeless youth and fro m
s e rvice providers, this may be attrib-
uted to a lack of extended family
members for Caucasians as com-
p a red with minority youth. Although
most African-American and Latino
youth who “hung around” on the
s t reets may not have been living with
their family of origin, they did not
sleep on the street. They were couch
s u rfers, staying with extended family
members or friends, and there f o re ,
w e re excluded from the study.
Although the 4 female part i c i p a n t s
said they considered themselves
bisexual, at the time of the study, they
w e re all in heterosexual re l a t i o n s h i p s .
F o u rteen of the 15 males described
themselves as heterosexual. One
male identified himself as bisexual.
I n t e rview questions explored the
experiences of informants and elicited
i n f o rmation about emerging themes.
T h e re were no preconceived notions
about the outcome of the re s e a rc h .
Some questions were form u l a t e d
b e f o re the actual fieldwork to help
guide the re s e a rch (Morse, 1991).
H o w e v e r, the youth were very inform-
ative without the use of these guided
questions. Audio taped interv i e w s
conducted by the re s e a rcher began

with this intro d u c t o ry probe: “I am a
M a rtian, a being from another planet,
and I do not know anything about your
civilization. I landed here. Tell me
about your life on the streets.” This
usually led to the youth’s talking about
their daily lives, and then the
re s e a rc h e r ’s following up with ques-
tions as needed. Immediately after
each interv i e w, the re s e a rcher re c o rd-
ed field notes as well as observ a t i o n s
p e rtaining to the appearance of the
p a rticipants and their enviro n m e n t .
Analysis
Although the process of data col-
lection and analysis was intert w i n e d ,
S p r a d l e y ’s (1979) 12-Step Develop-
mental Sequence Method was fol-
lowed. These steps were 1) entering
the field and locating informants, 2)
doing participant observation, 3)
making a re c o rd, 4) asking descriptive
questions, 5) analyzing the interv i e w s ,
6) creating domain analysis, 7) asking
s t ructural questions, 8) perf o rm i n g
taxonomic analysis, 9) asking con-
trasting questions, 10) perf o rm i n g
c redible findings: 1) prolonged en-
gagement, 2) persistent observ a t i o n s ,

and 3) triangulation. Prolonged en-
gagement with study participants sen-
sitized the principal investigator to
multiple contextual factors influencing
the phenomenon being studied.
Persistent observation allowed the
most salient features of the adoles-
cents’ culture to emerge. Tr i a n g u-
lation of methods (such as part i c i p a n t
o b s e rvations, interviews, and re f l e x i v e
j o u rnaling) was designed to ensure
c re d i b i l i t y. Other strategies used for
c redibility as suggested by Lincoln
and Guba (1985) were peer debrief-
ing, re f e rential adequacy, and mem-
ber checking.
On-going data analysis was share d
with a peer- d e b r i e f e r, who was a fellow
doctoral student. In addition, interv i e w
transcripts and field notes were share d
with the first author’s (O’Sullivan
Oliveira) dissertation committee chair
(Burke) and her two dissertation com-
mittee members, who all had exten-
sive experience working with vulnera-
ble and marginalized populations.
R e f e rential adequacy was used to
keep some raw data aside, unana-
lyzed, until after themes emerg e d .
This was done with one follow-up
i n t e rview for each teen. The data were
then brought back into analysis for
comparison and confirmation of the
e m e rged hypothesis. Member check-
ing was accomplished by checking

the accuracy of statements and con-
clusions with the participants in the
s t u d y. Three participants, Casper,
Chains, and Elizabeth, were inter-
viewed as member checkers, and they
c o n f i rmed the findings.
C o n f i rmabiltiy was assessed to
a s c e rtain whether the findings were
g rounded in the data. This was done
t h rough the audit trail, by examining a
sample of findings and tracing them
back to the raw data (such as inter-
view and journal/field notes).
Findings
C u l t u re can be defined as a set of
guidelines that individuals inherit as
members of a particular society
(Helman, 2000). According to Spradley
(1980), when ethnographers study
other cultures, they must deal with
what people do (cultural behavior),
what people know (cultural knowl-
edge), and what people make (cultur-
al artifacts). The elements of the stre e t
c u l t u re of homeless adolescents were
identified by the study part i c i p a n t s ’
stories.
transfer energy between one
a n o t h e r. Then we will fill you in on
some history of our family
Wicca is an old Celtic re l i g i o n ,

which took on New Age philoso-
phies in the 1980s. We all have
been around for a long time. We
have a high council of members of
the family that have been in the
family the longest, that know all
the functions around the family,
the rules of the family. How things
a re supposed to be done the right
way and on council, where I’m the
eldest son. So I am next in line to
help protect my family. We all like
to protect each other, make sure
e v e rybody is safe at all times.
T h e re are always other members
in the family around at all times if
t h e re ’s ever an emergency or
something like that.
On the street, most come to
Wicca because it means family,
c o m m u n i t y, and commitment.
Wicca beliefs and practices aro s e
f rom a sense of community just
like the street family, within the
early clans. To “go it alone” was
not a traditional Wicca value. We
believe in following our own intu-
ition and own personal code of
ethics and morality. Wiccas look
within, perceiving themselves to
be both student and teacher at the
same time. A lot of it is street fam-
i l y, but we tie in Wicca. Most of the
family members are Wi c c a .

We have one member, the
newest member of the family;
s h e ’s fairly new to the Wicca and
Pagan religion... we are slowly
bringing her in and letting her
know what is going on. We are
doing it so it is not overw h e l m i n g
or scary. We are just slowly show-
ing her this is what happens. I feel
that in some way, everybody is
Wicca or Pagan because there is
always energy transferred no mat-
ter what, human or inhuman.
( 2 / 0 2 )
Street Families
Although these youth had run fro m
or been abandoned by their families of
origin, they had not, in fact, aban-
doned the cultural ideal of a family
unit. To survive on the streets, they
f o rmed new street families complete
with pseudo parents, siblings, and
other extended family relationships. A
s t reet Mom and Dad in their 30s and
f o rmer homeless youth helped scout
out squats for sleeping and were
i n s t rumental in resolving conflicts. In
this street family unit, there were two
Environment
Ty p i c a l l y, homeless youth found
one another at the P i t, a Mecca to
homeless youth. This sunken plaza

was adjacent to the subway stop
a c ross from a major university. A vari-
ety of individuals could be found at the
Pit, including musicians, re b e l l i o u s
teens (with and without homes), stu-
dents, and tourists. The enviro n m e n t
p rovided a cultural center and a place
to belong.
Religion and Rules
C u l t u res are made up of customs,
m o res, and ethos that are based on a
belief system. The roots of these youth
w e re grounded in the practice of
Wicca. The ritualistic religion of Wi c c a
e m e rged in almost every part i c i p a n t ’s
i n t e rv i e w. Religion, particularly Wi c c a
(a pre-Christian pagan religion), was
one of the strongest threads holding
these street youth together. Wi c c a ’s
major influence was on the rules of
conduct and ethics of their culture .
These youth felt a connection with
pagan rituals that were inclusive and
p rovided a sense of family and com-
m u n i t y. Experienced members tutore d
those who were new to the streets in
the ways of Wicca. This became an
i m p o rtant bonding process and a fac-
tor in whether the new member would
be accepted into the street family.
For Bam-Bam, as for many others
living on the street, religion (whether
m a i n s t ream or alternative) played a

significant role in homeless “family”
ties. Bam-Bam stated he had been
practicing Wicca for over 8 years. In
p resenting a portrait of Bam-Bam, the
practice of Wicca was re p o rted as a
central component to the stru c t u re of
the subculture of these homeless ado-
lescents. Divorced from families of
origin and mainstream society, these
youth have foraged for a sense of
s t ru c t u re and organization. Bam-
B a m ’s religious beliefs in Wicca, as
with many of his fellow homeless ado-
lescents, provide a mirror into this cul-
t u re. Quoting Bam-Bam:
T h e re is a large community
a round the “Pit,” and many of the
members in the “Pit” are part of
one joint community family. Our
family is Wicca/Pagan. We have
our parents. We have kids. We
have aunts and uncles. Being
Pagan, our family is definitely dif-
f e rent from most other families.
Most of us in the family believe
that we have been around for
many centuries on earth or what-
ever people want to call it, this
planet, this rock. You have to be
p a rt of our energy circle where we

family factions headed by elder sons
who were designated because of their
length of time living on the stre e t s .
Bam-Bam and Casper were re g a rd e d
as elders and initiated new homeless
youth into the family. These stre e t
families provided the homeless youth
with the re s o u rces and social support
needed to survive the danger, bore-
dom, povert y, challenges, and fru s t r a-
tions inherent in their transient and
fragile existence.
“The best thing that has happened
to me since I began life on the streets is
the making of my street family” (Jade,
female, 1/02). During each interv i e w,
a repetitive theme surfaced about life
on the streets and the formation of
“ s t reet families.” What most pro f e s-
sionals would re g a rd as a negative
experience was described positively
by many of these youth. The adoles-
cents had either run from or been
abandoned by their original families.
This left a void in their need for family
ties. Their street families took alter-
nate forms, as evidenced by both
B a m - B a m ’s and Jade’s accounts, and
for these vulnerable youngsters, such
ties were as important as food and
w a t e r. These youth felt they finally
belonged because they had estab-
lished a family bond and found uncon-

ditional acceptance. They now had a
family upon which they could depend,
and this generated feelings of security.
Some of these youth stated this was
the first time in their lives they could
“act like a kid,” while others said they
w e re discovering their lost childhood
and finally felt part of a family, a com-
m u n i t y, a society, and a culture .
Street Brands
Language is the primary symbol of
each social group and is fully under-
stood by its members. In this gro u p ,
the language was hip-hop or stre e t -
slang. The study participants were a
diverse group of adolescents who
identified themselves as fre a k s ,
g runge, taggers, Goths, punks, skin-
heads, hippies, wannabe thugs, vam-
p i res, hitchhikers, or squatters. They
c o n g regated in relative peace and har-
m o n y. There was an unspoken pact of
live and let live, despite their use of
d i ff e rent clothing, hairstyles, hair
c o l o r, tattoos, and other accessories to
distinguish themselves.
Thugs, for example, tended to wear
big, baggy clothing, while Fre a k s
donned chains, leather coats, spikes,
patches, black boots with white laces,
and long hair. Within the larger gro u p
of Punks were subgroups, such as
Skank Punks, Skin Punks, and Nazi

Punks. Punks wore every color of hair
Most admitted they sold small
amounts of marijuana to their inner
c i rcles or to others wanting to buy
d rugs.
Several individuals who smoked
marijuana did not consider it to be a
d rug. Many said they had been smok-
ing “weed” since they were 8 or 9
years old. Marijuana was a common
substance used in their homes and
communities of origin. When asked if
they believed they had a drug pro b-
lem, they insisted they did not, even
though they smoked pot all day long.
Marijuana use was considered a cul-
tural norm among homeless youth in
this study. It played a significant role in
their communal life. It was something
they used re c re a t i o n a l l y, as well as for
self-medication for anxiety, depre s-
sion, fear, hunger, and sleep.
The code “420” is a euphemism for
smoking marijuana and is widely
known by adolescents. There are dif-
fering renditions of oral history that
relate to the origin of the term 420, but
these youth agreed that the term orig-
inated in California. Some believed it
was a California police code for mari-
juana smoking or that it was a crimi-
nal code number. There is no evidence
to support these claims. Anecdotes

w e re off e red in support of an urban
legend that the term 420 had originat-
ed on the West Coast in 1971 with
some California high school students.
The youth often met after school to
smoke marijuana at 4:20 p.m. each
d a y. Whatever the origin, the term was
e n t renched in this homeless youth
s o c i e t y. A blunt, an inexpensive larg e
marijuana cigarette, would serve the
e n t i re group during a smoke-out ses-
sion every day at 4:20 p.m. This activ-
ity was reminiscent of a peace pipe
smoking ritual in the Native American
tribal culture. The smoke-out session
was an incentive to attend street com-
munity meetings. Several Intern e t
sites had developed as part of the 420
c u l t u re, and they were popular among
these homeless adolescents. One par-
ticipant, Bat, described the use of
marijuana in this way:
I smoke pot because it’s fun.
I’ve done it for years, and it’s a
way to relax and kind of...like how
the college professor goes home
at night and has himself a brandy
and a cigar. That’s just my way
of...chilling out.
All participants re p o rted using
some drug or alcohol. Individuals who
re p o rted having previously been diag-
nosed with attention deficit hyperac-
tivity disorder (ADHD) said cocaine-

based drugs calmed them down, sim-
ilar to methylphenidate (Ritalin®) pre-
and proclaimed their unity thro u g h
their common interest in punk music.
They viewed themselves as a social
g roup, accepting and welcoming peer
obligations with a sense of family and
respect for the elders. Va m p i re
Wannabes dressed in full-length black
clothing, distinguishing them fro m
others as they listened to heavy metal
rock music.
Music
Music was re p o rted by part i c i p a n t s
as an important, if not t h e m o s t
i m p o rtant, component of their culture .
Though they owned very few material
goods, they owned their music. Most
youngsters possessed a port a b l e
compact disc (CD), Walkman, or a
musical instrument. For adolescents
in general, music and musical art i s t s
a re a big part of their lives, and this
was especially true for these homeless
youth. Music was a way to bond with
peers.
Various categories of music, with
specific themes and symbolic mean-
ings, provided each a place within the
s t reet family. Punks saw their music as
a cry for social change. Hip-hop
music re p resented freedom of choice

and a form of permission to smoke
d rugs or have casual sex. Music also
helped maintain strong bonds within
s t reet families. Specific lyrics and
compositions bonded these youth
together for physical, emotional, and
economic safety and comfort. The
lyrics of a popular rap song was a par-
ticular favorite and re p resented the
violent maternal abuse that a youth
had endured through Munchausen’s
S y n d rome by Pro x y.
Street Economy
Within this group, drug dealing was
re g a rded as a sporadic occupation
used to supplement panhandling/
s p a re changing (s’panging). Bam-
Bam said:
D rug transactions, that’s where
people can make a lot of serious
m o n e y...I live on the streets, mak-
ing my money and doing it hon-
e s t l y. Selling drugs may be illegal,
but I’m working. I’m earning what
I’m making.”
Individuals who sold drugs sporad-
ically said that although the main pur-
pose of selling drugs was to earn
enough money to eat, it also helped
s u p p o rt their own drug use.
T h e re is a familiar hierarchy within

the street culture. Leaders usually set
up the business, take care of the big
deals, and hire other homeless youth
to distribute and sell smaller amounts.
scribed when they were younger.
H e roin was aff o rdable and re a d i l y
available on the streets for as little as
$4.00 per bag. They re p o rted they
had begun by using opiates with more
expensive prescription pain medica-
tions, such as oxycodone (OxyContin®)
(8 mg pill – street value $80.00 per
pill). Within a few months, they
advanced to snorting heroin and rap-
idly pro g ressed to intravenous (IV)
use. Heroin was the least expensive
and purest drug used on the stre e t .
The average daily dose of heroin was
10 to 20 bags per day. However, the
end result of this spiraling addiction
was often death by overdose.
P a rticipants re p o rted witnessing
the ravages of IV drug addiction earli-
er in their lives when their parents died
of AIDS or hepatitis C. Several were
orphaned to the streets as a result of
their parents’ dru g - related deaths.
Poly-substance abuse was common
among the youth, all of whom re p o rt-
ed some form of substance use prior

to living on the streets. In fact, some
re p o rted using more substances when
they lived at home because pare n t a l /
g u a rdian substance use allowed easier
access to both money and drugs. The
most sought after drugs on the stre e t
w e re benzodiazepines, such as clon-
azepam (Klonopin®) (street name
“pins”), which were taken to alleviate
a n x i e t y. Youth re p o rted obtaining pre-
scriptions from psychiatrists at hospi-
tal emergency rooms. Part i c i p a n t s
also re p o rted overdoses and hospital-
izations due to mixing diff e rent types
of drugs.
Another drug fad re p o rted by these
s t reet youth was abuse of over- t h e -
counter Robitussin® cold tablets
(DXL), re f e rred to as “robo tripping.”
One participant re p o rted that ingest-
ing 18 Robitussin cold tablets “made
you feel like you were acid tripping.”
These over-the-counter medications
w e re somewhat costly, and thus,
shoplifting was often the means of
obtaining them. These youth were not
only endangering their health by abus-
ing this medication, but were also
b reaking the law by shoplifting, and
thus, risking an arrest.
Summary
Findings revealed that homeless
adolescents fashioned a defined cul-

t u re of unprecedented freedom and
b a ffling complexity that is neither seen
nor imagined by mainstream society.
It is a culture with rules but little stru c-
t u re, with values but questionable
m o r a l i t y, and with codes but not much
c o n s i s t e n c y. Although street life may
generate social capital, it can also be
transvestites and prostitutes over age
18.
The youth in this study felt better
c a red for on the streets than at home
because of the camaraderie and nur-
turing within their subculture. There-
f o re, they were not necessarily opting
to be homeless per se, but were
selecting a safer and more welcoming
e n v i ronment. The street community
o ff e red tangible support thro u g h
s h a red re s o u rces, such as food, shel-
t e r, money, and other basic necessi-
t i e s .
These homeless adolescents also
f o rmed nationwide networks that they
re f e rred to as a community or family,
and whose members were cultivated
t h rough Internet communication.
They accessed the Internet via com-
puters at public libraries or social
s e rvice centers, exchanging email
a d d resses and communicating with
each other as they traveled across the
c o u n t ry. They sought out companion-

ship and acceptance from other youth
who came from similar backgro u n d s ,
and this spawned a sense of belonging
to this street family culture. The more
these youth felt embraced by their
s t reet family, the longer they re m a i n e d
on the streets.
Homelessness among adolescents
is recognized as a social problem of
i n c reasing magnitude. Social capital
t h e o ry provides a useful way to under-
stand the pathways taken by commu-
nities to survive and flourish. Social
capital refers to positions and re l a t i o n-
ships in groupings and social net-
works, including memberships, net-
work ties, and social relations that
enhance an individual’s access to
o p p o rtunities, information, material
re s o u rces, and social status (Ebaugh
& Curry, 2000). In the lives of people
who are not homeless, personal con-
tacts and networks are sources of
social capital used to find jobs, get
a p a rtments, locate daycare, and find
reliable medical care. The homeless
adolescents in this study displayed
relationships that emphasized surv i v a l
and resilience through tru s t w o rt h i n e s s
and exchange of social capital.
Social capital was one of the many
re s o u rces or types of capital used by
these homeless adolescents in daily
life. Mobilization of social and human

capital occurred most often in the
i n f o rmal economy that operated as
p a rt of their street life. Informal eco-
nomic activities (such as s’panging)
w e re essential to the survival achieved
by youth and their street families.
Their relationships included stre e t
family members who provided social
and economic capital, re p l e n i s h i n g
d a n g e rous because of youth’s en-
gagement in multiple risk activities,
such as drug use and survival sex.
Limitations
The limitations of this study involve
the areas of self-re p o rt and generaliza-
tion. The risk of bias is always pre s e n t
in self-re p o rting. People sometimes
tend to romanticize answers to ques-
tions while telling life stories. As pre v i-
ously described in the “Methods” sec-
tion, the principal investigator con-
ducted observations in a variety of
settings over an 18-month period dur-
ing 2001-2002. This study was con-
ducted among a small group of home-
less youth (n = 19) in a particular city
during a particular time frame.
Although these youth travel, there is
no evidence to support that this
s t u d y ’s findings reflect populations of
homeless youth in other cities, and
t h e re f o re, should not be generalized to
them. Nevertheless, recent national

re p o rts about homeless adolescents
describe similar characteristics and
issues (National Coalition for the
Homeless, 2008; National Runaway
S w i t c h b o a rd, 2008). As an ethnogra-
p h e r, the principal investigator’s
(O’Sullivan Oliveira) active part i c i-
pant observation was limited because
of personal safety issues. There had
been a rash of violent crimes and vic-
timization against the target gro u p
during her study, and the youth
e x p ressed concern for her safety if vis-
iting outdoor campsites or squats.
D ru g - related activities were also off
limits. Although the principal investi-
gator spent a considerable amount of
time with the youth, she was not pre s-
ent during drug dealings or drug use,
and relied upon participant inform a-
tion through informal and formal inter-
views.
Discussion
By understanding how homeless
youth fit into the broader picture of
society and their subculture, one can
begin to understand some of the ways
in which their situation differs fro m
those of other adolescents. Much of
the current literature on street youth
focuses on them as victims who lack
any agency or choice. In this study,
h o w e v e r, many of the homeless youth
revealed that their decision to live on

the streets was a logical and rational
a l t e rnative to remaining in a danger-
ous and unstable home enviro n m e n t .
This study sample of homeless ado-
lescents ages 16 to 21 years is pro b a-
bly more typical of today’s stre e t
youth as compared to Coleman-
L u n d y ’s (1995) study that focused on
the capital that had been absent or
lost from their mainstream culture .
These findings are consistent with
what Ferrell and Hamm (1998)
described as the phenomenon of
s t reet youth capitalizing on a stre e t
c u l t u re to generate social capital, even
though the means to that end entailed
illicit activities. As Ta y l o r-Seefer et al.
(2008) noted, “Youth who wind up on
the streets are, at times, the stre n g t h
of the families, as demonstrated by
their visions of a better life, conviction
that they do not deserve maltre a t m e n t
and abuse, and ability to pursue and
achieve a life with re s o u rces, connec-
tions, and dreams” (p. S86). Success-
ful coping promotes positive self-
esteem that in turn stre n g t h e n s
resilience in homeless youth (Kidd &
S h a h a r, 2008).

Findings from this study indicated
that well before their exodus to the
s t reets, these homeless adolescents
w e re engaged in multiple risk activi-
ties that were harmful to their health
and well being. Clearly, every clini-
c i a n ’s encounter with an adolescent is
an opportunity for teaching risk/harm
reduction. Because homeless youth
r a rely seek assistance, use of out-
re a c h - s t reet workers has been shown
to be the most effective way to access
these high-risk adolescents. Reaching
out to street youth is not an easy task.
Many mainstream social serv i c e
agencies encourage youth to leave the
s t reet families/culture and enter into
traditional programs. However, some
of these youth re p o rted that street life
was less menacing than remaining in
their homes, where they tended to be
m o re fearful. The street may have
been the only positive family unit they
t rusted, and thus, they were re l u c t a n t
to leave.
I n t e rd i s c i p l i n a ry collaboration is
needed to form networks of care that
stimulate positive changes thro u g h
access to health care, housing, educa-
tion, and re c reation. For some of these
youth, survival sex was a means of
revenue, which carried a number of
physical and mental health risks. Non-
judgmental re p roductive health serv-

ices should be available to these
youth, including screening for sexual-
ly transmitted diseases (STDs) and
easy access to condoms and birt h
c o n t rol. In re g a rd to substance use
and other risk factors, there is a need
to explore the effectiveness of harm
re d u c t i o n / h a rm minimization pro-
grams rather than focusing exclusive-
ly on zero tolerance programs for
homeless adolescents (Osgood,
F o s t e r, Flanagan, & Ruth, 2005; Single,
1996; Stimson, 1998; Wodack, 1999).
school diplomas or a GED), job train-
ing, food, and facilities for personal
hygiene (showers and laundry).
Some youth in this study verbalized
plans to eventually leave the stre e t s .
Although many of their goals for
c a reer and pro p e r ty acquisition
seemed unrealistic, they were similar
to the goals of domiciled adolescents
who live in mainstream society.
Adolescents in general tend to be opti-
mistic or somewhat naïve about
achieving their goals, and homeless
youth were no exception. Of note,
h o w e v e r, is the fact that these home-
less youth did have personal goals,
including a desire to leave the stre e t .
Considering their difficult circ u m-
stances, the level of optimism that
many homeless adolescents had
about life was both surprising and

i m p re s s i v e .
Conclusion
Assisting homeless adolescents in
successfully managing the transition
to adulthood is both a challenge and
an opportunity for pro f e s s i o n a l s
(Osgood et al., 2005). There is no one
right approach and no absolute inter-
vention that guarantees success.
T h e re are, however, many possibili-
ties. These must be grounded in an
authentic human connection focused
on genuine caring, mutual re s p e c t ,
enduring patience, and a willingness
to work together to create a safe envi-
ronment in which to learn from life
experiences.
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can be used to help homeless adoles-
cents explore their ambivalence about
change (Baer, Garrett, Beadnell,
Wells, & Peterson, 2007; Miller &
Rollnick, 2002; Peterson et al., 2006).
Homelessness interf e res with healthy
youth development. Adolescents in
general are negotiating new roles to
become socially competent. Wi t h o u t
a p p ropriate adult guidance, they are
at increased risk for engaging in life-
t h reatening behaviors. Homeless
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stance abuse, and sexually transmit-
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tal in the community to help support
families and youth in turmoil. Pediatric
nurses play a key role in pre v e n t i o n
and outreach. Disenfranchised youth
who drop out of school lose their pri-
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may be the first place to intervene in
p reventing homelessness in the ado-
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need for alternatives for adolescents
who run away, are thrown away, or
simply age out of the public system of
c a re. If an adolescent is on the stre e t s ,
especially during winter months, then
it is a good indication that something
is wrong at home. Family pro b l e m s
can include physical, emotional, and
sexual abuse, as well as neglect.
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mon pediatric health conditions, such
as asthma, seizure disorders, anemia,
skin problems, and obesity, to name a

f e w. However, nurses and helping pro-
fessionals must keep in mind that
high-risk adolescents may initially
resist overt u res for help and outre a c h
i n t e rventions because they are coping
with fears from unsuccessful past
experiences. Adolescents who leave
home because of rigid family rules or
harsh parenting practices may avoid
s t ru c t u red programs that they per-
ceive as exerting authority and
expecting conform i t y. However, youth
living on the streets need ready access
to health care and services, such as
housing/shelter (options for those
under 18 years of age as well as
youth-friendly environments), educa-
tional opportunities (for acquiring high
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Clinical Pediatrics
2014, Vol 53(1) 38 –40
© The Author(s) 2013
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0009922813499067

cpj.sagepub.com
Article
As more families in the United States become at or
below the poverty level, many will also become desig-
nated as homeless. Among these, homeless youth will
number more than 1 million.1 As these families become
known to the health care system, it is important to iden-
tify them as homeless and to determine the circum-
stances precipitating their homelessness. Understanding
the specific reasons for homelessness enables the health
care provider to deliver focused services within 2 con-
texts of homelessness: involuntary and voluntary.
The involuntary homeless are victims of circum-
stances that force them to live openly on the streets, con-
tinuously use temporary housing, couch surf, share
housing with other families, or reside in a shelter as their
principal residence.1,2 These families may be a product
of poverty, low wages, or domestic incident. Tracking
the numbers of youth among the involuntary homeless is
difficult because they may not be a part of a social wel-
fare system or have not entered the legal system.
Voluntary homeless are the missing person adult or
runaway youth. Runaway youth are 18 years and younger.
They are more likely to describe themselves as homeless
rather than a runaway because they feel forced to leave
their residence because of abuse or rejection.3 Numbering
the voluntary homeless may be less tedious than number-
ing the involuntary homeless when tracked by police
missing person reports. But, regardless to the context of
homelessness, the more than 1 million homeless youth
has a staggering 750 000 who are school-aged children

and younger who have no stable residence on a given
night.1 This magnitude of homeless youth quantifies the
need for establishing an early and strong rapport with
their families to facilitate the best outcomes.
Engaging adult family members of homeless youth
cannot be overemphasized. Adult members of the home-
less family have higher incidence of depressive symp-
toms and one third of homeless mothers reportedly have
attempted suicide at least once.4 The impact of adult
family member’s mental health dynamics translates into
increased rates of anxiety, depression, behavioral, and
developmental concerns among homeless youth with
whom these adults abide.4 Additionally, homeless youth
have poorer overall health associated with global
somatic complaints, increased rates of asthma, ear infec-
tions, stomach problems, and disorders in speech.4-6
The interconnectedness of adult mental health on
the family highlights the need for a mental health
assessment on youth as well. A mental health screening
will better depict the health landscape of both the indi-
vidual and family. Overall, 4% to 8% of adolescents
499067CPJXXX10.1177/0009922813499067Clinical
PediatricsAnthony
research-article2013
1PCC Community Wellness Center–Austin, Chicago IL, USA
Corresponding Author:
Inger Anthony, PCC Community Wellness Center–Austin,
1421 W. Harrison Street, Chicago, IL 60607-3201, USA.
Email: [email protected]
Meeting the Challenge: Responding to
Health Care Needs of Homeless Youth

Inger Anthony, DNP, MS, APN, CPNP-PC1
Abstract
Purpose. This article presents a worldview of youth who are
victims of homelessness. A view of family dynamics
and how they affect the emotional, psychological, social, and
physical health of homeless youth is presented. Results.
Homeless youth and their families are at high risk for poor
health outcomes. Those who present for health care
services are least likely to return to the same site for follow-up
care. Conclusion. Understanding the dynamics of
homelessness and its effect on youth and family will facilitate
efforts to engage the family and increase the likelihood
for follow-up with the same provider. A patient-centered
cognitive approach when managing these youth and their
family will improve communication, potentiate engagement,
whet creative decision making, and facilitate continuity
of care.
Keywords
youth, sexual minority, voluntary homeless, involuntary
homeless, couch surf, temporary housing, house sharing,
continuity of care, engage
at CALIF STATE UNIV LONG BEACH on September 10,
2016cpj.sagepub.comDownloaded from
http://cpj.sagepub.com/
Anthony 39
are clinically depressed with the mean age of onset
being age 14 years.7-9 Positive assessments for self-
harm behaviors and suicide ideation are likely to be

associated with a positive depression screen. Runaway
sexual minority (lesbian, gay, bisexual, or transgen-
dered) have an added risk for intentional self-harm. In
fact, 59% of sexual minority males and 38% of sexual
minority females attribute their attempts at suicide to
issues concerning their sexual orientation.10 Although
there is no single mental health screening tool that can
be applied to all pediatric ages, the need for one is
clear. The Pediatric Symptom Checklist (PSC) is a
mental health screening tool applicable to ages 4.5 to
19 years.11 The brevity of the PSC lends its application
to both primary care and the acute care settings.
However, this is a parent report tool. Further develop-
ment of the PSC instrument as a self-reporting tool
would make it ideal for self-reporting young children
and adolescents during a brief office visit or the quick-
paced emergency department.
The dependence of younger children on adults to
facilitate access to health care is legalistically obvious,
but the interdependence of health care–seeking home-
less adolescents has gender-specific characteristics.
Gender specificity is more notable among runaway
youth. Specifically, runaway females appear for care
more often than runaway males and are usually accom-
panied by a friend.2,12 Sexual minority adolescents and
young adults generally appear alone for services.2,12
There are 6 areas of health care to be addressed when
homelessness is part of the family landscape: physical
health, nutrition, mental health, sexual health, substance
use, and victimization.3 All 6 assessment areas deserve a
family-focused review followed by a patient-centered
assessment. Although a family assessment is probably
unrealistic considering the dynamics afflicting the fam-
ily, a social worker referral is warranted so that the lead

family member has the option to complete a family
assessment. Coordinating care with the social worker
will also assist in securing resources for the family while
leaving the provider exclusively available for assessing
and responding to individual medical needs.
When conducting the physical exam, assessments
that trigger a red flag include problems with personal
hygiene, skin rashes, global constitutional complaints,
and problems due to prolonged exposure to the environ-
ment.3 A nutritional assessment in conjunction with lab
work may reveal nutritional deficiencies.3,4 Females
seeking to confirm a pregnancy should receive early
confirmation and intervention to minimize their high
risk for perinatal and neonatal complications inherent
with gravid adolescents.
Homeless youth are at increased risk for victimiza-
tion.3,13 Adolescents further increase their risk for vic-
timization when they respond to their problems with
illegal activity, such as theft, prostitution, pornogra-
phy, or drugs. And, because sexual minority males and
females report homelessness 4 to 13 times more than
their heterosexual peers, they are more likely to be
victimized by virtue of their sexual orientation.1,13,14
The predisposition for the sexual minority to rely on
vice to sustain themselves explains in part why sexu-
ally transmitted disease appears 5 times higher in sex-
ual minority males and 2 times higher in sexual
minority females when compared with their hetero-
sexual counterparts.7
The worldview of homeless youth is integral to facil-
itating the patient–provider relationship and fruition of a
focused health assessment. The magnitude of risk and
the complexity of the patient–provider relationship

stress the importance of having a structured encounter to
maximize health management. To facilitate a focused
interview, techniques that ask questions that proceed
from general to intimate can be integrated from the
HEADSS tool.15 This strategy is especially critical when
interviewing the sexual minority among whom disclo-
sure16 is impeded by learned mistrust and fear of stigma.2
In addition to the general questions of a focused inter-
view, when conducting an interview with the runaway,
there are 5 questioning themes to be addressed: the real-
ity of exiting street life, how to negotiate dangerous ter-
ritory, rethinking return to family, inherent hazards of
being a runaway female, and how to navigate the health
care system.2
Facilitating the process of engagement is primary to
establishing a long-term connection with homeless
youth and their families. The provider who understands
the dynamics of homelessness and its effect on youth
and family can readily identify with and address their
concerns in the context of homelessness. A patient-cen-
tered cognitive approach when managing these youth
will improve communication, potentiate engagement,
whet creative decision making and facilitate continuity
of care.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author received no financial support for the research,
authorship, and/or publication of this article.

40 Clinical Pediatrics 53(1)
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