ASAP

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-

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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

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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

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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.

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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

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160 PEDIATRIC NURSING/May-June 2009/Vol. 35/No. 3

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.

R e fe r e n c e s A l ex a n d e r, B., & Schrauben, S. ( 2 0 0 6 ) . O u t s i d e

the margins: Youth who are different and their special health care needs. P ri m a ry C a r e, 33(2), 285-303.

A rm a l i n e, W. ( 2 0 0 5 ) . Kids need stru c t u r e : Negotiating ru l e s, powe r, and social con- trol in an emergency youth shelter. A m e rican Behav i o ral Scientist, 48( 8 ) , 1 1 2 4 - 1 1 4 8 .

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B a e r, J. S., Garrett, S. B., Beadnell, B., We l l s, E.A., & Peterson, P. L . ( 2 0 0 7 ) . B rief moti- vational intervention with homeless ado- l e s c e n t s : E valuating effects on substance use and service utilization. Psychology of A d d i c t i ve Behav i o r s, 21(4), 582-586.

B a r ry, P., Ensign, J., & Lippek, S. ( 2 0 0 2 ) . E m b racing street culture: Fitting health care into the lives of street yo u t h . J o u rn a l of Tra n s c u l t u ral Nursing, 13(2), 145-152.

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Motivational enhancement techniques 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 youth face multiple risks, including mental health disorders, violence, self mutilation, suicide, homicide, sub- stance abuse, and sexually transmit- ted diseases (Rew, Chambers, & K u l k a rni, 2002; Rew, Grady, Whittaker, & Bowman, 2008; Solorio, Milburn , Andersen, Trifskin, & Rodriguez, 2006; Van Leeuwen, Rietmeijer, LeRoux, White, & Petersen, 2002; Whitbeck et al., 2007).

Health care providers need to be able to recognize and use social capi- 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- m a ry connection to mainstream soci- e t y. Thus, truancy is a red flag for pos- sible behavioral or social issues, and may be the first place to intervene in p reventing homelessness in the ado- lescent population. There is a critical 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.

Homelessness exacerbates com- 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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Lost in the Shuffle: Culture of Homeless Adolescents