pediatrics
October 2004, VOLUME114 /ISSUE 4

The Pediatrician’s Role in the Prevention of Missing Children

  1. Barbara J. Howard, MD,
  2. Daniel D. Broughton, MD,
  3. Committee on Psychosocial Aspects of Child and Family Health

Abstract

In 2002, the Second National Incidence Studies of Missing, Abducted, Runaway, and Thrownaway Children report was released by the US Department of Justice, providing new data on a problem that our nation continues to face. This clinical report describes the categories of missing children, the prevalence of each, and prevention strategies that primary care pediatricians can share with parents to increase awareness and education about the safety of their children.

  • missing children
  • runaway children
  • thrownaway children
  • family abduction
  • nonfamily abduction

INTRODUCTION

Missing children are of considerable concern to parents, children, and the nation. In one study, nearly 75% of parents acknowledged worrying about their children being kidnapped, and 35% said they were very concerned.1 The issue of missing children is complex and needs to be dealt with in the appropriate context. When considering how to counsel parents about this issue, it is important for pediatricians to have a good understanding of the problem.

Of the 837 055 missing persons reported in 2001,2 it is estimated that 80% of them were children.3 Fortunately, approximately 99% were found within hours or days by usual law-enforcement response. However, 7115 to 7534 children nationwide were missing for prolonged periods.

There are several categories of missing children. Most children reported missing are runaways and children taken by noncustodial parents, both of which are preventable events. A small but indeterminate number of children are abducted by nonfamily members. Most of these nonfamily abductions occur as a result of direct contact between the perpetrator and the child. However, with the increase in Internet use, an increasing number of children have been reported as missing through contact with people they have met only through this medium. Abduction of newborn infants has been nearly eliminated through additional security and educational measures implemented in hospitals.

Pediatricians have an important role in helping parents put the problem of missing children in perspective, recommending general safety measures to be discussed without frightening children or adults, advocating for services for dysfunctional families and for children after runaway events, and condemning the use of commercial techniques that exploit fears about missing children.

CATEGORIES OF MISSING CHILDREN

In 2002, the US Department of Justice released the Second National Incidence Studies of Missing, Abducted, Runaway, and Thrownaway Children (NISMART-2).4 Children who had been missing according to their families in 1999 were put into one of several categories: nonfamily abductions; family abductions; runaways or thrownaways (children forced to leave their homes by their parents); missing involuntary, lost, or missing; and missing benign explanation.

Nonfamily Abductions

According to the US Department of Justice, nonfamily abduction occurs when a nonfamily perpetrator takes a child by the use of physical force or threat of bodily harm or detains a child for at least 1 hour in an isolated place by the use of physical force or threat of bodily harm without lawful authority or parental permission or when a child who is younger than 15 years or is mentally incompetent, without lawful authority or parental permission, is taken or detained by or voluntarily accompanies a nonfamily perpetrator who conceals the child’s whereabouts, demands ransom, or expresses the intention to keep the child permanently.5 According to NISMART-2, more than 50 000 children and adolescents were taken in this manner in 1999.6 Most victims of nonfamily abductions were girls (65%), and most were 12 years old or older (58%). Forty-six percent of the victims were sexually assaulted while missing. Most nonfamily abductions lasted less than 1 day (91%), with 29% lasting 2 hours or less. Less than 1% of children were not yet returned at the time of the study. Although much less common, classic nonfamily kidnappings pose the greatest risk of death or serious harm. According to law-enforcement statistics, a few more than 100 children were kidnapped in this sense in 1999.4 Although these numbers are small, the effects on the child, family, and community are enormous. All nonfamily abductions are part of a continuum. On one end are relatively brief episodes in which there is no physical harm to the victim. At the other extreme are the horrific cases of classic kidnappings that often grab the nation’s attention.

The statistics on abductions are powerful reasons for teaching safety principles to older children, especially girls. As an example, the National Center for Missing and Exploited Children has developed a campaign to get kids to “know the rules”7 when going out:

  • Don’t go out alone.

  • Always tell an adult where you are going.

  • Say “no” if you feel threatened.

These are good rules, because they lessen the risk for children and adolescents to develop serious problems from getting into situations in which they are most vulnerable to exploitation and harm, whether with unfamiliar people or as in “date rape.”

We all can remember our parents and teachers giving admonitions such as “don’t take candy from strangers,” hoping to keep us safe. Unfortunately, we now know that most people who perpetrate these crimes on children are not strangers in the eye and mind of the child. A neighbor, a familiar face in a child’s daily routine, or someone the child’s parents know well enough to speak to or whose name the child knows is probably not viewed as a stranger by the child. The perpetrators usually understand and practice seduction techniques that make themselves appear nonthreatening to children. Such techniques include calling the child by name, becoming familiar with their family or friends to provide a sense of familiarity, and providing toys or sweets for enticement. Often, these perpetrators will ask the child for assistance in looking for something such as an address or a lost puppy, thus becoming a new “friend” or ally. In cases of long-term kidnappings in which the child was found alive, 85% of the victims did not consider the kidnapper to be a stranger. In at least 65% of the cases in which a child was found dead and the perpetrator was identified, it was clear that the child would not have considered the person a stranger.8 These strategies make it ineffective to give simple instructions to children not to talk to or go with strangers, because these people do not seem to be strangers by the time the abduction occurs. Use of an “appropriate stranger” such as a police officer or a store clerk or manager may be of great assistance to a lost child. Careful supervision of children, screening of references of potential caregivers, and excellent communication between parent and child are the best defense. Children sense unease in inappropriate relationships and can report this as long as parents routinely take all of their concerns in life seriously rather than downplaying or shaming them. Children should also be taught from an early age that they need not kiss, hug, touch, or sit on the lap of anyone, relative or not, if they do not wish to. This respect for their comfort and wishes translates into self-respect and the ability to differentiate unwanted contacts without generating fear.

Runaways and Thrownaways

Most children reported as missing left of their own accord, often from adverse family or living situations. In fact, leaving home as an impulsive act of protest is very common, occurring in an estimated 1 of 7 children younger than 16 years in England, with 11% being younger than 11 years,9 with girls leaving twice as often as boys.10 Traditionally, most of these children were not reported as missing to national authorities, however, and were not included in national statistics from earlier surveys. In 1983, the Inspector General of the Department of Health and Human Services estimated that there were as many as 1 million and possibly more than 2 million runaways annually in the United States.11 Children who run away commonly live in difficult situations such as poverty or reconstituted homes. Many of them were truant previously.

Runaway or thrownaway children missing for a prolonged time commonly were subject to physical abuse (up to 75%), sexual abuse (up to 20%),12 or other harsh treatment from which they were seeking escape and felt they had no other way out. A variety of additional risk factors are more common among runaways than among other children and adolescents, including psychological problems, strained family relationships, school difficulties, and adverse peer-group pressure.13 Up to 30% of runaway children ran away from foster care.9 Runaways gone for a prolonged time are at risk of many medical and psychological problems including disease, crime (both as victims and perpetrators), injuries, alcohol use, illegal drug use (one third)10 and selling, sexual contact, and death. They may pose for pornography or prostitute themselves to provide income to survive or be taken into prostitution as a form of “sheltering” relationship. As a result of this activity, they are at high risk of pregnancy and sexually transmitted diseases including human immunodeficiency virus infection. In urban areas, these children often join gangs or are involved in burglary or armed robbery and other crimes. The psychological effect of the coercive parenting they were receiving and their subsequent experiences can be severe. Many have learning disabilities and school failure and belong to deviant peer groups preceding the runaway event, which makes recovery more difficult.

NISMART-2 data about runaways show that 68% of runaways were 15 to 17 years of age, 28% were 12 to 14 years of age, and 4% were 7 to 11 years of age.14 Runaway episodes are most likely to occur during summer (39%), with the runaway going more than 10 but no more than 50 miles from home (31%), and most were gone from 24 hours to 1 week (58%). Although many such episodes seem minor, 7% of runaways were missing from 1 to 6 months, 23% traveled more than 50 miles from home, and at least 9% traveled out of state. Many of the runaways are harmed during the episode, with 1% having been sexually assaulted or having had someone attempt to do so and 4% having been physically assaulted or having had someone attempt to do so.

Preventing children from becoming runaways and thrownaways lies in detecting family situations that include behavior problems or coercive interactions, especially when discipline is inappropriately harsh. Early and ongoing intervention for these families can promote more positive understanding of their children and better strategies for coexisting. Often, these children are targeted for punishment for the act of running away or for the associated misdeeds of substance use, theft, or prostitution when what is really needed is medical and psychological treatment, family realignment, or foster placement. Pediatricians should support community shelter and hot-line programs for runaways (eg, the National Runaway Switchboard at l-800-621-4000) that provide comprehensive medical and psychological care. Quality follow-up care is also needed to monitor for psychological and family adjustment and long-term sequelae. Problems that warrant treatment include skin, respiratory, gastrointestinal, and genital infections; dental disease; accidental or inflicted trauma; lack of immunizations; poor nutrition; and pregnancy in addition to preexisting and subsequent learning and psychological disorders.13 On reunion, if it is possible, the entire troubled family needs to be addressed. The pediatrician needs to work as part of a team with the goal of long-term recovery for these children.

Family Abductions

One of the most prevalent categories of missing children is abduction by a noncustodial parent or unauthorized extended visits with family members. NISMART-2 research found that 203 900 children each year were victims of family abduction.15 Thirty-five percent of these children were 6 to 11 years of age, 23% were 3 to 5 years of age, 21% were younger than 2 years, and 17% were 12 to 14 years of age. Thirty-five percent of abductions occurred in the summer, 26% occurred in the fall, 24% occurred in the winter, and 15% occurred in the spring. Twenty-four percent of these abductions lasted 1 week to 1 month, and less than 1% of children were still absent at the time of the research. Police were contacted in 60% of the cases.

Pediatricians have an important but difficult role to play in preventing family abduction through monitoring for marital difficulties or substance abuse in the family. It is important to offer early advice on ways to protect the child from marital discord and prompt referral to counseling or mediation. In the case of parental separation, the pediatrician may need to give advice on how to manage affected children.16

Children abducted by family members may be at increased risk of physical and sexual abuse or neglect.17 However, data from NISMART-1 indicate that sexual abuse of children may be relatively uncommon in parental kidnapping. Although children abducted by family members can be with familiar and loving caregivers, emotional trauma still occurs. The children are separated from other loved ones and exposed to uncertainty and secrecy, and care is provided by an adult who is usually experiencing his or her own pain or anger. The goal of the adult taking the child generally is revenge or manipulation toward the ex-partner rather than the benefit of the child. In one study18 of children after family abduction, 16 of 18 had emotional effects including severe fright, mental indoctrination, grief or rage about parental abandonment, rejection of the offending parent, and exaggerated identification with one parent. The 2 children abducted by fathers without any apparent reaction were told the truth, maintained contact with the mother, and came from such lifestyle chaos that this event seemed insignificant.

Missing Benign Explanations

A very large number of children who have not been abducted nor run away end up missing with benign explanations. In fact, this is the second largest category of missing children. “A missing benign explanation episode occurs when a child’s whereabouts are unknown to the child’s caretaker and this causes the caretaker to 1) be alarmed, 2) try to locate the child, and 3) contact the police about the episode for any reason, as long as the child was not lost, injured, abducted, victimized, or classified as runaway/thrownaway.”5 NISMART-2 data show that 374 000 or 28% of missing children were in this category. NISMART-1 included a category called “otherwise missing” to include those who were missing but did not fit into any of the other categories. There were nearly 440 000 children in this category with one third of the episodes being concerning enough for the parents to have reported them to the police. Children who have wandered off or disappeared in this way are at significant risk even though they have not been abducted or run away. They are vulnerable to abuse and exploitation, may become disoriented, or may be injured unintentionally. One in five suffered some type of physical harm, and 1 in 7 was abused or assaulted while missing, which emphasizes the point that every case in which a child is missing must be taken seriously regardless of the reason or perceived reason the child is gone.

Neonatal Abductions

From 1983 to 2001, the number of neonatal abductions per year ranged from 0 to 12. The perpetrators of this crime were typically females of childbearing age who had had a miscarriage or had been unable to conceive and had carefully planned an abduction to replace the lost child or maintain a relationship with a lover. The infant was usually kept in the area within 25 miles of the hospital19 and in 95% of cases was returned to the parents.20 Prevention of infant abductions has been successful through a combination of increased security measures in hospitals, including video cameras and alarm devices, and education of staff and parents about precautions to take while in the hospital. It is critical not to allow anyone without identification to take an infant for any reason and to keep the infant within sight of the parent or nursery staff at all times. These measures should be largely invisible and create a sense of security rather than increasing parental fears about abduction. Apparently as a result of these measures, there were no reported infant abductions from hospitals in the United States in 1999.21 Infant abductions did occur in 2000 and 2001, but at a lower rate than in previous years. The National Center for Missing and Exploited Children provides free security and training consultations (1-800-843-5678). Pediatricians should support appropriate safeguards in the hospitals they serve but should also reassure parents of the rarity of this crime in a sensitive way so as not to promote a sense of vulnerability at this especially sensitive time of family formation.

Internet Issues

Although still relatively uncommon, the practice of pedophiles and child molesters approaching children on the Internet is occurring more frequently. In some cases, pedophiles and/or child molesters have arranged meetings with children. Nineteen percent of children using the Internet had received unwanted online requests to engage in sexual activities or provide intimate sexual information. Almost half of these solicitations were from other children. However, at least one quarter of them were from adults.22 The National Center for Missing and Exploited Children reports that approximately 840 cases of people (of unspecified ages) “traveling to or luring” children they had contacted on the Internet are “proven or under investigation.” Parents need to be advised to supervise Internet use by their children, discuss Internet experiences with their children, and set clear rules about contacts with people met via the Internet. Any computer with access to the Internet should always be kept in an open place (eg, living room, family room) in any home with children and should not be in a room in which the door can be closed or locked. It is important to monitor where children and adolescents have been surfing on the Internet. Parents may find it desirable to use filtering or censoring devices on the computer or limit access to restricted passwords. Eighty-five percent of parents in a national survey indicated that they had warned their children about the dangers of chats on the Internet, but only one third had used any blocking devices. Children need realistic education about the potential of the Internet as part of their media education but without generating fears for their safety.

IN THE EVENT OF A MISSING CHILD

In the event of a missing child, parents should:

  • immediately call local law enforcement.

  • provide police and/or the Federal Bureau of Investigation with a detailed description of the child, including clothing or jewelry worn at the time of the disappearance, and medical and dental information.

  • be sure that the child is entered into National Crime Information Center logs by their local police.

  • report abductions or suspected abductions to the National Center for Missing and Exploited Children (1-800-THE-LOST or www.missingkids.com) by parents or law enforcement.

  • report runaways to the hot line (1-800-621-4000) of the federal Runaway and Homeless Youth Program.

PREVENTION

The pediatrician’s advice for preventing missing children, as for many other health issues, needs to be a balance of safeguarding children while avoiding generating fear. None of this information needs to be taught specifically as abduction safeguarding, with all its overtones of danger and threat. Instead, it should be taught as developmental achievements to be praised for their own value in the growing child. The appropriate message allows the child to go forward with skill and confidence rather than fear and avoidance.

Pediatricians can help safeguard children older than 5 years by encouraging parents to teach them to memorize their name, address, and phone number, including area code, so that they can be identified readily if separated from their families. Older children can learn numbers for contacting parents at home or at work. Because abductions are rarely conducted by strangers, even in nonfamily abductions, teaching children not to talk to strangers frightens them without any proven benefit. Passive methods of identifying children such as the placement of microchips in the teeth and fingerprinting are primarily techniques for identification of bodies. Their use has become common for fund raising and as a “service to the community” often without considering the potential effect in frightening children and inappropriately raising fears in adults without any perspective provided on the real nature or rareness of abduction.23,24 On the other hand, keeping recent photographs of children and promptly reporting incidences to the police are extremely helpful measures. Law-enforcement officials consider photographs the number one tool in finding missing children. In addition, photograph campaigns such as direct mail cards and “rogues’ galleries” in magazines have resulted in 1 in 6 children being located as a direct result of the photograph. Parents should be instructed to keep a high-quality photograph of each child, updated at least every 6 months. School photographs serve this purpose with only positive connotations.

The importance of a prompt response in missing-children cases is demonstrated in the AMBER (American’s Missing: Broadcast Emergency Response) Plan. Patterned after the emergency weather warnings, the AMBER Plan is intended to flood a region with information regarding high-risk missing children when time is of the essence. Strict criteria are in place to initiate an AMBER Plan response. It was introduced in Dallas, Texas, in 1997 and became a national program in 2002. Since its inception, the AMBER Plan has been credited with successfully recovering more than 130 children. When combined with the success of the photograph-distribution campaigns (1 in 6 featured long-term missing children found as a direct result of these programs), we see the value of both a prompt response and persistence in searching in missing-child cases.

Learning about personal safety is an important part of a child’s education. Schools should be encouraged to include such a program as part of their K-12 curriculum. Many such programs exist but vary greatly in quality and effectiveness. The National Center for Missing and Exploited Children, in cooperation with the American Academy of Pediatrics and other child-advocacy groups, has developed a tool to help school districts evaluate these programs and select one that best fits their individual needs (Guidelines for Programs to Reduce Child Victimization: A Resource for Communities When Choosing a Program to Teach Personal Safety to Children25).

ADVICE FOR PEDIATRICIANS

  1. Help parents and children put the risk of becoming missing in perspective.

  2. Encourage families to teach children self-identifying information without connecting it to a threat of becoming missing.

  3. Encourage families to keep a high-quality and current photograph of each child.

  4. Encourage families to teach children to accept only touches that are comfortable to them regardless of the toucher’s relationship to them.

  5. Encourage families to teach older children, especially girls, to “know the rules”:

  • When going out, don’t go out alone.

  • Always tell an adult where you are going.

  • Say “no” if you feel threatened.

6. Consider advocating for an appropriate personal-safety curriculum to be taught in schools and check its approach.

7. Continually screen for risk factors for missing children (ie, family discord, divorce, coercive parenting, substance abuse, school failure, deviant peer group, etc) and intervene early with appropriate work-up and referrals.

8. Assess whether adolescents consider themselves to have several sources of support, including the pediatrician, so that they need not resort to running away.

9. Be skeptical of new patients presenting with vague stories about absent parents or children who report mysterious parent deaths or separations without contact, because they may represent abductions.

10. Insist on prompt transfer of medical records as a routine practice.

11. Support programs that serve runaways.

12. Consider providing or coordinating comprehensive care to any families who have just had a missing child returned.

13. Expose programs spuriously generating fear of abduction.

14. Look at and encourage others to look at pictures of missing children.

Committee on Psychosocial Aspects of Child and Family Health, 2002–2003

Jane Meschan Foy, MD, Chairperson

William L. Coleman, MD

Edward Goldson, MD

Cheryl L. Hausman, MD

Ana Navarro, MD

Thomas J. Sullivan, MD

J. Lane Tanner, MD

Joseph F. Hagan, Jr, MD

Past Committee Member

Barbara J. Howard, MD

Past Committee Member

Liaisons

F. Daniel Armstrong, PhD

Society of Pediatric Psychology

Janet Mims, MS, CPNP

National Association of Pediatric Nurse Practitioners

Sally E. A. Longstaffe, MD

Canadian Paediatric Society

Frances J. Wren, MD

American Academy of Child and Adolescent Psychiatry

Consultant

George J. Cohen, MD

National Consortium for Child and Adolescent Mental Health Services

Invited Contributor

Daniel D. Broughton, MD

Staff

Karen Smith

Footnotes

  • The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

NISMART-2, Second National Incidence Studies of Missing, Abducted, Runaway, and Thrownaway ChildrenAMBER, American’s Missing: Broadcast Emergency Response

REFERENCES