Introduction
Any person supported by DDS who is missing may be considered at risk. This risk may be greater for people who require regular 
monitoring or medical supervision.  This brief will cover strategies to assess the risk of a person being reported missing, suggestions for prevention strategies and an overview of DDS’s protocol for missing persons incidents.    

When is someone with intellectual/developmental disabilities considered to be “missing” ?
A person with ID/DD is considered “missing” after any period of time without contact if they are considered to be in immediate jeopardy without regular monitoring or medical supervision, or if they are out of contact for more than 24 hours without prior arrangement.  Each 
person’s level of neighborhood (or traveling) independence will vary due to their personal ability. For some people, a provider’s safety 
assessment, or their Individual Support Plan (ISP) may indicate a 
specific period of time that they can be safely out of contact with 
family and or community associates before there is cause for concern or a need to implement the Missing Protocol.  
 
What are common causes of missing person reports?
Historically, some of the main reasons people are reported missing 
include voluntary elopement, lack of communication with providers/families, becoming lost or disoriented when away from home.  Less common reasons include confused wandering due to psychiatric conditions or dementia/Alzheimer’s Disease, and abduction.

What should be done if someone with I/DD is suspected to be missing?
DDS developed a missing persons protocol, covered on pg 3, and available at: www.mass.gov/dds. It is important to note that there is no 24 hour waiting period for a person to be considered “missing” if the person has a disability; law enforcement may be immediately 
contacted and notified that the person is missing and has a disability.

considered “missing” if the person has a disability; law enforcement may be immediately 
contacted and notified that the person is missing and has a disability.

DID YOU KNOW?

People served by MA DDS are reported missing most often during 
morning and evening transit and often involve transition between 
locations such as the 
person’s residence and day service or community trips.  

Adult males are reported missing about twice as often as females.

People served by DDS are reported missing more often in summer months.  
 
Adults aged 25-44 have the highest rates of 
missing persons incidents of all age groups.  

· Risk Assessment	     · Prevention Strategies	· MA DDS Protocol 

Quality Is No Accident

Massachusetts DDS  ·  Quality & Risk Management Brief  ·  June 2010

Missing Persons 

Quality Is No Accident was developed by the Center for Developmental Disabilities Evaluation and 
Research (CDDER) of the E.K. Shriver Center/University of Massachusetts Medical School.

Remind people to be aware of their surroundings and not to go with people that are unfamiliar to them.

Risk of elopement: 
Does the person verbalize a desire to leave or threaten to run away?
Has the person previously left home without the needed supervision or run away?
Does the person have a psychiatric condition which may make them more likely to elope (i.e. paranoia, severe anxiety)? 
Does the person have diminished decision- making capacity?

Abduction Risk: 
Is the person easily lured by incentives or are easily influenced in social situations?
Does the person have a diminished 
decision-making capacity?  If so, have they been trained about how to handle 
approaches by strangers, such as through role-playing?

Risk of wandering: 
Does the person wander or have exit 
seeking behavior?  Is there a past history of wandering? 
Does the person have dementia or 
Alzheimer’s disease?
Do a person’s medications make them 
confused or disoriented at times? 

Encourage people to use the buddy system, especially at night; people traveling in groups are less vulnerable than people traveling alone.

Make sure new staff are clear on monitoring protocols and individual supervision needs as covered in each ISP.  
Discuss the importance of communication with people whose ISPs allow for non-contact periods to prevent missing situations. 

If the person has eloped 
before, consider what caused them to elope previously.  Are they at risk of eloping again in a similar situation?  Discuss strategies to address the cause of previous elopements with DDS risk managers or other appropriate DDS staff.    

There are three main reasons why people are reported missing: elopement (voluntarily 
missing), wandering/disorientation and abduction (involuntarily missing). Consider the following questions when assessing a person’s risk for each situation. 

Tip: Has a consumer developed new 
wandering behavior and been confused when located?  This can be an early sign of dementia or Alzheimer’s Disease, and 
dementia screening may be helpful.  People with Down Syndrome are at higher risk for dementia at early ages (40’s +).  

Preventing Abduction: 

Assess & Manage Risk

Tips to help find people quickly: 
Update emergency fact sheets (online or paper) with current photos and descriptions. 
Updated versions of this 
information can be essential to quickly finding missing people.  
Whenever possible, make sure consumers know their home 
address and telephone number.  
People who cannot communicate their name and home address should carry identification at all times.  For people with  dementia, a medical bracelet with pertinent data should be used. 

Preventing “Missing” Incidents

Preventing Elopement or Wandering:

When someone is found: 
It is advisable to have the person medically screened even if there are no visible signs of injury. This will identify issues with dehydration, lack of medication or more serious problems. 

A team review should be held to determine what circumstances led to the incident and if current 
support needs have changed.  A referral to the DDS Area Office Risk Committee may be considered if there is not a current risk plan.

DDS Missing Persons Protocol

In 2009, DDS revised the Missing Persons Protocol. This protocol applies to people eligible for DDS services that are suspected to be missing.  It outlines immediate action steps for people living in supported residential settings, procedures for people living independently, and possible further action steps such as media involvement.  A brief overview of information in the protocol is listed here. Please refer to the protocol for more details: www.mass.gov/dds

Persons in immediate danger if missing:
The person who was last in contact with the missing person (DDS Area Office staff person, provider or family member) should call Emergency Services/Police Department (911).
The DDS Area Office should be notified. The Area office will facilitate a search of the 
immediate area. This may be conducted by the provider agency, family or guardian. 
DDS Providers/Area Office should complete an Incident Management Report in HCSIS. 

Info needed when reporting a person missing: 
The time and place last seen; 
Description of the clothes the person was wearing; 
Any unusual identifying characteristics; 
Language spoken; any communication difficulties; 
Note if the person carries a cell phone; 
Any immediate medical needs; 
Note any location where person has gone frequently, has talked about going to, or has been found in the past; 
contact info for the police to let someone know when the person is located.   

All other missing persons: 
First, consult the person’s ISP, which specifies the amount of time the person can safely be out of contact with family and/or community contacts.  For some people, unplanned trips are not atypical. 
For people living independently whose whereabouts are unknown to usual contacts for more than 24 hours without prior arrangement, the DDS Area Office should be notified. The person’s team will consider their previous patterns and 
behaviors to discuss with the risk team.   
If necessary, the DDS Area Office/provider will talk to known contacts and check familiar areas that the person frequents. 
If appropriate, the DDS Area Office, family, 
provider or guardian can involve the local 
police department.  

Media Involvement
An Area Office may consider alerting the media after consultation with the Regional Director, Risk Management team and 
Central Office.  Factors to consider before 
taking this step are:  person’s history, 
capacity and other factors.  Media 
notification should be done within 24 hours in urgent situations.  DDS may also notify the EOHHS Media Relations team to apprise them of the missing person.

 Real Data from incidents reported to DDS in FY’08 & FY’09

Analyses conducted by:
Center for Developmental Disabilities 
Evaluation and Research (CDDER), 
E.K. Shriver Center, UMass Medical School

Reports of missing persons in the DDS HCSIS system were analyzed for FY’08 and FY’09.  The goal of this analysis is to gain a better understanding of trends and patterns for the population served by DDS in order to inform future prevention and risk mitigation strategies. Information presented here includes only those incidents that occurred during the provision of DDS-funded services.
Overview
Each year, about 1 in 100 adults served by DDS are reported missing. In FY’08 there were 201 reports filed in HCSIS, and 272 reports in FY’09.
Of people reported missing, between 14-21% went missing multiple times within the same 
fiscal year.  More people had multiple missing incidents (2-11 incidents/person) in FY’09.  
People with repeat incidents tend to be younger adults under the age of 50.
In FY’08 and FY’09 about half of all missing persons incidents involved law enforcement. 
Who is reported missing?
Males are about 50% more likely to be reported missing as females.  
However, when females are reported missing from either their residence or while out in the community, it is much more likely (300-700%) that law enforcement will 
become involved.  This may indicate that the incidents tend to be more serious.
From where are people reported missing?
People are most likely to be reported missing while in the community or from their own residences.  Other locations such as day services, work sites, vehicles and family residences accounted for a smaller proportion of incidents.  
Incidents where people are reported missing from family residences are more likely (400%) to involve law enforcement than reports of people missing from other types of locations.  Similarly, incidents where people are reported missing from the community are slightly more likely (40%) to involve law enforcement.  Incidents of people reported missing from day services are less likely to involve law enforcement. 
People were reported missing more frequently while transitioning between locations— such as between their residence and day service or during community trips.  Missing reports for more independent consumers were related to the person not informing a provider or family member of their plans, or being out contact longer than is typical or allowed in their ISP.  
When are people reported missing?
More missing person incidents occur in the afternoon or evening, particularly around travel and busy transition times.  Incidents later in the day (after 3pm) are more likely to involve law enforcement.
Fewer incidents are made in the months of December—March.  The summer months typically have the most missing person incidents.

For more information on the prevention of missing persons events and the MA DDS Missing Person Protocol, contact 
Janice O’Keefe, Director of Risk Management, DDS
 Janice.O’Keefe@state.ma.us 

Analysis of Missing Person Incidents